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Recognizing When Things Are Are Things Heading South? Well, It's All About the Clues

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Investigating for Low Milk Supply Objectives Recognizing When Things are 1. Differentiate the three main categories of milk production problems. 2. List at least 3 risk factors for lactation problems in the early postpartum 3. Relate the importance of current pregnancy history to lactation capability 4. Explain the impact of infant suck on What’s going on? maternal milk production Lisa Marasco MA, IBCLC, FILCA [email protected] © 2019 ~No disclosures~ Are things Gathering good clues Start by listening to mom’s story heading south? Is there really a problem? No Reassure, educate Yes Take a detailed history Risk factors for delays Breastfeeding Management Yes Further Observations Infant assessment Well, it’s all Feeding assessment about the clues Maternal Assessment Differentiate delayed, primary and/or secondary causes Early weight loss Start Here → Is baby getting enough? >7%? >10%? Vag Lots of smaller stools OR Delivery Less often but blow-outs C-sect Once milk comes in, baby Delivery should start to gain 30- 45g/day in the first 1-2 mo Flaherman, et al. (2015). Early weight loss nomograms for exclusively breastfed newborns. Pediatrics How does baby look and act? Use day 2 weight as baseline for % loss - Noel-Weiss 2011 © Lisa Marasco 2019 1 Investigating for Low Milk Supply APPROXIMATE weight gain for babies in the 25th to 75th percentiles Week 1 Initially, loses up to 7-10% of birth weight (Note: weight at 24 hours may be more accurate true birth weight) Week 2 Regains to birth weight, or has started to gain 1oz (30g) per day WHO Velocity Weeks 3 & 4 Gains 8-9 oz (240-270g) per week Growth Charts Month 2 Gains 7-10 oz (210-300g) per week Month 3 Gains 5-7oz (150-210g) per week From: Riddle & Nommsen-Rivers (2017). Low milk supply and the pediatrician. Month 4 Gains 4-6 oz (120-180g) per week Curr Opin Pediatr. Month 5 Gains 3-5 oz (90-150g) per week or 12-22 oz (360-660 g) per month For full WHO velocity charts by birthweight: who.int/childgrowth/standards/w_velocity/en/ Month 6 Gains 2-4 oz (60-120g) per week or 9-18oz (270-540g) per month Months 7 & 8 Gains 7-16 oz (210-480g) per month Months 9-12 Gains 4-13oz (120-390g) per month If something is Milk at breast? wrong Weight gain/rate Oz expressed milk? Fast, slow, on target? Oz Formula? Is it Mom or is it Baby? If things really are heading south… Is baby not getting enough because mom isn’t making enough? #1: Feed the Baby Or is there enough milk but baby can’t get enough out? #2: Protect/Work on Supply Or was there enough milk but now there isn’t because baby killed off the supply? #3: Find the problem © Lisa Marasco 2019 2 Investigating for Low Milk Supply First fork in the road DELAYED ONSET: Milk in >72hrs (noticeable fullness) Happens to over 1/3 of mothers in U.S. studies! Did milk production Or did milk production → 40% of those babies lose >10% BW by day 4 struggle to get going? start off well, and then start to die later on? The first week Nommsen-Rivers 2010: “Delayed onset of lactation is epidemic; risk factors are multidimensional” Risk Factors for Delayed lactogenesis DOL Risk Factors Stress in labor (Grajeda, 2002) Long labor or Prolonged stage 2 labor Age ≥ 30 (Nommsen-Rivers, 2010) (Dewey 2003, 2001; Chen 1998) Caesarean delivery, especially unscheduled Incidental finding in bfg during pregnancy (Dewey 2003, 2001; Evans 2003) study: milk intake on Ineffective or infrequent breast emptying (Chen 1998; day 2 decreased 25g for Nommsen-Rivers 2010) each 5-year increment of maternal age Vacuum-assisted deliveries (Hall 2002) Marquis, G. S., Penny, M. E., Diaz, J. M., & Marin, R. M. (2002). Postpartum consequences of an overlap of breastfeeding and pregnancy: reduced breast milk intake and Severe bleeding (Livingstone, 1996; Willis 1995) growth during early infancy. Pediatrics, 109(4), e56. DOL Risk Factors DOL Risk Factors Obesity (Rasmussen 2001, 04, 07; Nommsen-Rivers, 2010) Big Baby (birth wt >3600g) (Nommsen-Rivers, 2010) Diabetic Pregnancy (De Bortoli 2015) Hypertension (Hall 2002) Severe pp edema “Suboptimal glucose tolerance may be HELLP (Nommsen-Rivers, 2010; Chantry 2011) a key factor in the relation between obesity and delayed onset of lactation” - Nommsen-Rivers 2016 © Lisa Marasco 2019 3 Investigating for Low Milk Supply DOL Risk Factors Retained placental tissue DOL Risk Rarer: Gestational ovarian theca-lutein cyst Factors Classical: High testosterone during pregnancy hemorrhage uterus Subtle: persistent red Lact II commences bleeding, cramping, when levels drop sufficiently passing clots Placenta accreta, increta, percreta: ↑ risk w/previous c-section, age >35, multiple Hoover & Platia (2002) Photo by Matthew Peterson MD, University of Utah, Betzhold, Hoover & Snyder (2004) pregnancy, placenta previa Health Sciences. Used with permission. DOL Risk Factors DOL Risk Factors SSRIs? Hormonal contraception first wk postpartum (Hurst 2007; Betzold 2010) From: Serotonin Transport and Metabolism in the Mammary Gland Modulates Secretory Activation and Involution J Clin Endocrinol Metab. 2010;95(2):837-846. doi:10.1210/jc.2009-1575 J Clin Endocrinol Metab | Copyright © 2010 by The Endocrine Society Mom’s early reactions… DOL Risk Factor? Failure of early removal of colostrum may Hyperemesis inhibit lactogenesis II despite normal gravidarum hormonal changes. Neville M, Morton J. Physiology and Endocrine changes underlying human lactogenesis II. Journal of Nutrition. 2001;131(11):3305S-3008S. How was it treated? Breastfeeding frequency impacts Timing/duration? the start of lactogenesis II, which in turn influences how long a Dosage? woman exclusively breastfeeds Galipeau R, Goulet C, Chagnon M. Infant and maternal factors influencing breastmilk sodium among primiparous mothers. Everett, M. (1982). Pyridoxine to Suppress Lactation. JR Coll Gen Pract, 32(242), 577-578. Breastfeed Med. Aug 2012;7:290-294. Gupta, T., & Sharma, R. (1990). An antilactogenic effect of pyridoxine. J Indian Med Assoc, 88(12), 336-337. © Lisa Marasco 2019 4 Investigating for Low Milk Supply The second fork in the road- A Did milk production Or did milk production struggle to get going? start off well, and then start to die later on? How well did mom manage breastfeeding? Rule out Maternal Management Premie management issues Problems Gestation Lack of touch Frequency of milk removal Efficiency of milk removal Stress over infant condition Pumping in lieu: Pumps aren’t perfect: Using Do not take responses hands makes a difference at face-value: Check and re-check answers How often do you pump? Day AND night? How many times in 24hrs? Morton http://newborns.stanford.edu/Breastfeeding/MaxProduction.html © Lisa Marasco 2019 5 Investigating for Low Milk Supply Pumping for work Second fork in the road- B Did milk production Or did milk production start off well, and then struggle to get going start to die later on? and never got there? How well did baby do her job? The Magic Number Pumping Equipment Mom may own the equipment, but… The Baby Drives the Supply Baby’s early feeding experiences at the breast factor into long-term production Has baby been latching well and often from the start? Baby’s early feeding experiences at the breast factor into long-term production Infant & Feeding Assessment Infant birth and health history Physical assessment Suck assessment How does mother describe baby’s feeding behavior in relation to available milk supply? Observe a feed and/or test-weighing Look What do you see and hear Consider that a problem may be multi- and when baby factorial tries to latch Listen & suck? © Lisa Marasco 2019 6 Investigating for Low Milk Supply What do we know about baby? Infant suck affects prolactin surges Zhang et al. (2016). Are Prolactin Levels Linked to Suction Pressure? Low suction pressure High infant birth weight Smaller than average surge Shorter gestational age Because it’s all about suck High maternal pre-gestational BMI Prolactin surges affect the lactation Infant suck affects milk removal curve Baseline a product of surges Poor milk removal → Influenced by frequency Residual milk → & quality of stimulation Lower persistency → PRL clearance = 180 min; Decreased milk 200-400 ng/mL >8x sustains elevation (Cox 1996) production 60-110ng/mL “Cows with a higher percentage of residual milk usually have a lower Pregnancy persistency of lactation” 8-20 ng/mL Non-lactating - Hurley 2010 Preg 0 3mo 6mo BIRTH 1 mo 2 mo 3mo 4mo 5mo 6 mo 9mo Red Flags Suck Problems: Jaw Difficult birth Receding chin (retrognathia) Livingstone, 2000 © Lisa Marasco 2019 7 Investigating for Low Milk Supply Less Common Infant Issues Soft palate cleft Cleft of Lip & hard palate Submucosal Cleft Bifid uvula Bifid uvula Photo by Catherine Watson-Genna Borderline early & premature Fatiguing The Sleepy / Lethargic / Worn Out Baby Typically symptomatic of poor milk flow May also indicate infant stress from poor muscle tone Heart problems All can inhibition of tongue mobility affect suck! infection Central Nervous System problems The self-limiting feeder Low muscle tone Photo courtesy of Diana West © Lisa Marasco 2019 8 Investigating for Low Milk Supply Red Flags Frequent choking, sputtering & pulling away Airway: Strategy for airway issues Laryngomalacia Remember that air wins over food every time Inspiratory stridor due to -Cradle hold can make it worse- prolapse of walls in larynx facilitate latching upright, with during inhalation head extension May worsen over the first few months, but usually -Paced feeding (breast/bottle) resolves by 2 yrs -Time for physiological maturation
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