Introduction to Breastfeeding

Based on a powerpoint by Anita Bordoloi, MD given February 14, 2012

ACOG statement

AAP Policy

The American Academy of Pediatrics (AAP) recommends that babies be exclusively breastfed for the first 6 months of life.

United States Preventative Services Task Force (USPSTF)

The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding.Grade: B Recommendation.

Physiology of Breastfeeding

Breast Anatomy

Breast milk Species-specific Bio-active Composed of:

› Immunoglobulins (especially IgA)

› Growth modulators› Protein› Carbohydrates› Minerals› Vitamins› Fats

Lactation Cyclical process of milk synthesis and

secretion Activated by prolactin, oxytocin,

TSH, and human placental lactogen (hPL)› Prolactin: milk production› Oxytocin: milk secretion

Inhibited by progesterone and estrogen

Prolactin Initiates milk production Elicited by suckling Produced by anterior pituitary gland Stimulates mammary glandular ductal

growth and epithelial cell proliferation

Oxytocin Milk ejection or letdown Suckling activates touch receptors that

stimulate dorsal root ganglia via intercostal nerves (4, 5, 6) to release oxytocin in a pulsatile fashion

Secreted by posterior pituitary gland Causes contraction of myoepithelial

cells that line the ducts of the breast

Hypothalamus

Breastfeeding and Contraception

Can breastfeeding act as contraception?

Moderate contraceptive effect › Dependent on suckling intensity and

frequency› Equivalent to OCP (98%) only in

amenorrheic women who exclusively breastfeed at regular intervals for first 6 months

› With menstruation or after 6 months, chance of ovulation increases

› Supplemental feeding increases chance of ovulation

Other contraceptives and effect on breastfeeding

Intrauterine contraception› Does not affect milk volume or composition

Progestin-only contraceptives› Historically preferred method of hormonal

contraception› Does not affect milk volume or composition

Estrogen-progestin contraceptives› Traditionally thought to suppress milk

production› Recent study shows no effect on

breastfeeding duration or infant growth

Breastfeeding and Contraception

Double-blind RCT examining the effect of progestin-only compared with combined hormonal contraceptive pills on rates of breastfeeding continuation

Similar breastfeeding continuation rate at 8wks, contraceptive continuation, and infant growth parameters

Benefits of Breastfeeding

Benefits of Breastfeeding - Infant Death

SIDS Infectious disease Diabetes Obesity Hypercholesterolemia Asthma Atopy Lymphoma/leukemia/ Hodgkin’s disease Cognitive development

Case-control study examining association between breastfeeding and postneonatal death, N=1204

Ever breastfed, OR 0.79 Longer breastfeeding associated with lower

risk Decreased incidence of infectious cause

(OR 0.76), injury (OR 0.59), and SIDS (0.84)

Benefits of Breastfeeding - Maternal

Postpartum bleeding Menstrual blood loss Risk of Breast CA Risk of Ovarian CA Risk of osteoporosis and

hip fractures (post-menopausal)

Type 2 DM Postpartum depression Postpartum weight loss

Benefits of Breastfeeding - Community

Annual healthcare costs in United States

Cost for public health programs, i.e. WIC

Parental employee absenteeism

Environmental burden

Contraindications to Breastfeeding

Contraindications Maternal active,

untreated TB Maternal HTLV+ Maternal HIV

(developed countries)

Maternal HSV lesions on breast

Maternal exposure to radioactive materials

Mothers receiving anti-metabolites or chemotherapy

Maternal drug use Classic

galactosemia

NOT Contraindications Maternal +HepBsAg Maternal Hepatitis C Maternal seropositive CMV carriers Febrile mothers Mothers exposed to low-level

environmental chemical agents Maternal tobacco use Maternal alcohol use – wait 2

hours

Breastfeeding 101

Keys to Successful Breastfeeding The sooner, the

better Relaxed and

supportive environment

Father’s assistance and support

Keys to Successful Breastfeeding

Positioning the infant› Cradle hold (most common) › Football hold

Keys to Successful Breastfeeding Presenting the

breast› Hand positions:

C-hold or palmar grasp

Scissor grasp› Ensure nipple is

not tipped upward

Keys to Successful Breastfeeding Achieving latch-

on› Suck-swallow

pattern› Bring nipple

towards infant’s mouth

Keys to Successful Breastfeeding Timing

› 8-12 times a day during the first 4-5 days

› Unrestricted breastfeeding based on infant’s demand

Problems and Troubleshooting

Insufficient milk supply

Solutions:› Frequent breastfeeding every 1.5-2

hours during the first few days › Galactogogues (milk production

enhancers): Herbal: fenugreek, fennel seeds, milk thistle,

goat’s rue Medical: Reglan, Domperidone

Breast Engorgement

Solutions:› Frequent breastfeeding› Manual expression, breast massage› Cool compresses or ice (to relieve pain)› Frequent warm showers (to express milk)› Mild analgesics› Manual or electric pumping› +/- Cabbage leaves (to relieve pain)

Nipple pain

Sore nipples: due to improper latching› Encourage mother to place areola/nipple

in infant’s mouth Cracked nipples

› Begin breastfeeding on less-affected side› Place a drop of milk on each nipple and

allow to air-dry after breastfeeding› High-grade lanolin or nipple shields› Avoid coarse fabric, bras w/ seams

Mastitis More common in

engorged breasts Presents with flu-like

symptoms Most common

pathogens: S. aureus, streptococcus, E. coli

Treatment: ibuprofen, dicloxacillin, cephalexin, clindamycin

Continue to breastfeed while taking antibiotics

Frequent emptying

Breast Abscess Rare – incidence of 0.1% Requires incision and drainage, antibiotics Pump affected side Continue to breastfeed on unaffected side

References Centers for Disease and Control, Breastfeeding Report Card – United States, 2010.

http://www.cdc.gov/breastfeeding/data/reportcard.htm. Accessed March 13, 2011. Chen A, Roga, WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics

2004; 113:5 e435-e439. Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding:

an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008 Oct 21;149(8):565-82.

Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects. Obstet Gynecol. 2007 Feb;109(2 Pt 1):479-80.

Dewey KG, Heinig MJ, Nommsen LA. Maternal weight-loss patterns during prolonged lactation. Am J Clin Nutr. 1993 Aug;58(2):162-6.

Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, Eidelman AI; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005 Feb;115(2):496-506.

Kaunitz A. Postpartum and postabortion contraception. Up to Date, Inc. http://www.uptodate.com/contents/postpartum-and-postabortion-contraception?source=search_result&search=contraception+postpartum&selectedTitle=1%7E150#. Accessed Feb 8, 2012.

Merewood A, Mehta SD, Chamberlain LB, Philipp BL, Bauchner H. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics. 2005 Sep;116(3):628-34.

Speroff L, Fritz MA (2005). The Breast. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 625-633. Philadelphia: Lippincott Williams and Wilkins.

Wagner, C. Counseling the Breastfeeding Mother. Pediatrics: Cardiac Disease and Critical Care Medicine, Dec 14, 2010 .

Wagner, C. Human Milk and Lactation. Pediatrics: Cardiac Disease and Critical Care Medicine, Dec 14, 2010 .