LactationLaktation & Breastfeeding & Stillen ZeitschriftMagazine der of theEuropäischen European LactationLaktationsberaterinnen Consultants Alliance Allianz • www.elacta.eu • ISSNISSN 1614-807x1614-807x

COVER STORY PRACTICAL KNOW HOW PRACTICAL KNOW HOW Breastfeeding After Cosmetic Infant Hand Movements During Do Mothers Really Have The Choice th Breast Surgery – page 15 Breast Seeking – page 6 To Breastfeed? – page 10 3 • 2017 30 Volume

Foto: Field exchange 48 2 EDITORIAL

EDITORIAL Dear members, dear colleagues, dear readers,

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summer has gone, it has started raining, the wind is blow- Company Information: ELACTA European Lactation ing and leaves are falling from trees. In this ELACTA mag- Consultants Alliance azine you will find some nice issues to read about, even by www.elacta.eu authors from overseas. About situations that will come up Email: [email protected] ZVR-Nr.: 708420941 unexpectedly and are sometimes unwanted. Our profession is really important, also after hospitalization. Convince your ELACTA president: Karin Tiktak, IBCLC colleagues and other health care providers about the impor- [email protected] tant role you play as an IBCLC. Editorial and project Actually the ELACTA board is writing this editorial from coordination: Opatija in Croatia. It is a beautiful place where one of our Eva Bogensperger-Hezel, IBCLC board members lives and does her job as an IBCLC in her pri- Email: [email protected] vate practice. We have board meetings on Friday and Saturday Team: from 9 am to 5 pm. During this enjoyable time together, we Andrea Hemmelmayr, IBCLC Elke Cramer, Ärztin, IBCLC bridge the differences we experience in lactational care. Be- Kathrin Meier, IBCLC ing the president of this important association makes me feel Bärbel Waldura, IBCLC grateful and responible. Beside a laugh and a tear, we work Zsuzsa Bauer, Dr. phil Gudrun von der Ohe, Ärztin, very hard and efficiently to reach the goals we have given our- IBCLC selves. One goal we have reached is opening the registration Translations: th st of the 10 ELACTA congress in Rotterdam on 1 September. Annika Cramer, Martina Hezel, Please find your way to the website, to catch up with the latest Elizabeth Hormann, IBCLC news on this upcoming event. You are invited to register ear- Photos: © as mentioned on the ly for this conference on the amazing steamship Rotterdam. photos; Coverphoto: © Catherine German translation will be provided. Watson Genna Last but not least it is my pleasure to thank our editorial Layout: Christoph Rossmeissl team for this magazine! They have managed again to make a Published quaterly at the end professional and interesting issue! Have fun reading! of March, June, September and December Warm regards, Deadline: 15 January, 15 April, 15 July, 15 October Karin Tiktak With its articles, Lactation and Breastfeeding wants to President ELACTA go beyond expert information about breastfeeding and also stimulate discussion. Therefore, we welcome your views. Please send Letters to the Editor to the following email address: [email protected] The articles published in Lactation and Breastfeeding do not necessarily reflect the opinions of the editors or of ELACTA. Rather, they are the author’s own personal views

www.elacta.eu Lactation & Breastfeeding 3 • 2017 CONTENTS 3

Photo: © Catherine Watson Genna

Photos: © Gina Weissman

2 EDITORIAL

4 LETTERS TO THE EDITOR Jaundice Therapy: Discussion About Breastmilk Icterus And The Supplementary Feed Of Formula

6 PRACTICAL KNOW HOW Infant Hand Movements During Breast Seeking Do Mothers Really Have The Choice

Photo: © Kzenon/fotolia To Breastfeed?

13 HANDOUT Sudden Weaning –Actively Structuring a Difficult Situation

15 COVER STORY Breastfeeding After Cosmetic Breast Surgery

21 PRACTICAL KNOW HOW Dental Treatment During Breastfeeding Cerps International May 24th-28th 2017 Salzburg Austria

27 ELACTA NEWS Impressions of CERPS International Photo: © Andrea Hemmelmayr 2017 in Salzburg 4 LETTERS TO THE EDITOR

Jaundice Therapy: Discussion About Breastmilk Icterus And The Supplementary Feed Of Formula

Dear editorial team, Letter to the editor in regard to breast-fed babies have higher bilirubin the article “Hyperbilirubinaemia“ values than children fed on formula today I am writing to you because I want by Petra Schwaiger and Anke probably depends on a stronger en- to express my praise and thanks for your Prothmann, terohepathic circulation of the bibliru- magazine and in particular for your suc- Lactation and breastfeeding 2/2017 bin due to the ß-glukuronidase in the cessful and competent latest issue of L & S. bowels of the breast-fed child, which is Again you have succeeded in getting me to he subtitle of the article deals with inhibited by the protein components in read your magazine with enthusiasm even T prevention, breastfeeding manage- the formula. Reasons like the increased after having had 20 years of experience as ment and a new family-friendly thera- intake of maternal hormones that com- an IBCLC myself. What I found extremely py approach. In these days of an early petitively inhibit the Glukuronyltrans- fascinating was the article “A different way discharge of mothers and babies after ferase in the child´s liver or other in- of breastfeeding“. It sounds very consist- birth it is outstanding if the photother- hibitors of the Glukuronyltransferase, ent, logical and very much hands-on ori- apy as described by the authors would such as an elevated fat-content in the entated and encourages me in my efforts be offered more frequently and would breastmilk, an increased concentration to use none or at least as little lactation be paid for by both statutory and pri- of free fatty acids, a strikingly divergent equipment as possible because I often ex- vate health insurances in the future. composition of specific fatty acids in perience it as cumbersome and disturbing This is cheaper and also less stress- the breast milk as well as an increased and only rarely helpful for the breastfeed- ful than being sent to hospital again activity of the lipoprotein lipase and ing relationship. I also find the controver- where rooming-in is rarely possible. the stimulable lipase which is stimulat- sial discussion in the articles about the Apart from the minimization of the ed by the bile acid have been excluded use of nipple shields really interesting and enterehopathic circulation, photother- so far. helpful. It is amazing how you deal with apy the therapeutic strategy of choice Nonetheless it is argued that ac- the topic neither taking extreme points whereby the separation of mother and cording to AWMF guidelines feeding of view nor being one-sided. Although I, baby is described as the most severe formula is considered to be an optional myself, really never use nipple-shields as a side-effect in the AWMF guideline. therapy in order to break the enteroh- lactation consultant I am often confronted The importance of a successful epathic circle. This is not expicitly de- with them if mothers get in touch with me. breastfeeding management from the scribed as a therapy for icterus prolon- Thank you so much for the good job you do very beginning is illustrated very im- gatus. Generally speaking the possiblity and for this wonderful scientific magazine. pressingly. Newborns that suffer from of making good use of it exists. Yet the an elevated bilirubin value, are tired side effects should not be neglected; in Gabi Hörandner, IBCLC whereby it is unclear if they are breast- this case it would be a negative effect Schörfling, Austria fed insufficiently due to their tiredness on the microbiom of the child´s intes- or if they are tired due to their bilirubin tines with longterm effects. It is es- value. sential to exclude other reasons as the What counts is that by nursing the authors cite from the AWMF guideline. baby frequently/feeding mother´s milk With the help of good breastfeeding and a higher defecation frequency the management and photo therapy with- enterohepathic circulation is mini- out separating mother and child, feed- mised. ing formula can be marginalised. What is yet irritating is the para- graph on the so-called “breastmilk icter- Gudrun von der Ohe, us“, which is rather known as „Icterus physician and IBCLC, prolongatus“. This phenomenon that [email protected]

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Jaundice Therapy: Discussion About Breastmilk Icterus And The Supplementary Feed Of Formula

Hyperbilirubinemia – additional with certain risk factors such as a neo- of the breastfeeding this is a a much less comment natal jaundice automatically receive a intrusive measure that leaves the breast- better basic medical care because thus feeding relation intact and minimises he article was written on the the effort of additional necessary medi- the stress for mother and child. T grounds of our experiences with ba- cal treatment can be reduced. Successful Generally, all the professional groups bies that suffer from elevated bilirubin breastfeeeding without disruption can that get in touch with mother and baby values and the resulting problems and be more easily achieved for more moth- during the early stage of developing their strains for both parents and infants as er-child pairs. relationship or mother-child-relation- well as for the nursing staff. It is our aim Criteria and recommendations for ship, should work together very effec- to make our contribution in the fields of prevention and therapy of Hyperbiliru- tively and closely. prevention and successful breastfeeding binemia of the newborn can be found in From my point of view it is also es- management and thus to contribute to the AWMF guideline (2015) and in the sential that the professional exchange the relief of the strain for all parties in- ABM protocol 22 (2010). about different approaches in treatment volved. In case the bilirubin value remain el- does not disregard the experience-reality evated throughout weeks in the further of those people who do practical work To prevent irritations a further ex- course, some paediatricians often wish for newborns and their mothers under planation will be given: to confirm their diagnosis “ breastmilk difficult working conditions every day. There are two periods of time that have jaundice“ by interrupting breastfeeding Not in order to paint a positive picture to be regarded considering different as- or/and lowering the bilirubin values. If of something that does not work well. pects. First of all in the the mother has to inter- But to increase the understanding why birth clinic, risk detec- rupt breastfeeding and things work differently from what we tion, prevention and dif- must discard the expressed would all expect them to. Having a closer ferent methods of treat- milk, even if it is only for look can enable us to develop effective ment are at the centre of half a day or a day, it mas- solutions to sustainably improve the sit- attention. Later on in the sively interferes with their uation. domestic and outpatient breastfeeding relationship. sector it is mainly about It conveys the feeling to Petra Schwaiger, pediatric nurse, lacta- prolonged, mother´s milk the mother that her milk tion consultant IBCLC in private praxis, associated Icterus, which is hazardous for her child. Munich, and one of the authors of the is usually referred to as For this reason it is impor- article “breastmilk icterus“ or “ tant to initially check if the breastmilk jaundice“. bilirubin value puts the It is generally known child in danger and has to that in the daily hospital routine con- be lowered. If this question has to be an- flicts between different professional swered affirmatively there are other ways groups on the best prevention available of lowering the bilirubin values apart and the best therapy tend to occur and from disrupting breastfeeding. We have additionally there are shortages in staff already introduced the outpatient pho- due to work overload. Defined, harmo- totherapy. By a supplementary feed of DETAILS ON THE nised standards and algorithms on a about 5 ml of formula in each feed, par- SOURCES Both authors have sub- recent scientific basis can help to defuse ticularly with partially hydrolysed for- mitted detailed sources conflicts. If efficient measures are taken mula, the bilirubin value can be lowered which can be obtained as standard, also mothers and babies as well. In comparison with a disruption at [email protected] 6 PRACTICAL KNOW HOW Infant Hand Movements During Breast Seeking Catherine Watson Genna BS, IBCLC

Picture top left: Infant hugs the breast, improving neck, jaw and tongue stability and contact with mother’s trunk.

Picture top right: Tongue-tied infant pulls breast into her mouth with her fists.

Photos: © Catherine Watson Genna

Pictures below: Infant shapes his mother’s breast with his hands to bulge out the areola to facilitate latch.

nfant hand to mouth movements can Hand to mouth behaviors are associat- that the frequency of mouth opening in I be a source of frustration for new ed with swallowing during fetal life. Miller anticipation of hand contact increased mothers and health care professionals 3, in an ultrasound exploration of the de- with each week of gestation. Direct brain during early breastfeeding attempts, velopment of swallowing behavior, found stimulation in young children and adults and many restrain the baby’s hands that fetuses invariably brought their hand undergoing epilepsy surgery showed that with positioning or swaddling. There is to their orofacial area before swallowing the particular movement pattern of a clos- no doubt that hand and mouth move- amniotic fluid. Myowa-Yamakoshi 4 and ing hand approaching an opening mouth ments are linked in young infants. New- colleagues (2006) observed fetal move- is encoded in the precentral gyrus of the born infants flex their fingers (make a ments on ultrasound and found that 50% brain 6 (Desmurget, 2014). This implies fist) more often as the time since their of hand to face movements made contact that feeding related movements important last feeding (and inferentially, their with the mouth. Moreover, the majority to survival are specially encoded as a com- hunger) increases 1 (Turkewitz 1966). of fetuses began moving the hand with plete pattern so they can be more easily de- Mouthing or sucking the hand, (espe- the mouth closed, and opened the mouth ployed and require no prior learning to use. cially in combination with an unhap- as the hand approached. The researchers In adults, the intended objective of move- py facial expression) is recognized as a interpreted this as showing the fetus’ in- ments affected kinematics (organization of hunger cue by breastfeeding mothers 2 tent to bring the hand in contact with the movement in space and time) of the right (McNally et al). mouth. Reissland 5 and colleagues showed hand. The intent to place an object in the

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mouth made right hand movements more breast to better position the nipple, pull- efficient (smaller opening of the hand, less ing the breast into the mouth with both wasted movement) than grasping the same fists, and lifting the breast for better nip- objects to move them 7 (Flindall, 2014). ple access. Using positions which improve USING THIS INFORMATION IN CLINICAL So far, fetuses have not shown consistent gravitational stability (use gravity to press PRACTICE: differences between left and right hand the infant to the mother’s body) free the › Use gravity: lean mom back on a movements. babies’ arms and hands from supporting chair or sofa or in side-lying on a Infants are born with an understanding their position and allow better control of safe mattress. of how hands operate. Eye tracking tests hand movement 16 (Bertenthal & Von, › Position baby at breast with his are often used to test preverbal infants’ 1998). These semi-prone positions improve arms hugging the breast and his chin understanding of the world 8,9 (Aslin & the functioning of many feeding-related on the breast and his chest and belly against mother. McMurray, 2004; Gredebäck, Johnson, & reflexes, both infant and maternal 17 (Col- von Hofsten, 2009). Infants look longer at son, Meek & Hawdon, 2008). Bringing the › Allow the infant to use his hands to move and shape the breast to im- things that are surprising, counterintuitive, baby to breast with his arms “hugging” the prove his access to the nipple area. or physically impossible, such as a square breast can help facilitate their use of their moving unaided uphill. 24-48 hour old ba- hands to move and shape the breast while › Allow baby to suck his hand at the breast, expect him to spontaneously bies look longer at videos (but not still pic- simultaneously improving trunk contact reposition himself and latch where tures) of impossible hand movements than with mother’s body 15. Newborns may fa- the hand was touching. possible ones 10 (Longhi, 2015). tigue while trying to use their hands while › Educate mothers about these Immediately after birth, infants placed lifting their heads in completely prone infant behaviors so they can work skin to skin with their mothers initiate positions 18 (Soska & Adolph, 2014). If a with them. a series of behaviors to find and attach young infant seems to be tiring of lifting › Keep baby’s lower face or cheek in to the breast 11 (Widström, Lilja, Aal- the head, supporting them against their contact with the breast if mother’s tomaa-Michalias, Dahllöf, Lintula, & mother in a semi-upright prone or seated nipples are sore to suppress manu- Nissen, 2011). These behaviors include position may improve latching attempts. al searching. identification and massage of the ma- Newborns preferentially feel for the › If the baby returns to his hand re- ternal nipple with the infant’s hands 12 nipple area with their cheeks, lips and peatedly, either lift his upper body (Matthiesen, Ransjö-Arvidson, Nissen, & philtrum (the dent between the nose and so his face touches the breast above the nipple or bring him closer to Uvnäs-Moberg, 2001). Hand to nipple to upper lip) while drawn by the odor of the mom so his lower face touches the mouth movements seem to be an impor- areolar glands 19,20 (Varendi, Porter & breast below the nipple. tant part of this pre-feeding sequence, the Winberg, 1994; Doucet, Soussignan, more of these movements, the faster the Sagot, & Schaal, 2012). If the face falls infant latches on to the breast 11 (Wid- away from the breast, the baby brings the strom). Exogenous oxytocin given during hands to the nipple area to help identify labor suppresses the hand to nipple move- the nipple by manual touch. The face must ments and impairs the infant’s ability to remain in contact with the breast to sup- self-attach in the hour after birth 13 (Bell press manual searching, if there is room for 2013). Induction of labor with exogenous even a sheet of paper between mother and oxytocin increases the risk of abandon- infant, the baby will bring their hands to ing breastfeeding 14 (García-Fortea, P., the nipple area unless they are restrained. González-Mesa, E., Blasco, M., Cazorla, O., The baby may close his hand on the nip- Delgado-Ríos, M., & González-Valenzuela, ple or bring it right below the nipple and M. J. 2014). suck his fist. This seems to function to Even after the first attachment, in- orient the infant to the place his hand is fants use their hands to help identify the touching while calming himself for anoth- nipple and shape and move the breast to er attempt. If allowed to continue sucking help them latch 15 (Genna & Barak 2011). the fist, the infant will then move his Neonates have been observed pushing the head and hands and come back to the › 8 PRACTICAL KNOW HOW

Massage: Infant massages the contralateral nipple to stimulate milk Infant self-soothing and orienting to an optimal spot to subsequently ejection. grasp with his tongue.

› breast to attempt to latch to the area where the baby and the center of the earth allows his hand previously was touching. Very gravity to press the infant to the mother. If young babies may respond differently than the mother is not between the infant and older ones. Neonates can distinguish be- gravity’s pull, the baby can be pulled away tween self-touch when sucking their hand from the mother and lose his contact cues. and outside touch from the experimenter This can disorient and frustrate the infant. touching the corner of their mouth, and re- If the mother needs to sit upright because spond by rooting toward the experiment- of a back injury or fractured coccyx, she can er’s finger 21 (Rochat & Hespos, 1997). By be counseled to snuggle her baby in closely 4 weeks of age, the infants were more likely by hips and shoulders to aid his stability. to suppress rooting while sucking on their Babies use their hands to help them hands. Restraining the infant’s arms, cov- identify, shape and move the nipple to fa- ering their hands with mittens, or pulling cilitate latch. Allowing these normal infant their hands away when they are sucking behaviors by bringing the baby to the breast them can disorganize the baby and cause with his hands and arms surrounding it him to cry or shut down. and face to the areola under the nipple im- Occasionally, the baby gets stuck in a re- proves infant competence, unless mother’s flex loop, and returns consistently to suck- nipples are very sore can help maintain the ing his hand. In this case, lifting the baby’s baby’s organized state and maximize their upper body slightly so the cheek rests on ability to use their hands skillfully. the breast just above the nipple can allow the infant to root down to the nipple and Catherine Watson Genna attach 22 (Glover & Wiessinger). Bringing BS, IBCLC, the baby’s body and face in closer contact has been an IBCLC in private practice in New York City since 1992. She is with the mother so that the breast touches particularly interested in the scientific his face will also cause him to release his aspects of breastfeeding and human lactation and clinical application hand and orient to the breast 15 (Genna & of this knowledge to helping dyads Barak, 2011). with biomedical challenges. She is the author of Supporting Sucking If the baby is unable to locate the nip- Skills in Breastfeeding Infants ple area with their face or their hands, they (3rd edition, 2017, Jones and Bartlett Publishers) and Selecting and Using will use their arms to push away from the Breastfeeding Tools (Praeclarus breast to look for the nipple (figure). Moth- Press, 2009) as well as journal articles. In addition to lecturing to ers can interpret this behavior as unwilling- health care professionals around ness to breastfeed. Providing explanations the world, she serves as associate editor of the USLCA journal Clinical for the baby’s behavior before they occur Lactation, and collaborates in a can calm the mother and allow her to help lactation research collaborative with Columbia University & Tel Aviv her baby remain organized while searching University departments of Biomedical for the breast. Placing the mother between Engineering.

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Infant pushes off the breast to reposition himself when his arms are trapped between his body and his mother.

REFERENCES › [1] Turkewitz G, Fleischer S, Moreau T, › [8] Aslin RN, McMurray B. Automated › [15] Genna CW, Barak D. Facilitating Birch HG, Levy L. Relationship between corneal-reflection eye tracking in infancy: autonomous infant hand use during feeding condition and organization Methodological developments and breastfeeding. Clinical Lactation. 2010 of flexor-extensor movements in the applications to cognition. Infancy. 2004 Oct 1; 1(1):15-20. human neonate. Journal of comparative Oct 1; 6(2):155-63. › [16] Bertenthal B, Von Hofsten C. Eye, and physiological psychology. 1966 Jun; [9] 61(3):461. › Gredebäck G, Johnson S, von Hofsten head and trunk control: the foundation C. Eye tracking in infancy research. for manual development. Neuroscience › [2] McNally J, Hugh-Jones S, Caton S, Developmental neuropsychology. 2009 & Biobehavioral Reviews. 1998 Mar 4; Vereijken C, Weenen H, Hetherington M. Dec 16; 35(1):1-9. 22(4):515-20.

Communicating hunger and satiation [10] [17] in the first 2 years of life: a systematic › Longhi E, Senna I, Bolognini N, Bulf › Colson SD, Meek JH, Hawdon JM. Optimal positions for the release of review. Maternal & child nutrition. 2016 H, Tagliabue P, Macchi Cassia V, Turati Discrimination of biomechanically primitive neonatal reflexes stimulating Apr 1; 12(2):205-28. C. possible and impossible hand breastfeeding. Early human development. › [3] Miller JL, Sonies BC, Macedonia C. movements at birth. Child development. 2008 Jul 31; 84(7):441-9. Emergence of oropharyngeal, laryngeal 2015 Mar 1; 86(2):632-41. › [18] Soska KC, Adolph KE. Postural position and swallowing activity in the developing [11] fetal upper aerodigestive tract: an › Widström AM, Lilja G, Aaltomaa- constrains multimodal object exploration in infants. ultrasound evaluation. Early human Michalias P, Dahllöf A, Lintula M, Nissen E. Infancy. 2014 Mar 1; 19(2):138- Newborn behaviour to locate the breast development. 2003 Feb 28; 71(1):61-87. 61. when skin-to-skin: a possible method › [19] Varendi H, Porter RH, Winberg J. › [4] Myowa-Yamakoshi M, Takeshita H. Do for enabling early self-regulation. Acta Does the newborn baby find the nipple Human Fetuses Anticipate Self-Oriented paediatrica. 2011 Jan 1; 100(1):79-85. by smell? The Lancet. 1994 Oct 8; Actions? A Study by Four-Dimensional [12] (4D) Ultrasonography. Infancy. 2006 Nov 1; › Matthiesen AS, Ransjö-Arvidson AB, 344(8928):989-90. Nissen E, Uvnäs-Moberg K. Postpartum 10(3):289-301. › [20] Doucet S, Soussignan R, Sagot P, maternal oxytocin release by newborns: Schaal B. An overlooked aspect of the › [5] Reissland N, Francis B, Aydin E, effects of infant hand massage and human breast: areolar glands in relation Mason J, Schaal B. The development sucking. Birth. 2001 Mar 1; 28(1):13-9. with breastfeeding pattern, neonatal of anticipation in the fetus: A [13] longitudinal account of human fetal › Bell AF, White-Traut R, Rankin K. Fetal weight gain, and the dynamics of mouth movements in reaction to and exposure to synthetic oxytocin and lactation. Early human development. 2012 the relationship with prefeeding cues anticipation of touch. Developmental Feb 29; 88(2):119-28. within one hour postbirth. Early human psychobiology. 2014 Jul 1; 56(5):955-63. › [21] Rochat P, Hespos SJ. Differential development. 2013 Mar 31; 89(3):137-43. Response by. Early development › [6] Desmurget M, Richard N, Harquel S, Rooting [14] and Parenting. Baraduc P, Szathmari A, Mottolese C, › García-Fortea P, González-Mesa 1997; 6:105-12. E, Blasco M, Cazorla O, Delgado-Ríos Sirigu A. Neural representations of › [22] Glover R, Wiessinger D. They Can Do M, González-Valenzuela MJ. Oxytocin ethologically relevant hand/mouth It, You Can Help: Building Breastfeeding administered during labor and breast- synergies in the human precentral gyrus. Skill and Confidence in Mother and feeding: A retrospective cohort study. Proceedings of the National Academy of Helper. In Genna CW (Ed.) Supporting The Journal of Maternal-Fetal & Neonatal Sciences. 2014 Apr 15; 111(15):5718-22. Sucking Skills in Breastfeeding Infants, Medicine. 2014 Oct 1; 27(15):1598-603. › [7] Flindall JW, Gonzalez CL. Eating inter- Jones & Bartlett Publishers, Burlington, rupted: the effect of intent on hand-to- MA. 2016 Jun 20: 113. mouth actions. Journal of neurophysiology. 2014 Oct 15; 112(8):2019-25. 10 PRACTICAL KNOW HOW Do Mothers Really Have The Choice To Breastfeed? “Breastfeeding is not just about breast milk. It is a relationship.”

very mother has the right to make “unreliable,” “painful” and “potentially dan- in their training and nothing after they fin- E informed choice to bottle feed her gerous” and ultimately its importance as ish their training. Babies respond to milk baby. Then why, when a mother makes “exaggerated.” When women are prevented flow and if the flow is slow, the baby tends an informed choice to breastfeed her from breastfeeding when they wanted to to fall asleep at the breast, especially in the baby, does she not have the same right? breastfeed they become angry and trauma- first few weeks of life. And this occurs sim- Surely, I jest? Mothers can breast- tized, unable to see and experience the joy ply because most mothers are not taught feed if they want, who is to stop them? of breastfeeding and they resort to all sorts the basics of breastfeeding, (including how Often, in fact, mothers do not seem to of coping mechanisms which resurface in to get a good latch, and how to know a baby have the right to breastfeed and are forced, discussions of infant feeding. is getting milk from the breast). by health professionals, judges and child Below are just a few examples of how Furthermore, premature babies have to protective agencies to bottle feed. There we don’t allow mothers to breastfeed their compete with the flow the baby was getting are mothers who want to breastfeed and babies. They are examples of how formula from the bottle and the fact that the moth- trust the health care system to help them feeding is considered the standard way of er’s milk supply is dwindling because they continue when in fact, they are frequent- feeding and breastfeeding is seen as a dis- were pumping instead of being skin to skin ly left feeling guilty for not breastfeeding, pensable, nice but not necessary. with their babies and breastfeeding. feeling that they “failed” or feeling that they “couldn’t” breastfeed for medical rea- 1. Mothers of babies born prema- 3. Mothers of premature babies are sons. A lot of formula feeding by mothers turely are almost universally told told they must “fortify” their who had originally intended to breastfeed (at least in North America) that they milk with cow milk based “fortifier”. It is unnecessary and not medically indicat- cannot put the baby to breast until the may be true that the tiniest of premature ed. Mother’s fear of the baby starving or baby is 34 weeks gestation (still 6 weeks babies need fortification (but fortifiers can his health being compromised are used as premature). This undermines breastfeed- be made from human milk, and the need scare tactics to get mothers to consent to ing because the doctors and nurses insist for fortifiers even by these very tiny ba- formula feeding and to shake her resolve to the “babies must to learn to bottle feed bies is starting to be questioned). But what breastfeed. before they can breastfeed.” Really? Where about a 33 week gestation baby? With good If the slightest problem arises with re- does that come from? Not from any scien- help, most babies of 33 or even younger do gard to the mother or baby and their breast- tific studies. But we do know from work in not need fortifiers. They need to breast- feeding relationship, the first thing many Scandinavia that premature babies will of- feed. Not even at 31 weeks do they nec- mothers will hear from doctors is “give the ten latch on to the breast at 28 weeks and essarily need “fortified” breast milk. But baby formula” or even “stop breastfeeding sometimes even earlier than that. Not all, again with tiresome regularity, the bottle altogether.” And mothers are often forced, but at least some. And it is not rare that is introduced, and breastfeeding under- not infrequently in cases of slow weight premature babies can be exclusively and mined. gain, with a threat of the child protection completely breastfed (at the breast) by 32 services taking away the baby if they don’t to 33 weeks gestation, 1 to 2 weeks before 4. Mothers of babies born at risk for comply with “doctor’s orders”. From our we even allow the babies to try to breast- low blood sugar are often forced experience with many thousands of moth- feed in North America. (It is necessary to give or allow the baby to be given ers having come to our breastfeeding clinic to add “at the breast” because so many in formula (by bottle of course). But it is during the past 32 years, I can say that in Western societies believe that giving breast known that breast milk, especially the very many such cases, with a little good help, milk in the bottle is breastfeeding – no, it’s early milk called colostrum, is better for the mother could carry on breastfeeding not at all the same). preventing and treating low blood sugar exclusively. Unfortunately, in only a small than formula. Most often, if the mother minority of cases do the mothers actually 2. Mothers of premature babies are gets good help with breastfeeding, the baby get the help they need. Sometimes the solu- told that they must supplement is protected by breastfeeding (at the breast, tion is easy, not complicated at all. Some- with a bottle because breastfeeding is because skin to skin contact also helps pre- times it’s not so easy, but it can be done. more tiring than bottle feeding (this is vent low blood sugar). Most of the time, however, mothers are left said about babies of any age actually). feeling frustrated and devastated because It is complete rubbish to say that breast- 5. Mothers whose baby has jaundice they desired to breastfeed and due to the feeding is tiring for a baby, but it is widely in the first few days are often lack of qualified help or incorrect medical believed because most health professionals forced to supplement their babies with advice they begin to see breastfeeding as learn almost nothing about breastfeeding formula, or even take the baby off the

www.elacta.eu Lactation & Breastfeeding 3 • 2017 PRACTICAL KNOW HOW 11

breast because the health professionals professionals need to start looking at the cisions. Both father and mother could be “helping her”, think that breast milk long term effects of their interventions, accommodated in terms of spending time causes jaundice. It doesn’t. What causes not just grabbing at the quick fix which for- with the baby if the judge realized that higher than average levels of bilirubin in mula feeding seemingly offers. breastfed babies are different from bottle the majority of babies of that age is that fed babies. And breastfed toddlers are even the baby is not getting enough breast milk. 8. Mothers are told that if they have more different. Whether one agrees or not, And the answer is not formula, but rather had breast reduction surgery, the breastfed baby and toddler derives helping the mother breastfeed better and they won’t be able to breastfeed. Maybe security from the breast. As mentioned get more milk to her baby. In the first few most won’t be able to breastfeed exclusive- previously breastfeeding is not just about days, it can be so easy to turn inadequate ly, but they can still breastfeed with addi- nutrition, a notion that seems foreign to so breastfeeding around and make it work tional donated breast milk or formula as many people, including judges. well and even prevent problems in the first supplements. And the baby can be at the place. Unfortunately, too many mothers breast, without bottles, the supplement 11. In many areas the child protec- and babies are not getting that help. And given with a lactation aid at the breast. tive services are a huge problem. the worst of it all is that because the baby’s Supplementing while the baby is still on the Instead of mothers getting help to contin- jaundice decreases rapidly once the baby is breast is important because, aside from the ue breastfeeding, what the mothers usually being formula fed, this proves to the health baby getting more milk even as the baby is get is “Stop breastfeeding, give formula, or providers that they were right, that the being supplemented, but very importantly, we will apprehend your child”. breast milk caused the jaundice, when in breastfeeding is so much more than breast These 11 problems are just a few of doz- fact, the reason the jaundice decreases is milk. It is a close, intimate relationship ens of situations when mothers are unnec- that the baby now gets more milk. Could between two people who are usually very essarily told to stop breastfeeding, must this decrease have been accomplished by much in love with each other. The value of stop breastfeeding, or else. Most of the helping the mother breastfeed more effec- that relationship is not measured by how time, the problems could have been pre- tively? Yes, but it happens only rarely that much breast milk the mother can produce vented in the first place or treated without mothers get this help and the default treat- and it is important that people start seeing using formula or stopping breastfeeding. ment is formula feeding by bottle. breastfeeding in its different forms. But most of the time, the mothers do not get the help they need. 6. Mothers are told that if their ba- 9. Too many mothers are told they I am not saying that breastfeeding will bies have a cleft palate then they must interrupt or stop breast- always work, even with the best of help, cannot breastfeed and should not even feeding for medications they are tak- but a lot more mothers and babies could be bother trying. True many can’t latch on ing. This is not true except with a very few, doing a lot better. to the breast, but some can. But one thing usually infrequently used, drugs, many of If I went through all the situations is certain; if one doesn’t try, breastfeeding which can be substituted by other equally I hear about on a daily basis, situations can’t happen. effective drugs. The vast majority of drugs where mothers do not have the right to don’t get into the milk in quantities that breastfeed even though they made an in- 7. Mothers are told that if their are harmful to the baby, the amounts being formed decision to do so, I would be writ- baby loses more than 10% of their vanishingly small. There are some drugs ing something longer than War and Peace. birth weight the baby must have formu- that don’t get into the milk at all and yet Even if I just went into details regarding la by bottle. But the notion of 10% weight mothers are told they will harm their babies the 11 problems, it would take a book. loss is based on nothing scientific at all and if they continue breastfeeding. In any case, results in many babies being unnecessarily the real question is this: Which is safer for supplemented and much too often ending the baby, breastfeeding with tiny amounts up only bottle feeding. Again, the mother of drug in the milk (and the amounts are and baby getting good hands on help can almost always tiny) or formula? Given the change the situation dramatically for the risks of not breastfeeding, in the vast ma- better. . People sometimes act as if getting jority of cases, breastfeeding is safer. Jack Newman, MD, the baby fed and the baby being breastfed FRCPC were mutually exclusive things. The goal of Judges dealing with access and International Breastfeeding 10. Centre, author of Dr helping mothers should be to get the baby custody cases, do not include the Jack Newman’s Guide to fed by improving breastfeeding. Health needs of the breastfed baby in their de- Breastfeeding 12 NEWS

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Laktation & Stillen Zeitschrift der Europäischen Laktationsberaterinnen Allianz • www.elacta.eu • ISSN 1614-807x

• ISSN 1614-807x

• www.elacta.eu

Quelle: www.elacta.eu/de/ausgabe-4-2016.html AUS DER PRAXIS TITELTHEMA WISSENSCHAFT LaktationZeitschrift der Europäischen Laktationsberaterinnen &Ein Allianz schwieriger Stillen Start Das zu kurze Stillen und Kariesrisiko – mit gutem Ende – Seite 7 Zungenband – Seite 18 Seite 27 2 • 2016 28. Jahrgang

BDL – Berufs- verband Deutscher Laktations- beraterinnen IBCLC VSLS Association of South Tyrolean/ 29. Jahrgang www.bdl-stillen.de Italian Lactation Consultants/ IBCLC VSLÖ – Verband der HANDOUT 1 • 2017 Still- und Lakations- www.stillen.it beraterinnen Öster- Seite 22 WISSENSCHAFT reichs SWILACTA, Schweiz PDA und Bindungsverhalten der Mutter-Kind-Einheit – www.stillen.at AUS DER PRAXIS Seite 4 Der Gebrauch des „Power-Pumping“ – Stillhütchens –

Seite 13 Superantrieb www.elacta.eu

TITELTHEMA Ein Plädoyer für die Einweisung in die Entleerung der für die Brust per Hand im frühen Wochenbettg – Milchproduktion Bleibt Ihre Milchproduktion hinter den Erwartungen zurück? Möchten/müssen Sie Ihre Milchproduktion rasch steigern? Autorin: Andrea Hemmelmayr, IBCLC

ielleicht kann Ihr Kind (noch) nicht effektiv ge- Vnug saugen oder ist zu schwach, die Brust aus reichend zu entleeren. Vielleicht sind Sie von Ihrem Kind getrennt, weil Ihr Baby krank, zu früh geboren ist oder Sie früh wieder an Ihren Arbeitsplatz zu- rückkehren. Möglicherweise müssen Sie Milch für Mehrlinge produzieren. Oder es fehlte Ihnen bisher - die nötige kompetente Begleitung und Beratung, so- dass ein Saugproblem Ihres Kindes bisher übersehen wurde oder es standen Ihnen keine ausreichenden Informationen zum Abpumpen zur Verfügung. Zu- dem beklagen viele pumpstillende Mütter, dass rund um die 6. Lebenswoche oder in besonderen Stress situationen ihre Milchbildung zurückgehe. Das „Po- wer-Pumping“ ist als zusätzliche Stimulation der Foto: Field exchange 48 Brust gedacht, wenn das Saugen des Kindes oder andere Pump produktion nichtphasen ausreichend mit der Milchpumpe aufbauen oder die erhalMilch-- - ten können. positiv auf die Milchbildung aus. Außerdem wird die, in Das natürliche Saugverhalten eines gesunden, akti- den kurzen Pumppausen, produzierte Milch sofort ge- ven Neugeborenen sorgt dafür, dass die Milchproduktion wonnen und macht Platz für weitere Milchproduktion.Foto: © wckiw/Fotolia der Mutter optimal angeregt wird. Im Laufe des Tages (sehr häufig abends) haben die meisten Neugeborenen Normales Abpumpen von Muttermilch und „Power- oder ältere Babys, welche die Milchproduktion ihrer Pumping“: Mütter anregen müssen, Phasen von kurzen, häufigen In den ersten 7–10 Tagen (in der Zeit des Milchaufbaus) Stillepisoden, nur unterbrochen von kleinen Pausen. Das sollte eine Mutter, welche auf die Milchpumpe angewie- „Power-Pumping“ imitiert diese sogenannten „Cluster sen ist, 8–12-mal in 24 Stunden pumpen; nach dieser feeding“-Phasen des Babys. Beim „Clusterfeeding“ oder Zeit mindestens 5-mal, besser 6–8-mal täglich, um die „Power-Pumping“ sind die Pumppausen sehr kurz.Der Milchproduktion aufrechtzuerhalten. Wenn ein Kind Prolaktinspiegel (Prolaktin = milchbildendes Hormon) zumindest teilweise direkt an der Brust trinken kann, hat keine Zeit auf sein Basis-Niveau zurückzufallen, ja ergeben sich je nach Fähigkeit des Kindes entsprechend er wird sogar noch weiter angehoben und das wirkt sich - weniger Pumpphasen.

Foto: Field exchange 48 Einige dieser Pumpsitzungen könnten durch „Power- Pumping“ ersetzt oder ergänzt werden. Bitte suchen Sie jene Methode aus, die für Sie am besten durchzuführen ist. Anpassungen sind möglich und erwünscht, wichtig sind die häufigen Pumpphasen und die kleinen Pausen zwischendurch.

www.elacta.eu Lactation & Breastfeeding 3 • 2017 HANDOUT

www.elacta.eu Sudden Weaning – Actively Structuring a Diffi cult Situation

Is weaning really necessary?

› Breastfeeding strike – the baby refuses the breast: It sometimes happens that a baby – mostly in the ages between three and eight months – suddenly, out of the blue, refuses the breast. Such a breastfeeding strike mostly lasts from a few hours to a few days and can stop as suddenly as it started.

› Medication: For most illnesses, there is a range of medications. Your doctor can often choose a prepara- tion compatible with breastfeeding, which can also be taken without limitation while breastfeeding.

› Interruption of breastfeeding: Taking some medi- cations, some diagnostic methods with radioactive isotopes or other circumstances may perhaps make an interruption of breastfeeding necessary. When a temporary impairment of the mother’s milk or a temporary absence of the mother is unavoidable, this Foto: © Mikolette, iStock must not necessarily mean weaning.

f you are forced to wean quickly, you and/or your I baby are probably in a diffi cult situation. Possibly your health or the health of your baby give you cause to worry. But be cautious here: Even if, at fi rst sight, it looks to be the case, weaning is not always really necessary. Perhaps you need more information. For the moment, feed your baby with infant formula and maintain your milk production with a milk pump. In this way, you gain time to be able to make a good de- cision that works for you. HANDOUT

Even with rapid weaning, allow for Weaning without medication? some time: is ancient art of weaning is frequent- 1 23 e breasts react in the sense of supply ly forgotten today. However, it is a good and demand. Even if, at the moment, possibility to actively structure the wea- little or no milk is requested, the breast ning yourself and to avoid the side eff ects needs some time to adapt to the new situation. of medication. After the immediate post-partum phase, If you also have a few days’ time, despite an urgent the eff ectiveness of prolactin inhibitors (weaning medi- reason to wean, fi rst replace only every 3rd - or, if neces- cation) has never been demonstrated. Because milk pro- sary, every 2nd feeding with infant formula and (depend- duction is no longer so strongly controlled by hormones ing on whether the time allows for it) two to three days after a few weeks, successful use of prolactin inhibitors is later, substitute for further feedings. In between, you unlikely. Even directly after the birth, the milk can come should express or pump only as much milk as needed to in despite taking prolactin inhibitors. If you gradually ease the painful tension in the breast. A certain residual delay the breastfeeding or pumping times as described pressure reduces the milk production. and/or express less and less milk, you support the re- If you are not allowed to or don’t want to put the baby gulatory capacity of your body itself to reduce the milk to breast from now on, a pump can help. If your baby was production and reabsorb milk that has already been pro- breastfed every two hours, you can, for instance, pump duced – completely without medication. every three hours and gradually lengthen the intervals. In this way, you can avoid uncomfortable engorgement. Consolation for the baby If you pump less and less milk, milk production will grad- Abrupt weaning is mostly traumatic for ually be reduced. mother and baby. Suddenly, the familiar A hot shower can be good preparation for pumping. source of comfort, closeness and food is After pumping, cooling compresses (i.e. quark – [curds] – no longer available. ere are many other or cabbage leaves) are comforting for most women. A bra possibilities (also, if necessary, by the father or other that fi ts well can support the full breast, but should not close attachment fi gure) to off er the baby closeness, body exert uncomfortable pressure. and skin contact, i.e. carrying the baby in arms or in a Drink according to your thirst. It may make sense to baby carrier, baby massage, a bath together, singing and limit your intake of table salt because salt binds fl uid in dancing with the baby in arms, gentle rocking in a ham- the body. mock or also a pacifi er. Give your fantasy and creativity Many women report good experience with sage or free reign! peppermint tea for milk reduction. During this diffi cult time, look for help and support from an IBCLC.

Contact your IBCLC IBCLC International Board Certifi ed Lactation Consultants are the only internationally approved breastfeeding and lactation specialists having a medical background. The decision to breastfeed or not to breastfeed has short- and long-term impact on the health of child and mother. However, breastfeeding sometimes turns out to be diffi cult and perhaps professional, competent assistance is needed.

www.elacta.eu Lactation & Breastfeeding 3 • 2017 COVER STORY 15 Breastfeeding After Cosmetic Breast Surgery From Myth to Truth Author: Gina Weissman DMD, RN, IBCLC, Israel

Reduction Surgery Vertical technique – note Photos: © Gina Weissman no horizontal incision

et’s start with the bottom line: in What is hiding behind the scar? The ly in the lower quadrant, may damage the L principle, all breast surgery is like- factors that affect postoperative milk fourth intercostal nerve that plays a crucial ly to affect a woman’s ability to breast- production. role in breastfeeding and the milk ejection feed. Breast reduction surgery has more The extent of the effects of breast surgery reflex affecting the amount of milk that the of an impact than augmentation but on breast feeding depend on a few differ- baby will receive. Stretching the nerve, not lifts, augmentation and other surgeries ent factors such as, preoperative mammary just cutting it, can also impair function. may also affect a woman’s milk supply gland function; types of incisions; degree (Neifert 1992) and ability to breastfeed. The question of removal or destruction of the glandu- we should be asking however is not: if lar tissue; the extent of the nerve damage; Breast augmentation a woman is able to breastfeed after sur- time elapsed between surgery and breast- There are many reasons for breast aug- gery or not, but rather: to what extent feeding; if there were breastfeeding expe- mentation surgery, usually related to a woman will be able to breastfeed. Al- riences or attempts between the surgery the woman’s self-image and may include most every woman who has undergone and the current breastfeeding; and most things such as asymmetry which may breast surgery can produce something. importantly the way breastfeeding is con- mean surgery on a single side. When (Harris et al., 1992) ducted and the mother‘s attitude toward breast milk production is assessed, the While full and exclusive breastfeeding are breastfeeding - as with every mother. condition of the breasts before surgery is not always possible after surgery, as in any a crucial component to be considered even situation where the mother’s milk supply Types of incisions before examining the effect of surgery. Al- is insufficient to meet the baby’s needs, The location, nature, and length of the inci- though a small breast does not necessarily the mother can often partially breastfeed sions in the surgery may affect breast feed- predict difficulty in breastfeeding, there and supplement with formula. Thus, both ing/milk production due to the damage to are certain breast structures that may in- mother and baby benefit from the breast- the glandular tissue and areolar nerves. An dicate difficulty in producing milk. feeding experience. incision near or above the areola, especial- Lack of breast tissue (­hypoplasia), › 16 COVER STORY

Photo 1: Augmentation with the PeriAreolar technique. Silicone leak-causing capsular contracture

› cone-shaped breasts, breasts very far Silicon and its implications on breast- attributed to the localized pressure of the apart; Lack of development or asymme- feeding implants which reduces the blood supply try. Women who choose augmentation In recent years, concerns have been raised that tumors need to thrive or perhaps the in these cases usually receive informa- about the transference of silicon to the body’s immune system’s response to im- tion that they lack breast tissue or that milk. The silicone used in modern implants plants reduces the risk of developing cancer enlargement may harm breastfeeding. In is a high viscosity silicone gel, this signifi- in the region. (Breast Implant Surveillance addition, they are sometimes mistaken- cantly reduces the risk of leakage from the Reports to the U.S. Food and Drug Admin- ly told that they can breastfeed normally implant. istration: Maternal-Child Health Problems from the breast that did not undergo sur- In 2001, the AAP Drug Committee S. Lori Brown, Joan Ferlo Todd, Judith gery. (Didie and Sarwer 2003) determined: „The levels of silicone in the U. Cope & Hari Cheryl Sachs) There are various implant insertion blood and milk of breastfeeding women methods designed to reduce scars and with silicone implants are similar to those Breast reduction surgery create a natural appearance. The fold of in milk of women without implants (Sem- There are many physical and psychological the breast is the most common position, ple et al., 1998). In addition, the levels of reasons that lead women with large breasts and today the implant is most often in- silicon in cow’s milk has been found to be (breast hypertrophy) to undergo breast re- serted under the muscle which allows the 10 times higher than that of the milk of duction surgery. They suffer greatly from surgeon to release the muscle without women with implants and even higher in their condition and in the end just want to damaging the mammary glands, preserv- formula.“ be like everyone else and are not necessar- ing the nerves and blood vessels of the In another study, „Silicon is found in a ily concerned with breast function and the nipple-areola complex. This is good news simplified form in the environment and it ability breastfeed in the future. The effect for mothers who want to breastfeed. (see is difficult to prevent ingestion.“ The study of surgery on breastfeeding depends on photo 1) concluded: „There is no reason why women the amount of tissue removed, the location with silicone breast implants should not of the removal and the extent of damage Revision breastfeed.“ (Berlin 1994) to the remaining tissue. There are many It is important to note that despite pre- Silicon is considered to be inert, and it methods to perform breast reduction sur- cise incision and location of the implant, is unlikely to be absorbed into the baby‘s gery and the one chosen is dependent on breast augmentation surgery revised on digestive system (Hale, 2008). From 1994- the woman‘s breast structure, surgeon‘s average every 7 years (Spears et al., 2003). 2006, the Food and Drug Administration preferences, experience and the purpose of This is often due to breast prolapse, a de- (FDA) banned the use of silicone because the surgery. Even standard methods vary sire to resize, hematomas, infections and of suspected increased risk of breast can- between surgeons, and all of them can im- other complications. (photo 1) This may cer. It later retracted the ban when it be- pair milk production. cause nerve damage, affect the milk pro- came clear that not only does silicone not The surgeries that most moderate- duction system, and reduce the chances of increase the risk of breast cancer, but may, ly affect milk production are the opera- breastfeeding. (Strom 1997, Michalopou- to some extent reduce the risk of breast tions where the nipple-areola complex is los, 2007) cancer. It is hypothesized that this can be not completely cut, but only shifted and

www.elacta.eu Lactation & Breastfeeding 3 • 2017 COVER STORY 17

Photo 2a: Reduction surgery – verticular technique 4 weeks pp; Photo 2b: Reduction Surgery Vertical technique – note no horizontal second birth, fully breastfeeding incision

the lower part of the breast attached to 0%, depending on the type of surgery per- not reach full milk supply, but with the sec- the nipple-areola complex remains intact formed. The large range reflects the lack of ond she will have more milk and perhaps (Sandsmark, M., et al 1992). (photo on page uniformity in the criteria for evaluating enough to exclusively supply the baby’s 15, photos 2a and 2b) This connection is breastfeeding. It is also important to con- needs. called a pedicle and contains ducts, nerves sider that additional health background Reinervation is the process in which and blood supply that are still attached to factors also influence success in breast- nerve cells may be regenerated and recon- their relative systems. The pedicle can be feeding. Women who undergo reductions, nected. in different areas of the breast and the scar are often also overweight, this is a risk The fourth intercostal nerve is the main position will be according to the placement factor for successful breastfeeding. They messenger to the brain from the breast, it’s of the pedicle. The use of the lower pedicle, may also suffer from hormonal effects lateral section innervates the nipple-areola which means that the blood vessels and that contribute to obesity and may affect complex and is located at around 4 o’clock nerves are in the area below the nipple-are- breastfeeding as well, such as polycys- on the left breast and 8 o’clock on the right ola complex, best preserves the ability to tic ovaries, diabetes, or hypothyroidism. breast. Its stimulation results in the release produce milk. With such a background, some difficulty of oxytocin triggering the milk ejection Other methods include: the free im- as a result of the surgery itself can even reflex and prolactin for the production of plant method in which the nipple-areola further challenge breastfeeding. milk. Regeneration of this neural-system complex is completely severed from the is an important key to milk production. breast and then re-connected; the vertical The body’s amazing repair process The degree of renewal does not depend on incision method, most common in Israel post surgery: the previous breastfeeding experience, but and the United States in recent years as Recanalization is an important physio- mainly on the location of the cut and de- it requires a shorter surgery. This is more logical phenomenon in women who have gree of damage to the nerve. aesthetic but more harmful to milk pro- undergone breast surgery. In this process, Severed nerves will regrow at a rate duction because the tissue is removed breast tissue is re-grown, cut-off milk duct of about 1 mm per month and may take from the lower part of the breast and usu- reconnects and new duct develop. The pro- 6 months to a year to regrow (Shaw et al., ally involves cutting the fourth intercostal cess is greatly enhanced as a direct result of 1997). When women show sensitivity to nerve; a Bellini cut is a cut made around breastfeeding, which encourages the milk heat and touch, it indicates a functioning the areola and then liposuction is per- production system to create new ducts. In nerve and will communicate the appro- formed, this technique is usually used for addition, branches of new ducts and fis- priate sensations to the pituitary gland minimal reductions or in addition to other sures are generated in small amounts in to produce prolactin and oxytocin. The methods. response to hormones released with each ability of the breast to function depends Many researchers have tried to deter- menstrual cycle. The more the mother has on the condition of the glands and the mine the effect of breast reduction sur- breastfed in the past, and the more cycles ducts, but the more time has passed after gery on breastfeeding, and have reached she has undergone since the surgery, the the surgery, the more it is likely for the different conclusions about the success more recanalization may occur. So, with nerves crucial for breastfeeding have of safe breastfeeding, between 70% and her first baby after the surgery she may resumed function. › 18 COVER STORY

Photo 3: Reduction surgery – Vertical technique engorgement 4 days pp, first birth.

› Breastfeeding challenges that Engorgement directly correlated with the duration of the mothers may face after breast surgery Women who have undergone breast sur- lactation period in previous births. gery tend to experience more engorge- Nipple pain: ment. If the breast produces milk and it Lack of fullness among mothers who Technique is a very important part of a is not used the cells begin the process of undergo augmentation due lack of pleasant and effective breastfeeding expe- apoptosis (degeneration) this occurs in the breast development rience for all women. All the more so for cells connected to the severed ducts. It is Postpartum mothers should to feel a women after breast surgery. It is there- important to pump to express the milk change in their breasts that will manifest as fore crucial to emphasize the importance from those cells whose ducts have not been a sense of fullness. If the mother does not of technique of a good latch to the breast cut so as not to lose this critical active tis- experience fullness in the lactogenesis 2 from the first breast feeding in order to sue mass. The faster the engorgement is re- phase, they need to be assessed by a doctor avoid nipple pain. lieved, the less it is likely to affect the func- as she may have low prolactin levels, result- Women who have undergone breast tional cells and impair milk production. It ing in insufficient prolactin to affect milk surgery may sometimes experience condi- is important to evaluate the efficiency of production. She also may not have enough tions which are rare in women who have breastfeeding and consider pumping after active mammary glands. The good news is not had surgery, such as vasospasm, which each feeding, especially in the early days. that there is usually something that can be causes the nipple to blanch after breast- Sometimes mothers experience a different done to improve this. feeding and can be accompanied by pain. degree of engorgement in each breast and Preventing any rubbing of the nipple with some will experience engorgement only in Lack of milk ejection reflex (MER): the tongue as a result of improper latch to certain areas of the breast. Absence of or partial sensation in the nipple the breast during breastfeeding may reduce After augmentation surgery, the im- may indicate nerve damage that may inter- this phenomenon. plant sometimes presses the gland, mak- fere with milk extraction and may adversely Some babies may have difficulty latch- ing it difficult to remove the lymphatic affect milk supply. Frequent breastfeeding ing and extracting milk because the nip- fluid, thus increasing engorgement. If the and extra milk extraction by manual expres- ple-areola complex may be incomplete due mother‘s breasts were relatively small be- sion and pumping with a good pump in the to surgical changes. A deep, asymmetric fore the enlargement surgery, and in ad- first few weeks will ensure that the breasts latch will increase the possibility of milk dition she experienced engorgement, she produce as many prolactin receptors as pos- flow, it is also recommended to experiment could lose quite a lot of her mammary sible, and the milk supply will reach its max- with different positions. In addition, there gland function. imum potential. (photos 4 and 5) are various techniques to help make the The engorgement experienced by most nipple more prominent when latching the women who have undergone breast reduc- Helping postoperative mothers baby to the breast, such as Dianne Wests’s tion surgery may increase from birth to to maximise their breastfeeding “Nipple Nudge” which can make it easier birth. (photo 3) This is a result of addition- potential for them. al regrowth and recanalization occurring If a mother who has undergone breast sur- with each pregnancy. Engorgement can be gery seeks help before she gives birth her

www.elacta.eu Lactation & Breastfeeding 3 • 2017 COVER STORY 19

Photo 4: Engorgement after augmentation The incision location Photo 5 Manual expression helped milk removal in the lack of MER prevented MER. due to large incision.

chances of achieving a successful breast- cess to maximise a mother’s breastfeeding to refer to sources of information and feeding experience are higher. There are ability and avoiding possible complications support for breastfeeding after breast sur- many proactive steps that she can take and such as engorgement and nipple pain. gery such as: factors that will contribute to her success › Clinics in Human Lactation: Breastfeed- such as, document breast changes in preg- Treat engorgement as quickly as pos- ing after Breast and Nipple surgeries nancy in order to predict breastfeeding sible by Diana West, IBCLC, and Dr. Elliot ability; considering birth approaches that Engorgement signals to the body that the Hirsch, MD minimize interventions; AME: Antenatal milk it has produced is not required and › The BFAR book: Defining your Own Suc- Manual Expression. this triggers the process of shutting down cess: Breastfeeding After Breast Reduc- the system and mammary glands that pro- tion Surgery by Diana West, IBCLC What to do once the baby is born: duced it, apoptosis. In the case of a mother › www.bfar.org › Early and frequent extraction of milk with many branches of mammary glands from the breast the shutting down of a few of them may Unless the duct in nipple-areola complex not affect her breastfeeding experience are completely severed by the free implant in any significant way. In a postoperative method, it is reasonable to assume that a mother who is likely to have fewer func- mother who has undergone breast surgery tioning branches of mammary glands it is can provide at least a little colostrum for critical to avoid engorgement as the loss of her baby in the first few days. As with all even a few could greatly reduce her ability new mothers the first hour and then the to produce milk. first 24 hours can have a huge effect on the amount of milk produced. The Parker Monitor Study shows that mothers who breastfeed It is very important to monitor the baby’s or express milk in the first hour and then stool and urine output and weight. It is breastfeed or express at frequent intervals possible that in the first few days the baby in the first 24 hours have significantly will gain weight well and will not need sup- more milk 2-3 days later when lactogen- plementation, but later weight gain may be esis 2 occurs. reversed and it will be necessary to reevalu- ate the need for formula supplements. Ensure Effective Technique An effective latch is an important part of Support any comfortable and successful breast- Studies have shown the importance of a Gina Weissman, feeding experience - for the postoperative supportive medical staff with knowledge DMD, RN, IBCLC IBCLC since 1999; Doctor mother even more so. Ensuring an effec- of successful breastfeeding after breast of medical Dentistry (DMD), tive latch is an important part of the pro- surgery. In addition, it is recommended Registered Nurse 20 COVER STORY

› RESOURCES › Silicone Breast Implants and Breast- › Clinical Results in 87 Patients Treated for Feeding CHESTON M. BERLIN, JR, Asymmetrical Breasts: A follow-up study Pediatrics October 1994, VOLUME 94 / Morten Sandsmark, Petter Frode Amland, ISSUE 4 Frode Samdal, Knut Skolleborg & Frank Åbyholm Pages 321-326 | Received 28 Feb › Breast Implant Surveillance Reports to 1992, Published online: 08 Jul 2009 the U.S. Food and Drug Administration: Maternal-Child Health Problems S. Lori › The impact of cosmetic breast implants Brown, Joan Ferlo Todd, Judith U. Cope & on breastfeeding: a systematic review Hari Cheryl Sachs and meta-analysis. The International Breastfeeding Journal. Schiff M., Algert › Factors That Influence the Decision to C.S., Ampt A., Sywak M.S. and Roberts C. Undergo Cosmetic Breast Augmentation (2014) Surgery. Elizabeth R. Didie and David B. Sarwer. Journal of Women’s Health. July › The Spontaneous Return of Sensibility in 2004, 12(3): 241-253. Breasts Reconstructed with Autologous

th Tissues. Shaw, William W. M.D.; Orringer, › Medications & Mothers’ Milk. 17 ed Jay S. M.D.; Ko, Clifford Y. M.D.; Ratto, 2017, Thomas W. Hale, Hilary E. Rowe. Linda L. M.Ed.; Mersmann, Cynthia A. › Is Breast Feeding Possible after M.S.N., R.N.C. Plastic & Reconstructive Reduction Mammaplasty?. Harris, Surgery: February 1997 Leonard .D., M.Sc.; Morris, Steven F. › Cosmetic Saline Breast Implants: A M.D., M.Sc., F.R.C.S.(C); Freiberg, Arnis Survey of Satisfaction, Breast-Feeding M.D., F.R.C.S.(C), F.A.C.S. Plastic & Experience, Cancer Screening, and Reconstructive Surgery: May 1992 Health. Strom, Sara S. Ph.D.; Baldwin, › The Effects of Breast Augmentation Bonnie J. M.D.; Sigurdson, Alice J. M.S.; Surgery on Future Ability to Lactate. Schusterman, Mark A. M.D. Plastic & Kostas Michalopoulos. The breast Journal Reconstructive Surgery: November 1997 4 January 2007 › BREASTFEEDING MEDICINE Volume › My Magical Breast: Where 10, Number 2, 2015, DOI: 10.1089/ No Breast Had Gone Before. bfm.2014.0089. S. Sullivan, C. Krueger, and Mohrbacher, N. (2016). Retrieved from M. Mueller www.nancymohrbacher.com­ › Long-Term Safety and Effectiveness › Breastfeeding after breast surgical of Style 410 Highly Cohesive Silicone procedure or breast cancer. Neifert M Breast Implants. Aesthetic Plastic NAACOG’s Clinical Issues in Perinatal and Surgery. 33, ( 3)430–436. Hedén P., Bronz Women’s Health Nursing [01 Jan 1992, G., Elberg J.J., Deraemaecker R., Murphy 3(4):673-682] D.K., Slicton A., Brenner R.J., Svarvar C., van Tetering J., van der Weij L.P. (2009 ). › Association of Timing of Initiation of Breastmilk Expression on Milk Volume › Breastfeeding and human lactation. and Timing of Lactogenesis Stage II Wambach, K., & Riordan, J. (2016). Among Mothers of Very-Low-Birth- Burlington, MA: Jones & Bartlett learning. Weight Infants L. A. Parker, Pages 336 - 343 › Increasing Your Milk – How To Make More Breast Milk. Retrieved from http:// breastfeeding.support/how-to-make- more-breast-milk Pearson-Glaze, P. (2016). › Reduced breast milk feeding subsequent to cosmetic breast augmentation surgery. Medical Journal of Australia 202 (6): 324-328. Roberts C.L., Ampt A, Algert C., Sywak M.S. and Chen J.C.(2015).

www.elacta.eu Lactation & Breastfeeding 3 • 2017 PRACTICAL KNOW HOW 21 Dental Treatment During Breastfeeding Elien Rouw, doctor and breastfeeding expert and Christina Ziegler-Zanotta, dentist in Basel respond to questions and concerns of breastfeeding mothers. Interview by Dr. phil. Dipl.-Biol. Zsuzsa Bauer

Cristina Ziegler- Zanotta, Dentist in Basel

Elien Rouw, Physician and Breastfeeding Expert

Photo: © Kzenon/fotolia

ental examinations and treatments which is occasionally recommended for Basic questions on dental treatment D are among the most frequent med- breastfeeding mothers, is questionable. and breastfeeding ical interventions while breastfeeding. The following interview covers the most Dear Dr. Ziegler, Dear Dr. Rouw: During At the same time, there is great uncer- important questions about visits to the pregnancy, maternal dental diseases tainty among breastfeeding mothers dentist while breast-feeding. can, in the worst cases, lead to a pre- about which treatments are risky and Our interview partners are den- mature birth or low birthweight of the which are not. These concerns are main- tist and breastfeeding mother, Cristina newborn. Do dental diseases during the ly focused on the substances used in the Ziegler-Zanotta in Basel and Elien Rouw, breastfeeding period also have negative course of dental treatment that might medical expert in the Arbeitsgemein- effects on the baby? reach the baby via the mother’s milk. In schaft Freier Stillgruppen (AFS) [Asso- the worst case, women forego necessary ciation of Free-Standing Breastfeeding C. Ziegler: Not as directly as in the preg- treatments or anesthetics or prema- Groups], member of the German Nation- nancy. However, attention should be paid turely - and unnecessarily - wean their al Breastfeeding Committee and Board to the fact that cavities are, simply ex- babies. Even a temporary interruption Member of the Academy of Breastfeed- pressed, an infectious illness. The ba- of breastfeeding for dental treatment, ing Medicine. bies are infected by adults with the › 22 PRACTICAL KNOW HOW

› bacteria that lead to the development of mother’s milk, are absorbed by the infant’s nancy and breastfeeding. Furthermore, it cavities by, for instance, the mother licking intestinal tract. Many of them are already depends on the individual substances. To the baby’s spoon. Furthermore, the moth- degraded in the baby’s gastrointestinal be on the safe side, one should fall back er is a model for her children and this also tract or are bound there and, therefore, are on the ordinary proven means. Here in applies to dental hygiene. If the mother has not absorbed into the baby’s bloodstream. Switzerland, the effective substance, artic- healthy teeth, takes care of them diligently Thus, many medications don’t end up in aine, is most often used for anesthesia as and goes to the dentist regularly, then her the baby’s circulatory system at all or only no noteworthy transfer into the mother’s children will have a better chance for their in minimal concentrations that are not milk is expected. For lidocaine the same teeth to remain healthy. harmful. applies. With other special substances (i.e. This means that, during breastfeeding, prilocaine) I would avoid it during breast- E. Rouw: This is how I see it too. It is two further factors must be considered: feeding. important that mothers go to the dentist The ability of the substance to pass into With the adrenaline additives, there while they are breastfeeding. This is impor- the milk as well as its absorption via the are different potencies: “normal” and tant, above all, for their own health, but intestinal system. Medications that are “forte” (stronger). I would avoid the also for that of their children. I frequently poorly absorbed into the mother’s milk, de- “forte” during pregnancy and choose the see the problem that dental appointments graded in the gastrointestinal tract or not “normal” potency. are put off due to the fear of undesirable well absorbed into the circulatory system effects on the child. However, this is prob- are not particularly problematic during E. Rouw: Adrenaline during the breast- lematic. When treatment is indicated, then breastfeeding and are, therefore, less crit- feeding period is assessed very differently it should also be carried out without delay ical than during the pregnancy. However, than during pregnancy. For adrenaline is while the mother is still breastfeeding. there are medications, which accumulate in destroyed in the intestinal tract. That is the the mother’s milk. In such cases, one must, reason it is injected and not given orally. Do the same precautionary measures naturally, be more careful. As a rule, local dental anesthetics during for medications during pregnancy apply breastfeeding are not harmful. during breastfeeding? Dental anesthesia and pain relief Local anesthetic injections, which make Which over-the-counter pain reliev- E. Rouw: No. Many medications are eval- possible pain-free treatment, contain ers can be taken for toothache during uated quite differently during breastfeed- local anesthesia and, mostly, adrenalin breastfeeding and which should be ing than they are during pregnancy. In the additives, in order to prolong the effect avoided? pregnancy, a medication goes directly from of the anesthesia. During pregnancy, the mother’s circulatory system, via the anesthetic injections are given in as C. Ziegler: Basically, during breastfeed- placenta and the umbilical cord, into the low a dose as possible in order not to ing, paracetamol, along with ibuprofen, are baby’s circulatory system. During breast- damage the fetus. Are safety measures the drugs of choice. For the usual kind of feeding, however, there are many interme- during breastfeeding, such as a lower toothache, these two agents are sufficient. diate stages. In order to affect the baby’s dosage or possibly an interruption of body, an active substance must pass, in an breastfeeding, still necessary? E. Rouw: I see it that way too. Acetylsal- initial intermediate step, from the moth- icylic acid (i.e. aspirin, Asa) is not recom- er’s bloodstream into her milk. Further- C. Ziegler: A low dosage should, in any mended as an additional over-the-counter more, not all substances contained in the case, be standard, not only during preg- medication. A single tablet is, however,

For the medication The second barrier is to reach the baby, the baby’s intestinal it must first be tract transmitted via the mother’s circulatory system to the mother’s milk. Many ingredients are only transmitted to the mother’s milk in small amounts. Others, however, concentrate in the milk.

Image: © Tigatelu, Fotolia Image: © Sebastian Kaulitzki, Fotolia

www.elacta.eu Lactation & Breastfeeding 3 • 2017 PRACTICAL KNOW HOW 23

acceptable. Other pain relievers may also Dental examinations E. Rouw: Here, I would only add that the be considered as needed. Diclofenac is also Are there any special features of diag- breastfeeding period should not be short- acceptable for brief therapy as is the rule in nostic examinations? In particular, can ened only to enable the treatment to be dental medicine. x-ray examinations be carried out while carried out earlier. If it is necessary, amal- breastfeeding? gam decontamination should be undertak- Are there concerns about the prescrip- en and the woman should continue breast- tion medications used after a tooth ex- C. Ziegler: All diagnostic examinations, feeding without any restrictions. traction or orthodontic measures, for including dental x-ray examinations can instance? be carried out while breastfeeding without Are the other materials for fillings, any problems. In dental medicine, we do crowns and bridges, such as gold, ce- E. Rouw: Most of the pain relievers that work without contrast agents, which could, ramics, resin composites and titanium are used for dental treatment can also be in fact, be a problem. Naturally, a visual ex- unproblematic while breastfeeding? used during breastfeeding. For in dental amination is no problem. medicine, medication is only used once C. Ziegler: These materials can also be or very briefly. Usually, mothers are given Materials for fillings, crowns and used while breastfeeding. There are no in- medication for a day or two. Mostly, that is bridges dications for potentially damaging effects. safe. This also applies to the opioid analge- For precautionary reasons, an amalgam sics as long as they are only used very brief- decontamination is sometimes post- Antiseptics and antibiotics ly, which is usually the case with dental poned during pregnancy until after the Controlling micro-organisms plays a treatment. It is not necessary to interrupt birth. Can an amalgam filling be put central role in dentistry in order to pre- breastfeeding. The mother can continue to in or removed while breast-feeding or vent cavities, gum inflammation and breastfeed without limitation. must the mother interrupt breastfeed- diseases in other organs. Various anti- ing or even wean beforehand? septics and antibiotics are used for this. Some women only want to take anthro- Local antiseptics (such as chlor- posophical or homeopathic medication C. Ziegler: Amalgam contains certain hexidine or cetylpyridinium chloride – even for a toothache or instead of an- metals, in particular quicksilver, which (CPC)) are used to treat gum inflamma- esthesia during treatment. Can alterna- one should better avoid during pregnancy tion. Povidone-iodine (PVI) is used for tive remedies replace the school medi- and while breastfeeding. If the removal of wound disinfection during tooth and cine analgesics and local anesthesia? amalgam is essential, there is still the pos- oral surgical interventions (i.e. when sibility of carrying this out with a coffer- a tooth must be pulled). With root ca- C. Ziegler: What we in dental medicine dam. This is a plastic cover which is placed nal treatment, strong antiseptic solu- have had good experience with – also for in the mouth to close off the mouth region tions with sodium hypochlorite, high treating pain – is hypnosis before or dur- from the throat region. In this way, it can strength chlorhexidine gluconate, per- ing dental therapy. Anxiety can be taken be ensured that the patient does not swal- oxides etc. are used. Are these substanc- away through the hypnosis and the pain low anything. However a small residual es permissible while breastfeeding? can be mitigated in this way. Also, certain risk of inhalation remains. If the removal acupuncture treatments are possible. In of the amalgam is not acutely necessary, C. Ziegler: During pregnancy and breast- follow-up care, arnica globules are said to I would wait until after the breastfeeding feeding, iodine should, in general, be avoid- support the healing process. period. ed. Otherwise: Root canal treatments are carried out with a cofferdam. In this way, having the bacteria in the saliva end up in the root canal that has already been de- contaminated can be avoided. At the same time, the cofferdam prevents swallowing No mother must the antiseptic solution. endure pain. Many pain medications are compatible with E. Rouw: Yes, iodine-containing disinfect- breastfeeding. ants should be avoided during breastfeed- ing because iodine can be concentrated in the milk. As regards the other antiseptics, I have no concerns. Even if it is swallowed, that is a one-time thing: Due to the inter- mediary steps, only very little reaches the baby’s circulatory system. ›

Image: © Sebastian Kaulitzki, Fotolia Photo: © Africa Studio, Fotolia 24 PRACTICAL KNOW HOW

› With gum infections or for periodontal in the body. Therefore, they should be giv- Pumping and discarding mother’s milk disease/periodontitis, antibiotics must en in as low a dose as possible and taken is only rarely appropriate. Sometimes an sometimes be used. Can breastfeeding as briefly as possible. But many drugs from interruption of breastfeeding must be ob- women assume that all antibiotics may this group are also acceptable, under these served until the concentration of a criti- be used for them or should they ask circumstances, both in dental medicine cal substance in the mother’s milk with a their dentists to choose alternatives and for other indications, because only a longer half-life time has gone down to a compatible with breastfeeding? very limited and non-toxic dose reaches permissible level. Through pumping, pain, the baby – due to the two intermediate engorgement and breast infections can be C. Ziegler: It is important that breast- stages. With dental treatment, short-acting avoided and the milk production main- feeding women inform their dentist so that drugs, such as lorazepam and oxazepam, tained. In dental medicine such measures s/he can choose an antibiotic compatible are used – and only once. No special safe- are, as a rule, not necessary. with breastfeeding. Not all antibiotics are ty measures must be taken. Even when the equally appropriate while breastfeeding. treatment is spread out over many weeks Bleaching the teeth with many treatment steps, the mother Peroxide is used for bleaching yellowed E. Rouw: Yes, that is true. However, most gets the benzodiazepine for only a short teeth. Can bleaching be carried out dur- antibiotics are unproblematic while breast- time each time. There is no need to inter- ing the breastfeeding period? feeding and there are a great many alterna- rupt the breastfeeding. tives should one antibiotic not be compati- The notion of pumping the milk and E. Rouw: Yes, that is no problem. ble with breastfeeding. discarding it to detoxify it, mostly does not make sense. Frequently, people assume Mouth washes Treatment of patients with dental that the breast is a closed system and that Can mothers use the conventional phobia which is in the milk can only be gotten rid mouth washes and gels for the preven- Even among breastfeeding mothers, of by expressing or pumping. But this is tion and treatment of plaque, gum in- fears of dental treatment occur. What not the case. There is a constant exchange flammation and mouth ulcers? about anti-anxiety and soothing agents, between the mother’s milk and the blood- laughing gas anesthesia and general an- stream. As soon as the concentration of a E. Rouw: Yes, of course! We should not esthesia? In particular, with the use of substance in the mother’s blood sinks, the make the life of a breastfeeding mother un- benzodiazepine one comes up against concentration in the mother’s milk also necessarily complicated. We want to ensure the recommendation that the mother sinks because substances from the milk that women breastfeed exclusively for six express enough milk before treatment are degraded and excreted via the moth- months and then continue to breastfeed, and for 10 hours after the treatment er’s bloodstream. Therefore, the concen- along with appropriate complementary express and discard her milk. What ap- tration of the drug in the milk sinks with foods, for two years and beyond in accord- proach do you advise? time even if the breast is not emptied. For ance with the WHO recommendations. But this reason, the guideline to the effect that, if we stir up anxieties and tell the mothers E. Rouw: With respect to the anesthesia, after general anesthesia, the baby can be that while breastfeeding they must not do the guideline is that the mother should put put to breast as soon as the mother is able, this and that and that this or that could the baby to breast as soon as she is able to. applies. When the mother can hold and possibly be dangerous, then must not be Benzodiazepines, which are used for calm- breastfeed her baby, then the concentra- surprised when women wean early. It is ing and reducing anxiety, are not a reason tion of the drug in the mother’s milk has well documented that premature weaning to interrupting breastfeeding. Benzodiaze- sunk so far that the anesthesia no longer entails clear health risks pines are a class of drugs which accumulate has any effect on the baby. Informing the attending dentists Should mothers also inform their den- tists that they are breastfeeding when Pumping and they receive routine treatment or only discarding the mother’s milk in the case of more complex measures is frequently (such as surgical interventions or per- recommended but is iodontal treatment)? not necessary with dental treatment. C. Ziegler: I would always inform the doctors so they can take it into consider- ation.

E. Rouw: I would only tell them for the more complex measures because otherwise we only stir up unnecessary anxiety. Pa- thologisation can lead to a mother feeling insecure so that she weans early or declines Photo: © Elke Cramer the treatment.

www.elacta.eu Lactation & Breastfeeding 3 • 2017 PRACTICAL KNOW HOW 25

Then, in the hustle and bustle of every- The German original, Arznei­ day practice, do dentists know straight mittel in Schwangerschaft und away what needs to be considered with Stillzeit, is written, updated a breastfeeding woman? and completely revised, about every five years, under the editorship of Dr. Christoph E. Rouw: No, they don’t know it. I am ab- Schaefer at the Embryonal­ solutely certain of it! Otherwise I would toxi­kologischen Beratungs­ not have received the myriad of inquiries stelle (Embryotoxicology from them. Information Center) in Berlin (www.embryotox.de) and three other colleagues in Berlin, C. Ziegler: For normal everyday practice, Dr. Horst Spielmann, Dr. Klaus breastfeeding does not mean any major Vetter and Dr. Corinna limitations: The usual local anesthetic can ­Weber-Schöndörfer. This is be used, you can x-ray, you can examine as the source which supports my statements. It is very reliable usua,l and put in the usual fillings. and far less restrictive than many other sources on medi- How and where can dentists look up cations during breastfeeding. information or get advice about how they can optimally treat breastfeeding mothers?

E. Rouw: Ideally, doctors, including den- How long does the breastfeeding tists, should have a copy of the reference period last? work, “Drugs during Pregnancy and Lac- When certain treatments are contrain- tation: Treatment Options and Risk As- dicated during breastfeeding, then the sessment”. It is available from the publish- question arises of how long the breast- er (Academic Press/Elsevier) and from the feeding period is understood to last. Dr. phil. Zsuzsa Bauer European Network of Teratology Infor- Does this depend on the maturity, on has been working for many years mation Services (ENTIS) at https://www. the age or the body weight of the baby in the biomedicalfield as well as in the field of nursing sience research entis-org.eu among other sources. or on how much mother’s milk he re- and journalism. Her recent Drug manufacturers do not conduct ceives? emphasis are publications on the promotion of breastfeeding. studies on the compatibility of medica- tions during breastfeeding because this is E. Rouw: With medicinal treatment of expensive and is not cost-effective. They the mother, the dosage that a breastfed frequently issue blanket warnings about baby receives is certainly greater when he the use of medications while breastfeeding. is still exclusively breastfed. Newborns They disregard the fact that not breast- and, in particular, premature babies are feeding or the postponement of treatment more at risk from some medications than also has side effects. In Schäfer/ Spielmann an older infant or a breastfed toddler with ACKNOWLEDGEMENTS: these aspects are also considered so that a more mature metabolism. On the other We thank both of our interview they often come to another – more de- hand, the side effects of not breast-feeding, partners, Dr. Elien Rouw (Bühl, pendable – result than other sources. an interruption of breastfeeding or even a Germany) and Dr. Christina Zielger- Apart from that, dentists can also fall single bottle with infant formula are much Zannotta (Basel, Steinvorstadt) for back on Protocol Nr. 15 “Analgesia and greater for a young baby than for a three- the time they took for this interview. Anesthesia for the Breastfeeding Mother” year old child who is already eating large A very special thanks to Alexandra Waldschmidt-Battenberg (AFS), from the Academy of Breastfeeding Med- amounts of other foods and is no longer who collected questions on dental icine, in which many questions of dental reliant on (just) breastfeeding. Fundamen- treatment and collaborated on the medicine are briefly discussed. The free tally, whether a mother breastfeeds or not development of the interview gui- online portal LactMed ® run by the U.S. should not influence when a treatment delines. Thanks as well to ­Sibylle National Library of Medicine is peer-re- takes place. Lüpold and La Leche League Swit- zerland for finding a dentist who viewed and updated monthly. It can be ac- was prepared to address this topic. cessed here: https://toxnet.nlm.nih.gov/ Dear Dr. Rouw, Dear Dr. Ziegler, Thank newtoxnet/lactmed.htm. you very much for the interview. The interviews were conducted by Zsuzsa Bauer, Ph.D. between the spring and fall of 2016. The original German was originally published under the following URL https://www.still-lexikon.de/ zahnarztbehandlungen-in-der- stillzeit › 26 ELACTA NEWS Cerps International May 24th-28th 2017 Salzburg Austria

In May of this year the biannual Cerps International was held in Salzburg Austria. Author: Janette Timmermans

Photo: © Andrea Hemmelmayr

omen from many different coun- and conversations. It made for an inclu- A perfect time away from our daily life W tries and cultural backgrounds sive learning environment and most of us getting to know women from the lactation met in the beautiful surrounds of the would say our language skills improved world and recharging our batteries while Austrian Alps. over those days. being inspired to continue our very impor- 19 Women who have the same passion Topics included: breastfeeding and tant work. for breastfeeding and lactation came to- Down Syndrome babies, lactation sup- I know that I speak on behalf of all who gether to share knowledge and stories and port in refugee camps, breastfeeding cul- attended CERPS International when I say enjoy the company of being with like-mind- tural and linguistic diversity, WHO code, we had the most amazing and fun time ed people. breastfeeding from conception to weaning, and we shared lots of laughs and all feel we Andrea Hemmelmayr organised our breastfeeding and tongue tie, laid back made new friends for life. stay in a comfortable family hotel just out breastfeeding, breastfeeding support in The organization of this event was of the city of Salzburg and we combined Egypt, breastfeeding and homeopathy. planned and delivered perfectly by Andrea learning and leisure during five wonderful The afternoons and evenings were for Hemmelmayr and we are very grateful for days. leisure and cultural activities. These includ- her dedication and commitment to the on- In the mornings after a scrumptious ed tasting the local cuisine, sightseeing going education and support of lactation breastfast we would divide into 2 groups; with a local guide, sliding down a salt mine, colleagues in Europe. the German speaking and English speak- taking a train ride up the mountain (Schaf- Please consider coming to the next ing group. However, we were very for- berg) at St. Wolfgang and having a mouth- CERPS International to be held in 2019. I tunate to have several bilingual women watering picnic lunch while absorbing the hope to see you there. amongst us who were willing and able mind-blowing view from 1800m height. to translate back and forth so that we all Other activities included walking, swim- Janette Timmermans, IBCLC enjoyed the presentations, workshops ming, dancing and shopping. The Netherlands

www.elacta.eu Lactation & Breastfeeding 3 • 2017 ELACTA NEWS 27 Cerps International May 24th-28th 2017 Salzburg Austria

ELACTA’s international board meeting – representants from Switzerland, Romania, Germany, Egypt, Austria, The Netherlands, Slovenia, Israel and Finland

learning in the green outdoors 28 ELACTA NEWS Impressions of CERPS International 2017 in Salzburg CERPS international is not a large congress; not being aware of that fact I was given one pleasant surprise after the other. Author: Sandra Gattiker

Photos: © Hemmelmayr und Alenka Benedik

s only members of ELACTA are ad- congress houses might also be located and was invited to a home-cooked lunch. A mitted to this event, I registered on the outskirts of a city. Eventually I At 2 pm our “organiser of spare-time ac- with Nicole Toffol, in order to inscribe ended up in a hotel and enquired at the tivities“ got up from her chair and said: myself as a member of “IG Swilacta“, reception in a somewhat stressed man- “I cordially welcome you to CERPS in- which represents Switzerland towards ner: “Do you incidentally know where ternational 2017 in Salzburg-Wals.“ My ELACTA. I was sent a bus schedule by the people of CERPS international are eyes were getting bigger and bigger and I the contact of ELACTA which included going to meet tonight?“ -“Well, walk looked utterly aghast and asked my Swiss all the bus connections to the venue. down the corridor and take the lift to neighbour “Is this all of us?“ The answer What an amazing service for so many the 3rd floor.“ “Yes, for the time being“ was the biggest participants (as I was still thinking). I see, I thought, so lunch is going to surprise of the day! Altogether we were 24 Andrea Hemmelmayr seemed to have be held only for those people who have participants after all. taken over the organisation of all been checked in by Geri, so I can relax, The “organiser of spare-time activities“ free time activities. What a well-man- together we will be able to find the way to Andrea abruptly took the role of the sole aged association! After a 6-hour train the congress centre. In one of the hotel leader of the whole congress. An adorable ride, now going on the scheduled bus appartments I encountered 14 ladies who organiser, guide, translator and lecturer. towards the venue, I saw with great were chatting in a lively way –“in English“. Again I would like to express a heart-felt astonishment that the surroundings I was given a warm welcome by the “or- thanks, Andrea! Four informative, inspir- were getting greener and greener. Well, ganiser of spare-time activities“ Andrea ing days full of humour were still to come

www.elacta.eu Lactation & Breastfeeding 3 • 2017 ELACTA NEWS 29

during which I had the chance of meet- ing wonderful, humorous and interesting women. Never before in my life had I been able to listen to lectures sitting comforta- bly in the lounge in the conservatory. The lecturers were genuine professionals! They were not troubled by tumbling screens or broken projectors. Lactation consultants that is what they were - being able to adapt to any kind of situation. The CERPS international meeting is worth taking part in in every respect – not only to collect CERPS- I would take part in it again at any time.

Sandra Gattiker, IBCLC Switzerland The gentle breastpump – quiet and powerful

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