Breastfeeding 101

December 6, 2010

Kimberly Williams, MD

Outline

• Brief Review of Benefits• Absolute Contraindications• Literature Review• How to Counsel Patients about BF• Initiation of BF/Supplementation• Common Questions/Problems• Co-Sleeping• Vitamin Supplementation• Galactogogues• Local Resources

Benefits

• Maternal– Weight Loss– Post partum Anovulation– Reduced risk of breast

and ovarian CA– Cardiovascular protection– Economic– $1000/year

formula– Sick visits/missed

work/etc– Bonding/Empowerment

• Infant– Prevention of illness

during breastfeeding• GE, Respiratory, Otitis

media, UTI, Sepsis

– Chronic Disease prevention

• Obesity• Childhood CA• Adult Cardiovascular

Disease

– Neurodevelopment• Benefits higher in pre-term

Healthy People 2010 Goal• An increase in one behavior—-breastfeeding—-can positively impact ten

percent of the Healthy People 2010 objectives, for nearly one hundred percent of the population.

• MPINC in Kansas results• Legislation

– provide that it is the public policy of Kansas that a mother's choice to breastfeed should be supported and encouraged to the greatest extent possible and that a mother may breastfeed in any place she has a right to be.  The law was amended in 2006 to excuse nursing mothers from jury duty

1998 Baseline 2010 Target Kansas-2007

Early Postpartum

64% 75% 79%

At 6 months 29% 50% 47.4% (18.5% exclusive)

At 1 year 16% 25% 20.2%

How Does KS compare?

http://www.cdc.gov/breastfeeding/pdf/BreastfeedingReportCard2010.pdf

Percent of infants who are BF at 6 mo

Maternity Practices in Infant Nutrition and Care (MPINC)

• 2007 Survey mailed to all US maternity facilities

• 89% of 76 eligible hospitals and birth centers in KS responded

• KS Composite Quality Practice Score: 59 (100 is best possible score)

• KS State Rank: 37 (states rank 1-52, 1 is the best)

MPINC in KS

Available at www.cdc.gov/mpinc

Contraindications to Breastfeeding

• HIV in a developed country• Herpetic breast lesions until lesions are gone• Untreated active TB (can initiate BF 2 weeks

after treatment initiation)• Maternal Drug Abuse• Ongoing Radiation Therapy• Human T-Cell lymphotropic virus• Check Medications

– http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT• Infant Galactosemia—inborn error of

metabolism

Evidenced Based Interventions• USPSTF October 2008• 38 RCTs, 36 developed countries, 2 developing

– Few focus on effects of breastfeeding interventions on child and maternal health outcomes

• Interventions ranged from Lay Support, Structured breast-feeding education, Professional support-individual level and system level, skin-to-skin contact, providing electric breast pumps, delaying pacifier use

• Results

Effectiveness of BF promotion on any BF

Short-Term Duration 1-3months

Intermediate 4-5 mo and Long-Term BF 6-9 mo

Summary of Results

• Formal/Structured breastfeeding education or individual professional support did not significantly affect breastfeeding outcome

• Lay support significantly increased the rate of any and exclusive breastfeeding in short term

• Combination and pre and post natal support may be beneficial

• No harm in any interventions

Evidence Based Interventions

• Annals of Family Medicine 2003– Meta-Analysis 30 trials, 5 systematic reviews– Results

• Educational sessions that review benefits of breastfeeding, principles of lactation, myths, common problems, solutions and skills training appear to have the greatest single effect

• One woman would successfully initiate and maintain breastfeeding for up to 3 months for every 3-5 women that attended educational sessions

• Few Scientifically Robust Studies

Prenatal Counseling

•What do you tell patients?

Breastfeeding Counseling Recommendations

• ASK, ASK, ASK!!!– Ask early—at 1st prenatal visit and ask often—at

each prenatal visit;

• Ask about breastfeeding history—success, non-success, age of baby at termination, why?

• Actively support breastfeeding—tell patients that you think it is best for baby

• Ask about family history of conditions that would be especially beneficial to have baby breast fed (DM, Obesity, Eczema)

Breastfeeding Counseling Recommendations

• Let your patient know that you will help get them the support, information they need to successfully breastfeed

• Address common barriers to breast-feeding (pain, supply, work, public)

• Encourage participation in breastfeeding class• Discuss expectations for delivery room• Do a breast exam and inform patient that

anatomy is sufficient for breast feeding, or if a problem try to address early

Prenatal Counseling

• Prenatal Classes at SFHC

• Breastfeeding Class at SRHC– Free if planning to Deliver there

• La Leche League Meetings

Initiation of Breast Feeding• All L and D nursing staff should be trained to

assist moms with breastfeeding• Nicole, Amber, Jill all have extra training and

you can ask for them to see your patient– Can see patients in consultation after discharge

• Goal is get baby to breast in 1-hour• Post C-section, baby to breast in recovery

room• Not currently a supplement policy

How can you help with initiation?

• Baby to belly at delivery

• Order supplements only if medically indicated

• Ask for lactation evaluation if needed

• See baby early in the office and assess breastfeeding at that visit, family physicians are the ideal provider to address BF

• Counsel about frequency, growth spurts, nipple soreness, output and getting enough

Supplementation• Indications for Supplementation

– Separation– Infant unable to feed at breast—congenital malformation, illness

• Possible indications– Asymptomatic hypoglycemia that is unresponsive to

breastfeeding– Clinical dehydration not responsive to BF– Weight loss >7%– Delayed lactogenesis (day 3-5) and inadequate infant intake– Hyperbilirubinemia with poor intake

• Method of supplementation– Supplemental nursing system, syringe at breast, bottle, cup– Expressed milk, formula– Glucose water not appropriate

Pacifiers

• AAP– Recommend pacifiers after breast feeding

well established, usually about 2 weeks

• Pacifiers often used in place of placing baby to breast

Common Problems/Questions

• Fear of Inadequate Supply– Weight gain, output, etc.

• Engorgement– Warm compress prior to breast feeding, cold after– Breast pads to prevent embarrassing leaking

• Sore Nipples– LATCH

• What is “let-down”?• Plugged Ducts• Night-Time Feedings

Candida Infection

• If Baby has thrush, treat Mom too• Also think about Candida if:

– Nipples remain painful after the first few weeks of breastfeeding

– Nipples are red and cracked– Nipple pain returns later on in breastfeeding– Recent antibiotic use in mom or baby

• Treatment– Nystatin suspension, apply to nipples after breastfeeding

and wipe off prior to next feeding– Can use topical nystatin—need to wash off prior to next

feeding– Oral fluconazole for failed therapy

Mastitis• Localized, painful inflammation characterized by fever and malaise• Differentiate from plugged duct• Clinical diagnoses—red, indurated, swollen area of breast with fever

in nursing mom• Treatment

– Evaluate breast feeding techniques– Keep breastfeeding, start with affected breast, position chin nose,

toward the blockage– Antibiotics

• Dicloxacillin 500mg QID or Keflex 500mg QID for 10-14 days• Severe, hospitalized—use vancomycin

– Pain control—ibuprofen, cold packs after feeding– Mom may need help at home, needs rest

• Can culture breast milk if no response to antibiotic in 2 days• About 3% will develop an abscess, can diagnosis on ultrasound and

drain with needle aspiration

Contraception

• Lactation Amenorrhea Method (LAM)1. Exclusive breastfeeding without

supplementation or delay in feeding (8-10 x per day, no more than 6 hours between feedings)

2. Menses has not returned

3. Baby is <6 months old

• Cochrane review pregnancy rates at 6 months 0.45-2.45%

Contraception

Method Typical Lowest

Male Sterilization 0.15% 0.1%

Female Sterilization 0.5% 0.5%

Depo-Provera 0.3% 0.3%

Combined Pill 5% 0.1%

Mini Pill 5% 0.5%

Copper IUD 0.8% 0.6%

Progesterone IUD 2% 1.5%

Male Latex Condoms 14% 3%

Diaphragm 20% 6%

Withdrawal 19% 4%

No Method 85% 85%

Contraception

• Barrier Methods– Condoms, diaphragms—should be re-fitted

post partum

• Hormonal– Progesterone only is better (mini-pill, IUD,

depo-provera)– Start at 6 weeks postpartum

Post-Partum Depression

• Exercise

• Psychotherapy

• Lexapro, zoloft, paxil—preferred meds

• Prozac—stays in breast milk longer

Return to Work

• Encourage Mom to take as much time off as possible

• Start pumping a couple of weeks before returning to work, more milk supply in the morning, pump after feeding

• Pump regularly at work, every 3 hours• Introduce bottle 1-2 weeks before returning to

work• Have Dad or other person give bottle• Encourage employers to be supportive of lactation

Storage of MilkLocation Temperature Duration Comments

Countertop, tableRoom temperature (up to 77°F or 25°C)

6–8 hours

Containers should be covered and kept as cool as possible; covering the container with a cool towel may keep milk cooler.

Insulated cooler bag 5-39°F or -15-4°C 24 hours

Keep ice packs in contact with milk containers at all times, limit opening cooler bag.

Refrigerator 39°F or 4°C 5 daysStore milk in the back of the main body of the refrigerator.

Freezer Store milk toward the back of the freezer, where temperature is most constant.  Milk stored for longer durations in the ranges listed is safe, but some of the lipids in the milk undergo degradation resulting in lower quality.

Freezer compartment of refrigerator with separate doors

0°F or -18°C 3–6 months

Chest or upright deep freezer

-4°F or -20°C 6–12 months

Co-Sleeping

• Co-sleeping vs Bed sharing• Definite studies show that babies that bed

share breast feed longer and more often• Breast-feeding moms are 3x more likely to

bed share• Definite unsafe practices

– Smoking, ETOH, obesity– Sofas, couches, daybeds, waterbeds, soft

bedding material– Baby in prone or side position– Bed sharing with other children

Co-Sleeping

• Where does baby end the night?• Journal of Pediatrics 2005

– Odds Ratios for SIDS• 12.2 infant in separate room and parent smokes• 28.6 sleeping between parents <11 weeks• 66.9 Sleeping on a chair or a couch• 10.2 Sharing a bed <11 weeks• 1.07 Sharing a bed >11 weeks

• Academic Pediatrics 2010– Strongest predictors of SIDS among bed sharers

were soft sleep surfaces, nonuse of pacifier, and maternal smoking

Vitamin Supplements

• 400 IU/day starting 1st week until vitamin D-fortified formula or milk totals 500ml per day—AAP policy Statement

Brand Vitamin D per serving (IU) Serving sizeCarlson Baby D Drops 400 1 dropEnfamil Poly-Vi-Sol Multivitamin Supplement Drops

400 1 mL

Enfamil Tri-Vi-Sol Vitamins A, C & D with Iron

400 1 mL

Sunlight Vitamins Just D infant vitamin drops

400 1 mL

Twinlab Infant Care Multivitamin Drops with DHA

400 1 mL

Casey, CF, Slawson DC, Neal LR. Vitamin D supplementation in infants, children and adolescents. Am Fam Physician, 2010 Mar 15; 81(6):703.

Inadequate Milk Supply• Review normal change in supply as baby ages• More frequent and thorough emptying of the

breast is best way to increase milk supply• Do a thorough evaluation of other reasons for

poor milk supply– Screen for maternal hypothyroidism– Look for medications that may decrease milk

supply (estrogen)– Look for inappropriate supplementation,

inappropriate duration of feedings, pumping, mother-infant separation

Galactogogues• Substances that increase breast milk

production• Metoclopramide

– Antagonizes the release of dopamine, thereby increasing prolactin levels

– Side effects—drowsiness, fatigue, diarrhea, restlessness, rare extrapyramdial side effects

– Contraindications—seizure disorder, history of significant depression, uncontrolled HTN, pheochromocytoma, intestinal bleeding, allergy

– Dose is 30-45mg/day divided TID-QID, full dose for 7-14 days and then taper over 5-7 days

Galactogogues

• Domperidone—not available in US due to toxicity shown in IV form, used worldwide 10-20mg po TID, similar to metoclopramide with fewer side effects

• Thorazine 25mg TID for 1 week effective in case reports

• Human Growth Hormone

• Thyrotrophin Releasing Hormone

Herbal Galactogogues• Fenugreek

– 1-4 capsules QID (580-610mg) (3 caps TID)– Caution in diabetics, can lower blood sugar– Side effects—diarrhea, increased asthma symptoms

• Blessed Thistle 3 caps TID• Goat’s Rue

– 1 tsp dried leaves in steeped in 8 oz water for 10 minutes—1 cup tea TID

• Milk Thistle– 1 tsp crushed leaves in 8 oz water for 10 minutes, 2-3 cups per

day• Mother’s Milk Tea

– Fennel, aniseed, coriander, fenugreek and blessed thistle, 8 oz boiling water over 1 tea bag steep 3-5 min, 3 or more cups daily

Local Resources

• SRHC– Nicole, Amber, Jill are certified lactation

consultants and able to meet with mom after discharge if needed.

• B&K—pump rental

• Saline County Breastfeeding Coalition– 6 hospital grade pumps that they loan out

Local Resources

• La Leche League– Good to attend prior to delivery– Monthly Meetings

• Trinity United Methodist Church 901 E. Neal (just one block West of S. Ohio St.)

• 2nd Tuesday of the Month 7-8:30– Website– Local Leaders

• Teresa Weigel (Theresa.weigel@gmail.com)• Theresa (785) 643-1800

Marci (785) 227-4269Kate (785) 577-3474

• Everything is volunteer basis, supported by donations

La Leche League• Becoming a Leader

– Process that takes about a year, training in breastfeeding, using resources, managing meetings, communication skills, must have breastfed for about a year

• Salina LLL has offered monthly meetings since 1968• Average per month activity stats: (2010)

• 14 - women attend monthly meeting• 12 - phone calls a month are answered by Leaders (usually more follow up calls

are made)• 12 - email correspondence (with follow up)• 8 - on site home visits for personal help ( usually an average of 1 ½ hours per visit)

La Leche League Websitehttp://www.llli.org/resources.html

La Leche League Website

Additional Resources

• Academy of Breastfeeding medicine– http://www.bfmed.org

• LactMed-TOXNET• http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?

LACT

• The Womanly Art of Breastfeeding• By Diane Wiessinger, Diana West and Teresa

Pitman

Breast Lump in Lactating Woman

• Likely Benign, but could be cancerous.• If symptoms of mastitis, treat• Consider plugged duct, use massage, warmth and

frequent nursing• If lump remains

– Consider ultrasound and/or Mammography– Can perform fine needle aspiration—can have milk

filled cysts called galactoceles– Core needle biopsy is ok during lactation– Open biopsy is ok during lactation, milk may leak if

ducts are cut and healing may take longer, ok to feed baby after surgery

Take home points• Ask about breastfeeding first prenatal visit,

pre-conception counseling and well-woman exams

• Be an advocate for your patient• Be knowledgeable about treating/diagnosing

common complications of breast-feeding• Be aware of local resources and utilize them• Family Physicians are uniquely positioned to

led the way in supporting breastfeeding

Questions???