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Breastfeeding
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Alison Stuebe, MD, MSc
[email protected]
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
Risks of Not Breastfeeding
Not Breastfeeding
Formula-feeding vs. breast-feeding: risk of adverse outcomes.
INFANT
MOTHER
Illness OR
Illness OR
Diarrhea 2.8
Premenopausal
1.4
breast cancer
Otitis media 2.0
Ovarian cancer 1.3
Pneumonia 3.6
Type 2 Diabetes 1.2
SIDS 1.6
Asthma 1.4
Leukemia 1.2
Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. AHRQ Evidence Report Number 153. April 2007.
Burden of suboptimal
Burden of Suboptimal Breastfeeding
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.
AAP
Recommendations
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.
Breastfeeding in North Carolina
Health People 2010 Goals
Adapted from “Racial and Ethnic Disparities in Child Health: North Carolina 2008” Reported July 2009, CHAMP data
Why Mothers Wean
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.
How confident are providers
about solving problems?
Taveras, E. M., R. Li, et al. (2004). Pediatrics 113(4): e283-90.
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
Case
 35 yo G1 with a family history of breast cancer
presents for 28 week visit, concerned about nipple
discharge.
Breast Development During Pregnancy
Early
pregnancy
Distal ducts proliferate,
creating more lobules and
more alveoli within lobules.
Women experience breast tenderness
and enlargement, which may be
among first symptoms of pregnancy.
Late
pregnancy
Lobular units begin to
differentiate into secretory
units.
Ongoing breast enlargement occurs
due to distention of acini with
colostrum and increased vascularity.
In late pregnancy, lactocytes
fill with fat droplets, and
colostrum distends acini.
Glandular changes replace
fat and connective tissue.
Many women report leakage of
colostrum.
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.
Postpartum
Breast Masses During
Pregnancy and Lactation
 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.
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
Case: Counseling
 Healthy 22 yo G1 presents for first prenatal visit.
 When do you ask about breastfeeding?
 How do you ask?
 What do you say?
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.
Patients listen to what their doctor say…..
DiGirolamo et al. Birth 2003;30:94-100
…..even when their doctors don’t think they
are listening.
Only 8% of
obstetricians
thought their
advice on
duration of
breastfeeding
was very
important.
Patient opinion of OB
advice:
Taveras et al. Pediatrics 2004;113:e405-11.
Very important
Somewhat / not important
Case: Not enough milk
 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”
How Does Lactation Happen?
Hypothalamus
PIF
Anterior
pituitary
Prolactin
Milk
production
Paraventricular
nucleus
Posterior
pituitary
Oxytocin
Milk
ejection
How Does Lactation Happen?
Speroff et al. Reproductive Endocrinology and Infertility.
How Does Lactation Happen?
Moving
Milk
Let
Down
Breastfeeding
Success
Latch
How Does Lactation Happen?
CORRECT
Moving
Milk
INCORRECT
Let
Down
Breastfeeding
Success
Latch
Photos © Jane Morton, MD, FAAP
AAP Breastfeeding Residency Curriculum
How Does Lactation Happen?
Moving
Milk
Let
Down
Breastfeeding
Success
Latch
How Does Lactation Happen?
Demand drives
supply
Moving
Milk
Let
Down
Breastfeeding
Success
Latch
The baby’s tongue
pulls milk from
areola to nipple
Ejection, not suction,
moves milk to the
areola
Case: Not enough milk
 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”
What are her risk factors
for breastfeeding difficulties?
 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
Taking a history:
Does mom have enough milk?
 ‘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
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?
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?
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?
Moving
Milk
Let
Down
Breastfeeding
Success
Latch
Is it comfortable when the
baby nurses? Are his lips
flanged out? Can you hear
the baby swallow?
Stress and Milk Volume
J. Pediatr 1948; 33:698-704.
Breastfeeding and Depression
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.
Restore Normal Physiology
 First line therapy:
 Lactation consultation
 Mechanical expression after breastfeeding
 If needed:
 Supplement after breastfeeding as indicated
 Continue pumping during supplementation
Augmenting milk supply
 Medication
 Second line treatment
 Offer trial of
metoclopramide, 10 mg
TID, and follow for sideeffects
Restore normal physiology, then consider
metoclopramide as an adjunct.
Kauppila et al. Lancet 1981;1(8231):1175-7.
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
How do drugs get into milk?
Drug entry
Maternal plasma
Clearance
Milk/plasma ratio
Breast milk
Oral Ingestion
Relative infant
dose
Infant plasma
Clearance
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.
Case: Treatment for hypertension
 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
Enalapril
Not all resources are equal
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.gov
Or Google “LactMed”
Enalapril

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
Eur J Clin Pharmacol. 1990;38:99.
Active metabolite, enalaprilat,
not orally bioavailable
Estimated exposure less than
0.2% of therapeutic dose
Four breastfed infants of
mothers taking enalapril not
affected
Case: Seasonal Allergies
 26 yo, 2 weeks postpartum, with seasonal allergies.
She is breastfeeding, and asks if she can take Sudafed.
Pseudoephedrine
Infant dose
39.6 g/kg/d
Relative dose
4.3%
AAP
Usually compatible w/
breastfeeding
Briggs
Limited Human Data –
Probably Compatible
MMM
L3 for acute use
L4 for chronic use
LactMed
May interfere with
lactation – avoid if
lactation not wellestablished
Aljazaf et al. British Journal of Clinical Pharmacology 2003;56:18-24.
Breastfeeding and Medications
•Breastfeeding mother needs medication
•No effective non-pharmacologic therapy available
Yes
no
Drug
systemically
absorbed?
No risk to infant,
reassure mother.
Look up drug on LactMed
http://lactmed.nlm.nih.gov
no
no
yes
Safer drug w/
similar
efficacy?
Good data re
safety, effect
on milk
supply?
yes
yes
Discuss risks of drug exposure in
milk vs. risks of not
breastfeeding, in conjunction
with pediatric provider.
With informed consent, choose a plan:
1. Continue breastfeeding w/ medication.
2. Express and discard milk during treatment
3. Start medication and wean.
Prescribe
alternative
medication
Prescribe originally
selected drug
Breastfeeding and Medications
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.
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
Case
 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.
Mastitis
 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
Workplace
For More Information
 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)): 1S16S.
 Academy of Breastfeeding Medicine
www.bfmed.org
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 Protocols
http://www.bfmed.org/protocols