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

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

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

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

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.

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

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?

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

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

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  Stress triggers: crying, feeding -Compensatory pumping as  Worse when lying on back (supine) needed  Usually does best with head hyper-extended -Galactogogues often very helpful

Red Flags: The kuk-kuk baby Red Flags: Leaking

Holds breath while swallowing

Baby not content after feed yet leaves lots of milk in breast

The Bib/Towel!

9 Investigating for Low Milk Supply

What happens if not all parts With mouth open, must be able to: of the tongue can move  Maintain extension properly and/or freely?  Elevate  Lateralize If Baby can’t suckle well, transfer is poor and  Cup milk production may suffer  Spread = a variety of movements

Assessing Suck Visual Anatomy Risk factors Digital Tongue contact Seal Tongue retracting Cupping Bunching Residual Milk Vacuum Wave No elevation At breast Tongue Mobility Ability to transfer available milk Restriction Red Flags

Red Flag: Clicking

10 Investigating for Low Milk Supply

Assessing lingual and labial frenum mobility

Tend to be thicker & partially or completely “underground”

How well does mother’s breast fit with baby’s suck/tongue issues?

Breast size Our job: Breastfeeding Small gape interventions to maximize Breast density Tongue curl back Engorgement Bunched tongue baby’s effectiveness Breast pliability blocking Bulbous areola? Tongue thrust Nipple length Tongue retractions Nipple diameter Nipple Inverted or retracting

Releases the restrictive band Positioning Usually done in office Anteriors have very adjustments Appropriate for Minimal anesthetic little blood Massage soft-tissue Speech restrictions, Posteriors may have Pathologist nerve a little more blood Occupational compressions, Improvement may Therapist traumatic birth be immediate Chiropractor Suck training Craniosacral Therapy Grooved Director

11 Investigating for Low Milk Supply

Timing may be critical

Many practitioners want to “wait and watch” BUT accumulated experience now suggests that success rate drops over time beyond 2 months Learned behavior eventually overrides the instinct to seek and Donati-Bourne et al; 2015. Tongue-tie assessment and division: a time-critical intervention to optimise breastfeeding. feed at the breast

The third fork in the road If you’ve ruled out baby…

Or did milk production How well did mom struggle despite good manage breastfeeding? Take the management and baby?? How well did baby do her job? Maternal Assessment Deeper

Detailed Maternal Assessment Previous Breastfeeding history  Previous breastfeeding history  Mother’s Reproductive history   Mother’s Health & Event history  This pregnancy history   Breast assessment   Hormonal Issues 

12 Investigating for Low Milk Supply

Reproductive Reproductive History History

 Fertility  Age of breast development  Hormonal issues  Age of menses  Breastfeeding experience of her mother, aunts, sisters, cousins  Menstrual regularity

Mat’l health & event history Current Pregnancy history  Illnesses  Breast sensitivity, changes?  Car or other accidents  Breast surgery/biopsies  Labs normal/abnormal?  Chest surgeries/wounds  Gestational diabetes?  Nipple piercings (Garbin 2009)  Total/rapid weight gain  Blunt trauma or burn wounds  Radiation therapy  Threatened premature labor?  Abscess/mastitis damage?  Milk in prior to delivery?  Spinal cord injuries  Lowered voice, virilization?  Gastric by-pass

Pregnancy & Birth complications Breast Assessment Note:  Overall symmetry Postpartum hemorrhage  Overall shape  Spacing between breasts Vaso-constricting meds such as methergine  Significant veining Possible damage to pituitary: mild  Sheehans  Fullness of each quadrant Anemia  Proportion of glandular to fatty/connective tissue  Nipple-areolar complex: Pregnancy changes? Bulbous? Overall density? Unusual nipple configuration? Pore patency?

13 Investigating for Low Milk Supply

Good veining

Good rib span

Good close spacing

PLASTIC SURGERY BREAST Rib span TYPES: VON HEIMBURG CLASS less Class I: hypoplasia lower medial quadrant Class 2: hypoplasia of both lower quadrants High inframammary with adequate areolar fold skin Class 3: hypoplasia both lower quads with limited areolar skin Class 4: hypoplasia of all quads Fig. 3. From: Hypoplastic Breast Anomalies in the Female Adolescent Breast. Classification of tuberous breast deformity (von Heimburg et al) (Reprinted with permission from von Heimburg D, Exner K, Kruft S, Lemperle G. The tuberous breast deformity: classification and treatment. Brit J Plast Surg 1996;49(6):339–345). Sebastian Winocour, et al. Semin Plast Surg. 2013 Feb;27(1):42-48.

Higher breast type # Wide spacing Flat space >1.5” © Jones & Bartlett 2000. Used with permission. Huggins, K., Petok, E., & Mireles, O. (2000). Markers of Lactation Insufficiency: A Study of 34 Mothers. Current

14 Investigating for Low Milk Supply

Lack of veining

Stretch marks w/minimal growth

Photo by Anna Swisher

Solving the riddle Is it IGT? Follow the clues Did she have enough milk in the beginning? Did mom enter pregnancy with normal appearing breast tissue? Yes No Yes No

When did it drop off, and what Did it eventually come in fully? Did her breasts appear to Are her breasts suggestive happened around then? No Yes respond well to the pregnancy? of hypoplasia? No Yes No Yes Delayed Lact 2 Check Check infant suck mgt Check breast surgeries, Any pregnancy Any history of breast Are there any other red Check for recent Check breast chest trauma, chemical infections, accidents development complications? surgeries, trauma to flags in her background exposures SGA baby? chest/breast? Severe mastitis to support possibility of ok or abscess? Nerve damage or abnormal development? (-) (-) Any significant impingements? exposure to No No Yes Likely metabolic/ chemicals at May be other hormonal issues home, job? hormonal issues

Putting it all together: Screening for hormonal problems: The Next Step?

To be continued….