One-Day Primary Care Breastfeeding Medicine Course Lecture Notes

One-Day Primary Care Breastfeeding Medicine Course Lecture Notes Table of Contents 1) The Biologic Components of Breastmilk Infant, and Maternal Risks of Not Breastfeeding 2) Prenatal Education and Support, Anatomy and Physiology of Breastfeeding 3) Positioning and Latch 4) Breastfeeding in the Immediate Postpartum Period 5) Breastfeeding Support and Management of Common Problems in the First Week Postpartum 6) Sore Nipples and Sore Breasts 7) Low Milk Production 8) Medications and Breastfeeding 9) Symptoms, Evaluation, and Management of Excessive Lactation 10) Pump Technology and Human Milk Storage 11) Weaning, Re-lactation, Induced Lactation, and Tandem Nursing

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The Biologic Components of Breastmilk • Conflict of Interest to disclose- None • Nursing credits and continuing education recognition Infant and Maternal Risks of Not points (CERPs) for IBCLE are awarded commensurate Breastfeeding with participation and complete/submission of the evaluation form. • For CMEs, please keep track of the hours you have attended, and completion of an evaluation is required

What is The Institute for the Advancement of Breastfeeding and Lactation Education (IABLE)? • Non-profit 501c3 membership organization of breastfeeding medicine and lactation educators • Mission – Create breastfeeding-knowledgeable health care institutions and community support systems • Provide a safety net for families, reduce risks, increase rates • Focus on the provision of evidence-based resources and educational courses – Breastfeeding medicine for physicians and other providers A bi-weekly blog highlighting recent important – Lactation education for allied health professionals policies, research, consensus statements – Educational tools for families- handouts, videos Lacted.org/questions/ www.lacted.org © IABLE 3 © IABLE 4

The Little Green Book of Breastfeeding Management For Physicians and other Providers 7th Edition 2020 Pocket-sized

Free

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IABLE Online Courseware for Physician/Provider Learning

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Objectives Medical Student Survey March 2015

• WHO and UNICEF have core competencies for • Recite 3 components of breastmilk that knowledge and skills during medical school provide immunologic protection from illness. • Out of 137 students surveyed: • Identify 6 infant risks of not breastfeeding. – 64% had no formal education on breastfeeding • Identify 4 maternal risks of not breastfeeding. – On a scale of 1-10, 10 being most confident: • 80% students rated themselves ‘5’ or less for ability to counsel on contraindications to breastfeeding • 68% rated themselves ‘5’ or less on ability to counsel on benefits of breastfeeding • 91% rated ‘5’ or less on comfort with assessing latch

Peptides (combinations of amino acids) Water VitaminSterols: A acetate Amino Acids: Fats:Antimicrobial Triglycerides factors: HMGF I (Human growth factor) Carbohydrates: PyridoxineSqualene hydrochloride (the building blocks of proteins) LongLeukocytes-chain polyunsaturated (white blood cells) fatty acids HMGF II Lactose ThiamineLanosterol mononitrate Alanine DocosahexaenoicPhagocytes acid (DHA) HMGF III Hormones: Corn maltodextrin Folic acidDimethylsterol Arginine ArachidonicBasophils acid (AHA) Cholecystokinin (CCK) Cortisol ONE HMO PhylloquinoneMethosterol FORMULATriiodothyronineAspartate (T3) LinoleicNeutrophils acid β-endorphins Protein: Biotin Lathosterol Clycine AlphaEoisinophils-linolenic acid (ALA) Parathyroid hormone (PTH) Thyroxine (T4) Partially hydrolyzed reducedEnzymes: VitaminDesmosterol D3 Cystine EicosapentaenoicMacrophages acid (EPA) Parathyroid hormone-related peptide (PTHrP) Thyroid stimulating hormone (TSH) (also known as thyrotropin) minerals whey proteinAmylase VitaminTriacylglycerol B12 Glutamate ConjugatedLymphocytes linoleic acid (Rumenic acid) β-defensin-1 Thyroid releasing hormone (TRH) concentrate (from cow’sArysulfatase milk) Enzyme:Cholesterol Histidine FreeB lymphocytes Fatty Acids (also known as B cells) Calcitonin Prolactin Fats: Catalase Trypsin7-dehydrocholesterol Isoleucine MonounsaturatedT lymphocytes (also fatty known acids as C cells) Gastrin Oxytocin Palm olein HistaminaseAmino Stigma acids:-and campesterol Leucine OleicsIgA acid Motilin Insulin Soybean oil Lipase Taurine7-ketocholesterol CorticosteroneLycine PalmitoleicIgA2 , IgG ,acid IgD , IgM , IgE BombesinGrowth Factors:(AKA neuromedin B) Coconut oil Lysozyme L-CarnitineSitosterol ThrombopoietinMethionine HeptadecenoicComplement C1acid NeurotensinCytokines High oleic safflowerPAF -oilacetylhydrolaseNucleotides:β-lathosterol GonadotropinPhenylalanine-releasing hormoneSaturatedComplement (GnRH) fatty C2 acids Somatostatininterleukin-1β (IL-1β) M. alpina oil (Fungal DHA)PhosphataseCytidine Vitamin 5-MP D metabolites GRH Proline StearicComplement C3 IL-2 C.cohnii oil (Algal ARA)Xanthine oxidaseDisodiumSteroid uridine hormones 5-MP Leptin (aidsSerine in regulation of foodPalmiticComplement intake) acid C4 IL-4 Minerals AntiproteasesAdenosineVitamins: 5-MP Ghrelin (aidsTaurine in regulation of foodLauricComplement intake)acid C5 IL-6 Minerals Potassium citrate a-1-antitrypsinDisodium Vitamin guanosine A 5-MP AdiponectinTheronine MyristicComplementacid C6 IL-8 Calcium Potassium phosphatea-1-antichymotrypsinSoy LecithinBeta carotene Feedback Tryptophaninhibitor of lactationPhospholipids Complement(FIL) C7 IL-10 Sodium Calcium chloride Vitamin B6 EicosanoidsTyrosine PhosphatidylcholineComplement C8 Granulocyte-colony stimulating factor (G-CSF) Potassium Tricalcium phosphate Vitamin B8 (Inositol) ProstaglandinsValine (enzymatically PhosphatidylethanolaminederivedComplement from fattyC9 acids) Macrophage-colony stimulating factor (M-CSF) Iron Sodium citrate Vitamin B12 PG-E1 Carnitine PhosphatidylinositolGlycoproteins: Mucins Platelet derived growth factors (PDGF) ZincNucleotides: Magnesium chloride Vitamin C PG-E2 LysophosphatidylcholineLactadherin Vascular endothelial growth factor (VEGF) Chloride(the structural units of RNA and DNA) Formula is Lacking Ferrous sulphate HumanVitamin DMilk PG-F2 LysophosphatidylethanolamineAlpha-lactoglobulin Hepatocyte growth factor -α (HGF-α) Phosphorus5’-Adenosine monophosphate (5”-AMP) Zinc sulphate Water Vitamin E Leukotrienes PlasmalogensAlpha-2 macroglobulin HGF-β Magnesium3’:5’-Cyclic adenosine monophosphate (3’:5’-cyclic AMP) Many Components Sodium chloride a-Tocopherol Thromboxanes SphingolipidsLewis antigens Tumor necrosis factor-α Lactose Copper5’-Cytidine monophosphate (5’-CMP) Copper sulphate Vitamin K Prostacyclins SphingomyelinRibonuclease Interferon-γ Oligosaccharides ManganeseCytidine diphosphate choline (CDP choline) Potassium iodide Whey proteinThiamine GangliosidesHaemagglutinin inhibitors Essential for Optimal Epithelial growth factor (EGF) IodineGuanosine diphosphate (UDP) Manganese sulphate Alpha-lactalbuminRiboflavin GM1Bifidus Factor Transforming growth factor-α (TGF-α) SeleniumGuanosine diphosphate - mannose Sodium selenate HAMLET (HumanNiacin Alpha - GM2Lactoferrin TGF β1 Choline3’- Uridine monophosphate (3’-UMP) Infant Immunity Vitamins: lactalbumin)Folic acid GM3Lactoperoxidase TGFSodium-β2 ascorbate Pantothenic acid Sulpher5’-Uridine monophosphate (5’-UMP) GlucosylceramideB12 binding protein Insulin-like growth factor-I (IGF-CaseinI) ChromiumUridine diphosphate (UDP) And Maturation Inositol Serum albuminBiotin GlycosphingolipidsFibronectin (also known as somatomedin C) CobaltUridine diphosphate hexose (UDPH) Choline bitartrate Non-protein nitrogens: GalactosylceramideOligosaccharides Insulin-like growth factor- II FluorineUridine diphosphate-N-acetyl-hexosamine (UDPAH) Alpha-Tocopheryl acetate Creatine Lactosylceramide(more than 150 different kinds!) Nerve growth factor (NGF) NickelUridine diphosphoglucuronic acid (UDPGA) Niacinamide Creatinine Globotriaosylceramide (GB3) 18 © IABLE 17 Erythropoietin MolybdenumSeveral more novel nucleotides of the UDP type © IABLE 18 Calcium pantothenate Urea Globoside (GB4) Riboflavin Uric acid

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HMO = Human Milk Oligosaccharides (>130) Postulated effects: Entero-Mammary Circulation of Antibodies

Predominantly sIgA

Many Bioactive Factors Have Duel Roles The Evidence- An Overview Lactoferrin • AHRQ (2007): Comprehensive review/analysis Iron of published literature, Ip et al • AAP (2012): Summarizes & updates AHRQ • WHO (2013): Systematic Reviews, Horta & Victora • Chowdhury et al (2015): Sys Review and meta-analysis maternal outcomes • Lancet BF Series Group (2016): Binds Iron, Kills Bacteria Systematic/Meta-analysis, Victora et al

Risks of Less Breastfeeding for Children • Increased mortality – NEC – SIDS • Increased Infection – GI – Respiratory – Otitis • Metabolic – Obesity – Type 1 and 2 DM • Cognition (IQ) A pregnant parent asks you whether infants who • Malignancy – Leukemia are breastfed are really any healthier than a – Lymphoma formula fed infant. What would you say? Dose Response Important- Higher Protection with Exclusivity

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Maternal Risks of 2014 Less Breastfeeding • Increased pp bleeding • Slower uterine involution • Decreased child spacing • Increased preg-related insulin resistance • Increased risk of cancer • ovarian • breast • endometrial • Increased abd (visceral) fat • Increased risk of type 2 DM • Increased risk of HBP and cardiovascular disease • Increased risk of stroke

United States Breastfeeding Calculator- http://www.usbreastfeeding.org/p/cm/ld/fid=438 © IABLE 25 © IABLE 26

Which ONE of the Following Conditions is Conclusions NOT Reduced by Breastfeeding?

• Biologic factors in breastmilk support, protect, and shape A. Childhood leukemia the infant’s immune system. B. Childhood gastroesophageal reflux • Infants who are not breastfed have a higher risk of NEC, diarrhea, lower resp infections, decreased IQ, ear C. Maternal visceral fat infections, obesity, type 1 and type 2 DM, and leukemia. • Mothers who choose to not breastfeed have a higher risk D. Maternal ovarian cancer of increased visceral fat, type 2 DM, CAD, breast cancer, ovarian cancer, hypertension, and stroke. E. Childhood obesity F. Sudden Infant Death Syndrome

A lactating parent calls you to report that they have been ill with vomiting and diarrhea for the last 2 days. They feel that they are able to keep up with fluids adequately. They are providing human milk for their 2 month old, and wonders if they should pump and dump, and give the baby formula until they feel better.

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Prenatal Education and Support Objectives Anatomy and Physiology of • Identify 2 infant health contraindications and 2 maternal health contraindications to Breastfeeding/Chestfeeding breastfeeding/chestfeeding. • Describe 3 demographic factors that increase the risk of not breastfeeding/chestfeeding. • Explain 3 ideas that can be implemented during prenatal care to educate and support pregnant parents to breastfeed/chestfeed. • Describe 3 anatomic changes associated with breast tissue differentiation during pregnancy. • Describe the role of prolactin and oxytocin in the function of the lactating breast.

Infant Illnesses Requiring More WHO, • Exclusive bfeeding until 6 mo • Add solids at 6 mo Evaluation Before Fully Breastfeeding ABM, AAFP • Nurse at least until 2 yrs • Infant galactosemia type 1 – Cannot bfeed • Exclusive bfeeding until about 6 mo • Add solids at around 6 mo • Can partially bfeed AAP • Continue for at least 1 year or as long as desired – Maple syrup urine disease – Phenylketonuria (PKU)

• Exclusive bfeeding for 6 mo ACOG • Continue for 1 year or longer

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Maternal Relative Contraindications to Centers for Disease Control 2020 Breastfeeding Breastfeeding Report Card • HIV • Herpes or shingles on nipple/breast – Milk fine from unaffected side • Active, untreated TB – Expressed milk is fine • Brucellosis • Ebola virus • A few meds, mainly chemotherapy • Most drugs of abuse

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2016 Breastfeeding Rates at 6 Months by Race/Ethnicity

Which individuals are more likely to breastfeed? Least likely?

2016 Breastfeeding Rates at 6 Months by Poverty Level 2016 Breastfeeding Rates at 6 Months by Urban/Rural Living

2016 Breastfeeding Rates at 6 Months by Marital Status 2016 Breastfeeding Rates at 6 Months by Education Level

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2016 Breastfeeding Rates at 6 Months by Maternal Age 2017 “Any and Exclusive”

Vitamin D Iron Supplementation

• AAP—400 IU per day • Not needed routinely –Ok to continue despite formula • Delayed cord clamping supplementation • Assess risk • IOM—up to 1,000 IU is considered safe – Preterm and late preterm – SGA – Illness • High iron solids at 6 mo + (11mg/day)

Anatomy and Physiology of Lactation Mammary (milk) Lines

©© IABLE2016 The 17 Milk Mob. 17 © IABLE 18

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Accessory Breast (No nipple= Hyperadenia)

Montgomery gland (or tubercle)

Anatomic Variation of Nipple Pores Inverted Nipple

Table 1. Cumulative Frequency of the Total Number of Duct Orifices in an Individual Nipple

No. of Cumulative Cumulative Frequency % orifices frequency % 13% of • 1-2 nipple 1 31 7.3 31 7.3 2 27 6.4 58 13.7 women have pores 3 47 11.1 105 24.8 4 60 14.2 165 38.9 5 60 14.2 225 53.1 70% of • 2-7 nipple 6 50 11.8 275 64.9 women have pores 7 36 8.5 311 73.3 8 37 8.7 348 82.1 9 36 8.5 384 90.6 10 16 3.8 400 94.3 • 10 or more! 11 9 2.1 409 96.5 Love, S. 17%M. and Barsky , S. H. (2004), Anatomy of the nipple and breast ducts revisited. Cancer, 101: 1947–1957. 12 7 1.7 416 98.1 doi: 10.1002/cncr.20559 Article first published online: 20 SEP 2004 13 3 0.7 419 98.8 14 2 0.5 421 99.3 Cancer, 2004 101: 1947-1957 15 1 0.2 422 99.5 17 2 0.5 424 100.0

Alveoli in a lobule Ducts

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Lactogenesis In Pregnancy

alveolus Ache and lobule grow

fat Increase in protein, Lactiferous duct lactose, Ig, Tissue Leaking growth and development STAGE 1 Lactogenesis

Prolactin Hormones Affecting Breast Growth Hormone Estrogen Progesterone Parathyroid hormone Prolactin • Increases throughout pregnancy – related protein Insulin-like Highest level at birth • Human Placental Lactogen Growth Factor Released by the anterior pituitary gland • Required for development of glandular tissue Fibroblast Growth Factor Insulin • Essential for production of milk Growth Hormone • Diurnal pattern Thyroid © IABLE 29 – Highest at 3 am © IABLE 30

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Prolactin Action can be Blunted By: Prolactin – Medications and drugs • Requires nipple – Nipple insensitivity stimulation – Pituitary trauma • Prolactin level ≠ – Insufficient demand Amount of milk – Hormonal blockage • Testosterone secreting ovarian • Increasing prolactin cyst won’t increase milk • Estrogen without breast • Progesterone emptying

Oxytocin Baseline a product of surges • The “Love Hormone” Influenced by frequency • Released by posterior pituitary via several & quality of stimulation sensory pathways PRL clearance = 180 min; • Causes milk ejection/let- 200-400 ng/mL down >8x sustains elevation (Cox 1996) • Lowers blood pressure, causes mild sedation, pain tolerance 60-110ng/mL • Tingly/tight sensation Pregnancy • Several let-downs occur

8-20 ng/mL Non-lactating during a nursing session • DMER Preg 0 3mo 6mo BIRTH 1 mo 2 mo 3mo 4mo 5mo 6 mo 9mo→

From Lisa Marasco MA IBCLC with permission © IABLE 33 © IABLE 34

What Inhibits So, What Controls the Rate of Oxytocin Release? Milk Production?

• Exact Mechanism is unclear – Stretch ➢Stress/anxiety – Concentration of bioactive factors ➢Pain • Remove it or Lose it! • Breasts are independent of each ➢Alcohol other ➢Nicotine

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Storage Capacity USPSTF 2016

The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding. (B recommendation)

AAP Baby Friendly Pediatric Office Practice 2017

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Educational Patients listen to what their doctors say… Socio-Cultural Barriers to Barriers to And do NOT say Breastfeeding Breastfeeding – Social conventions • Not nursing in public Failure of Counseling by • Bottle as the norm Medical Offices: – Lack of family/social ➢ risks of not support breastfeeding – Racial/ethnic barriers ➢ lack of educational materials • Few resources from one’s culture/race ➢ no encouragement to take a class

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Psychosocial Barriers Employment • Inconvenience Barriers • Sexuality concerns • Prioritization • Sharing feeding • Lack of support in the work place • Job stress responsibilities • Lack of compliance with the Fair Labor Standards Act on Break time for Nursing Mothers

Pediatrics 131(3) 2013 Photo by Julien Pouplard on Unsplash © IABLE 43 © IABLE 44

Lactation Medical Deterrents to Breastfeeding Challenges for Working Parents • Painful • Maternal breastfeeding depression • Low milk • Breast reduction • Childcare production • Maternal • Changes in the infant’s • Excessive milk illnesses and feeding behavior production medication • Effect on lactation

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Strategies for Prenatal Support Prenatal Toolkits

• ACOG – https://www.acog.org/About-ACOG/ACOG- Departments/Toolkits-for-Health-Care- Providers/Breastfeeding-Toolkit • Wisconsin Dept of Public Health/WIC- 15 Cards – https://www.dhs.wisconsin.gov/nutrition/breastfeeding/ed ucation.htm • Minnesota Bfeeding Coalition Prenatal Toolkit – https://mnbreastfeedingcoalition.org/prenatal-toolkit-2/ • Read-Set- Baby Carolina Global Health Institute – https://sph.unc.edu/cgbi/resources-ready-set-baby/

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Group Prenatal Classes Other Resources For Prenatal Education ACOG Committee Opinion #731 March 2018

• Other prenatal breastfeeding class • Centering Pregnancy • Online educational resources • Expect with Me – womenshealth.gov/breastfeeding/ – Llli.org • Pregnancy and Parenting Partners • Give handouts at each visit on a • Expecting and Connecting breastfeeding topic – Use from Prenatal Toolkits • Group classes as part of prenatal care increases • Give a book breastfeeding initiation and continuation rates – LLLI Womanly Art of Breastfeeding – Breastfeeding, Keep It Simple- Amy Spangler

Source: US Breastfeeding Committee

Incorporating Breastfeeding Education into Prenatal Care Breastfeeding Med 10(2) 2015 49

Verbalizing Support Initial Conversation

Identify myths Offer a prenatal Provide online resources lactation • Mothertobaby.org • Infantrisk.com consultation • NLM Lactmed • Verbalize support • Start with an open-ended conversation – How do you plan to feed your baby?

ACOG- Optimizing Support for Breastfeeding As Part of Obstetric Practice Opinion #658 2016 © IABLE 51 © IABLE 52

Prenatal Prenatal Counseling Evaluation

• Inform all pregnant • Breast history – Surgeries, masses? patients re the risks to – Aching and growth? formula feeding • Perform a prenatal breast • Avoid worry of instilling exam • Address any breast guilt concerns • No need to exert – Mention reassuring signs pressure or coercion • No need for prenatal nipple preparation

ACOG- Optimizing Support for Breastfeeding As Part of Obstetric Practice ACOG- Optimizing Support for Breastfeeding As Part of Obstetric Practice Opinion #658 2016 Opinion #658 2016 © IABLE 53 © IABLE 54

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Prenatal Explore History of Previous Breast Surgery Lactation • Reduction mammoplasty? Consultation • Augmentation mammoplasty? • History of breastfeeding problems • Prior lumpectomy or breast biopsy? – Recurrent mastitis – Low milk supply – Counsel re possible impact on lactation – Recurrent plugs – Sudden drop in supply – Pump problems • Anticipated possible breastfeeding challenges – Medications – H/o breast cancer, breast surgery – Medical illnesses, ie rheumatoid – Upcoming medical procedures postpartum

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Employment Socioeconomic Barriers Concerns

• Encourage partner/family members to join the pregnant parent for prenatal education, or for a prenatal visit • Refer to WIC if financial concerns re breastfeeding • Advocate for pts with employment barriers • Consider starting back part time • Talk to employer about accommodations • Talk to coworkers about their experiences at work • Provide back-to-work support resources

https://www.womenshealth.gov/breastfeeding/breastfeeding-home- IABLE work-and-public/breastfeeding-and-going-back-work 58

3rd Trimester Education 60 Consider Manual Expression During Labor

• Express colostrum for supplementation • Prepare parent for hospital practices prn • Document prenatal breast changes • Communicate risk factors to infant’s care provider • May aid labor process • Supportive, pre-emptive, breastfeeding guidance • Share resources for postpartum support • May have time to practice

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Impact of Mailed Formula Samples The Breastfeeding Infant Feeding Practices Study II

Friendly Office • Among 3031 dyads, 1741 (57.4%) received Environment a sample of infant formula via mail • Women most likely to receive formula by mail were wealthier, white, married, older, Source: US Breastfeeding Committee and more highly educated. • Comfortable place for parents to feed infant • Women who had stronger intentions to breastfeed were more likely to receive • Educated staff for phone triage/electronic formula messages and nurse visits • Less likely to breastfeed exclusively by 6 • Appropriate visual messages months • Support breastfeeding employees

ABM Protocol 14 Breastfeeding Friendly Physicians Office 2013 Breastfeed Med 2016 Jan-Feb; 11(1) 21-5 62 © IABLE 61

Which ONE of the Following is a Conclusions Contraindication to • Evidence indicates that educating Breastfeeding/Chestfeeding? parents, families, and office staff can A. Lactating parent positive hepatitis B surface increase breastfeeding rates. Ag • Families have medical, psychosocial and B. Lactating parent positive hepatitis C Ab employment barriers to breastfeeding C. Lactating parent with myasthenia gravis success. D. Infant galactosemia type 1 • Gift packs of formula send a negative E. A lactating parent with symptomatic breastfeeding message to families. norovirus gastroenteritis

Which one of the following is Not Which one statement is true about known to inhibit Oxytocin release? prolactin hormone during lactation?

A. The measured prolactin level predicts A. Progesterone-only mini pill milk volume B. Alcohol B. Prolactin levels are higher during C. Anxiety lactation than at the end of pregnancy D. Pain C. Prolactin’s effect in the lactating breast E. Nicotine is blunted by the estrogen-containing birth control pill D. Prolactin is responsible for milk ejection

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Positioning and Latch Objectives

• Describe and demonstrate 4 typical positions used when breastfeeding. • Explain 3 signs that a baby is latched deeply onto the breast. • Identify 1 risk of using a nipple shield, and 1 indication for the use of a nipple shield.

Positioning at the Breast is Positioning Tips for Optimal Latch KEY for:

• Deep Latch Firm, Maternal Mouth Comfort Nose to • Secure Proper Wide Maternal Comfort Alignment and Breast • Effective Milk Transfer Hold Support Open

©IABLE 3 Source: United States Breastfeeding Committee

Firm Secure Hold Proper Alignment

5 Source: USBC

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Maternal Comfort and Support Mouth Open Wide

Nose to Breast

Sitting in Lap Facing Mom; Mom is using a C-Hold

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GOOD

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Not Ideal

Ideal Latch?

Ideal Latch? Ideal Latch?

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Ideal Latch? Ideal Latch?

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Ideal positioning?

What supports would help this parent’s positioning?

©IABLE ©IABLE Source: US Breastfeeding Committee

Typical Nipple Shield Use Why Not a Nipple Shield? ➢An easy fix • Latching difficulties ➢Nipple shields might decrease • Sore Nipples prolactin o Risk of decrease in milk supply • Heavy letdown ➢Risk of insufficient milk • Improve milk transfer transfer • Premature infants ➢Need to pump after nursing ➢Does not teach nursing o ? Increase nursing challenges

Video Breastfeeding Med 5(4) 2010 p. 147-151 Breastfeeding Med 5(6)2010 © IABLE 22

Infant Needs to Reach Past Shield Safety Measures with Nipple Shield Use • Follow infant weights closely • Protect milk supply with frequent pumping • Watch milk supply closely • Gradually work on decreasing nipple shield use • Work on removing mid-feed • Intermittently try latching without it • Reduce milk supply if needed

Photo by Pop & Zebra on Unsplash

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You are seeing a lactating parent and baby on Conclusions day 5 postpartum. The parent complains that their nipples are quite sore and bleeding. What • Proper positioning and latch are essential to is the best initial intervention to help with prevent nipple trauma and optimize milk transfer. nipple trauma? • Dyads using nipple shields need to be followed closely over time to make sure that the milk production and infant weight gain are protected and supported.

You are seeing a mother 3 weeks postpartum who is A breastfeeding dyad 13 days postpartum is in your office. worried about her baby’s latch because she can still The baby didn’t latch well at 24 hours, so they were given a nipple shield. They have continued to use it regularly. The see portions of her areola during nursing. She has baby is gaining 1 oz (30g) a day, and is 2 oz (60g) below no nipple pain, and the baby is growing beautifully. birth weight. Mom’s breasts feel full when the baby is What do you advise? ready to feed. What are the risks of the nipple shield? When should you see her back? How can she stop using the nipple shield?

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Breastfeeding in the Objectives Immediate Postpartum Period • Identify 3 key hospital routines that enable breastfeeding within the first hour after birth. • Describe the physiologic triggers that lead to secretory activation. • Name 2 reasons why a newborn breastfeeding baby might have exaggerated jaundice. • Identify 2 ways to support breastfeeding when a newborn has not yet latched by the time of hospital discharge.

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BABY-FRIENDLY HOSPITAL INITIATIVE (revised 2018) Let’s look at Hospital Practice TEN STEPS TO SUCCESSFUL BREASTFEEDING Critical management procedures 1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions. 1b. Have a written infant feeding policy that is routinely communicated to staff and parents. 1c. Establish ongoing monitoring and data-management systems. 2. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding. Key clinical practices 3. Discuss the importance and management of breastfeeding with pregnant women and their families. 4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth. 5. Support mothers to initiate and maintain breastfeeding and manage common difficulties. 6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated. 7. Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day. 8. Support mothers to recognize and respond to their infants’ cues for feeding. 9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers. 10. Coordinate discharge so that parents and their infants have timely access to ongoing support 3 and care. ©IABLE Vermont Dept of Health

Early Skin-to-Skin Contact Tips For Breastfeeding - AAP 2016 Early Postpartum • Cardioresp stabilization • Decreased pain in newborn • Limit pain meds near the • Improved growth • Improved autonomic, GI, and end of labor neurobehavioral adaptation • Skin-skin right after birth • Improved thermoregulation • Prevents hypoglycemia • Encourage rooming-in • Decreased Infant crying • Increased maternal affectionate • Breastfeeding education love/touch • Staff observes feeds q shift • Decreased pp hemorrhage • Decreased maternal cortisol and • Avoid anti-lactation drugs depression • More organized breastfeeding 5 • Increased breastfeeding exclusivity AAP Pediatrics 138(3) Sept 2016 Source: The United States Breastfeeding Committee AAP Pediatrics 138(3) Sept 2016 Source: The United States Breastfeeding Committee

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Sudden Unexpected Postnatal Self-Led Latch Collapse (SUPC) • CDC- Healthy infants born at > 35 weeks, 10 min APGAR • Skin to skin awakens >6, who collapse suddenly and unexpectedly within the infant feeding reflex first postnatal week • “1st feed in 1st hour” • 2.6-19/100,000 live births • 36% in the first 2 hours of life • Organizes route to • 29% between 2-24 hours of life feeding • 24% between 24-72 hrs • 9% days 4-7 • Search->feel->root • Associated with • Baby finds the • Unsafe skin-to-skin practices nipple/areola and • Airway obstruction • Exhausted mother with inadequate supervision latches • Maternal mobile phone use

7 J Ped 2018;196:104-8 & Early Human Development 126 (2018) 28-31

COMPONENTS OF SAFE POSITIONING FOR THE Evidence for NEWBORN WHILE SKIN-TO-SKIN Rooming-In

➢ Infant’s face can be seen • Improved patient ➢ Infant’s head is in “sniffing” position satisfaction ➢ Infant’s nose and mouth are not covered • Decreased risk of ➢ Infant’s head is turned to one side abductions/switches ➢ Infant’s neck is straight, not bent • Decrease infant ➢ Infant’s shoulders and chest face mother abandonment ➢ Infant’s legs are flexed • Empowerment to ➢ Infant’s back is covered with blankets parents • Increased frequency of ➢ Mother-infant dyad is monitored continuously by staff in the delivery environ and regularly on the breastfeeding postpartum unit • Decreased ➢ When mother wants to sleep, infant is placed in hyperbilirubinemia bassinet or with another support person who is • Increased likelihood of awake and alert nursing up to 6 AAP Pediatrics 138(3) Sept 2016 months

AAP Pediatrics 138(3) Sept 2016 ©IABLE

Early Pacifier Use Meta- Lactogenesis After Birth Analysis • Pooled effect of the association between pacifier use and Exclusive breastfeeding interruption= 2.48 OR (95% CI = 2.16-2.85) • Might be a marker for breastfeeding problems

Matern Child Nutr July 2017 11 ©IABLE 12

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Key Points for Success in the First Colostrum Few Days Postpartum

• ~ 5-10ml per feed • Feedings 10-12 times a day • Requires frequent feeding • All sucking at the breast • Early weight loss is normal • Frequent, effective feeding crucial to securing the • Changes to transitional milk supply milk • Focus on baby, not visitors • No pacifiers or supplements unless medically indicated • Cracked, bleeding nipples not normal

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more milk Frequent Feeding Early Bathing Complete Emptying

Secretory Activation (30-120 hours) • AAP advises infants born to COVID+ mothers be bathed right away Decreased Frequency – Prevents skin to skin • Increased risk of poor feeding- https://pediatrics.aappublications.org/content/138/3/e20161889 less milk Engorgement or NO milk – Increases risk of hypothermia, causing fatigue and poor feeding - Poor milk transfer https://www.jognn.org/article/S0884-2175(18)30391-5/fulltext

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You are seeing a G1P1 mom and

baby in the hospital on day 4 after Edema Occurs in the Surrounding cesarean birth. She is set to go Tissues Outside of the Glands home, but notices that in the last 4 hours her breasts feel hard and painful. The infant now pops on and off the breast, and won’t sustain a latch. The baby is crying and fussy. • Days 3-5 pp She is worried re going home. • Increased blood flow What do you recommend? ©IABLE 18

3 1/4/2021

Effects of Engorgement Engorgement Infant fussiness Supplementation • Harder to latch • Sore nipples Decreased • Breast discomfort Trouble Latching Lower supply nursing freq • Reduction in milk production

Decreased Sore nipples Mom quits nursing freq

19 20

The Positive Trend in Milk Removal with Feeding The Negative Trend when Insufficient Milk is Removed During Feeding

Milk Infant Does Milk Infant Milk Milk Infant Gains Infant is Production Not Gain Infant Feeds Production Remains Infant Does Production Production Weight and sleepy/not Slows or is and Well Regulates to Strong and Not Remove Declines Increases Strength latched well Not Well Becomes Infant Needs Grows Well Milk Well Further Established Weak

21 22

Engorgement Management Medical Indications for Supplement

• Optimize latch • Hypoglycemia • Reverse Pressure Softening • Dehydration prior to latch • Delayed lactogenesis • Sandwich the breast • Day 5,>10% weight loss • Soften areola by hand expression • Severe hyperbilirubinemia • Heat to promote flow before feeding • Infant not latching • Ice/cool compresses while • Known maternal supine after feeding insufficient supply • Breast reduction • Breast massage • Breast radiation • Insufficient glandular tissue Academy of Breastfeeding Med Protocol #3 bfmed.org

4 1/4/2021

Neonatal Jaundice in 2 Types of Jaundice Related to Breastfed Infants Breastfeeding • Lack-of-adequate breastfeeding • Physiologic jaundice • Breastfed babies- 3-6x • 10-18% of fully bfed newborn lose >10% more likely to have high bw TSB compared to • Decreased glucose in gut • Glucose induces glucuronidation formula fed babies • Increased reabsorption of unconjugated • 30-40% of bfed babies bili from the gut • T bili >5 at 3-4 weeks • Breastmilk jaundice • Adequate intake of calories • Prolonged jaundice • Polymorphism of UGT1A1 Pediatrics 2014;134:e340–e345 ©IABLE

Why is Breastfeeding a Late Premies at Risk for Risk Factor for Jaundice? Kernicterus • Bilirubin undergoes glucuronidation by • Bilirubin production exceeds the ability to UGT1A1 keep it protein- bound in blood – Intestinal UGT1A1 plays a big role • Moves into extravascular spaces • Hereditary risk of hyperbili with genetic • Late preterms polymorphisms of UGT1A1 • Insufficient breastfeeding skills – Crigler-Najjar • Starvation jaundice – Gilberts • Liver immaturity • Common, UGT1A1 activity 30% of normal • Weak blood brain barrier • 3-9% of people globally • Late preterm + other risk factors • Breastfed babies with UGT1A1 underactivity • Bruising develop breastmilk jaundice • ABO incompatibility – Breastmilk suppresses UGT1A1 activity • Routinely supplement late pre-terms until • Unclear which factors they prove to be effective breastfeeders – Formula induces UGT 1A1 activity ©IABLE 27

The Newborn Who Won’t Latch Hypoglycemia AAP, WHO, NIH

• For Healthy Term Infants: • Routine BG checks are not necessary • Routine BG checks have negative consequences for breastfeeding • Healthy term infants do not develop clinically significant hypoglycemia due to limited duration or frequency of nursing

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5 1/4/2021

You are seeing the following dyad at 26 hours No Latch in the postpartum: Hospital -G1P1 healthy mother, infant born NSVD 40 weeks, no complications • Variable nursing day 1 -Nursed well within 90 minutes after birth • Improved nursing skills -Baby slept most of the last day, has not nursed since first by day 2 feeding • Hand-express colostrum -Baby was fussy last night, screamed and would not latch every 2-3 hours on day 1 -Parents wonder what to do about feeding if no latch What do you recommend? – Avoid a nipple shield – Supplement with colostrum – Keep baby skin-skin

©IABLE Source: United States Breastfeeding Committee

Sleepy/Premature Infant

• Falls asleep at the breast • Sluggish suck/swallow reflex • Often needs supplementation until nursing improves

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LPI=Great Pretenders Bottle Preference

• Limit length of feeds to 30 min • Demand feeds fine BUT no > 4 • Babies become imprinted hr gap ‘come to recognize (another animal, person, or thing) as a • Avoid excess wt loss: >3% by 24 parent or other object of habitual trust’ hrs, >7% by 48 hrs • A bottle has • Supplement w/ 5-10 cc/feed day 1, then 10-30 cc/feed – firm stimulus to palate thereafter – immediate and low resistance • Don’t overheat; safe sleep practices milk flow • Close F/U with written feeding plan

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6 1/4/2021

Low Milk Production Anatomic and Motor Problems • Baby stops latching due to frustration and hunger • Tongue Tie • Often has been given bottles or a finger feeder • Torticollis – Won’t latch on one • Supplementer at the breast helps breast • Nasal obstruction • Pain • Flat or inverted nipples • ENGORGEMENT Source: United States Breastfeeding Committee

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Skin to Skin for the Non- What are the Pros/Cons with a Nipple Shield Latching Baby In The Case of The Baby Not Latching Chest to Chest at 26 hours ?

Bobs and Pecks

Moves Down To Breast

Roots and Latches

©IABLE Breastfeeding Med 5(6)2010 © IABLE 40

No Latch by Discharge

• Hands on pumping q3 hours • Skin-skin Spoon- – Infant-led latch Feeding • Infant feeding – Spoon Feeding – Finger feeding – Cup feeding – Bottle feeding • Lactation referral • Encourage patience

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7 1/4/2021

Ideal Situations for

Cup Manual Expression feeding Tube Feeding • The first week postpartum at the Breast • Engorgement • Low milk supply • No pump available • Infrequent need • Preference • Cultural Norm

Finger Feeding

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Conclusions Help Mom Maintain • Skin to Skin and Rooming-In are key steps in Lactation During successful breastfeeding initiation. Separation • Proper management of engorgement is crucial to prevent sore nipples and loss of milk supply. • Breastfeeding should be supported during • Initiate milk expression within 1-2 hrs pp treatment of hypoglycemia and hyperbilirubinemia. • Hands- on pumping • Mother’s milk production should be protected when infants do not latch well in the first few days • Skin-to-skin when able of life. • Early licking at breast • Even if not able to fully nurse 45 ©IABLE ©IABLE

Advice on safe positioning for Skin to Skin According to the Academy of Breastfeeding Medicine immediately postpartum include all but Protocol 2014 on Neonatal Hypoglycemia, which which one? statement is FALSE: A. An asymptomatic breastfeeding baby who has a blood A. Mother should be awake and alert while holding her sugar of 32 may continue to nurse if the repeat blood baby skin to skin. sugar does not rise, even if IV glucose is being B. Keep baby uncovered, to avoid suffocation. administered. B. Routine blood sugar checks for all term healthy infants C. A trained observer should monitor mother and baby has a negative effect on breastfeeding success. while skin to skin immediately postpartum. C. A baby who has only nursed twice in the first 24 hours D. The infant’s head should be in the sniffing position. needs routine blood sugar checks. E. The infant’s legs should be flexed. D. Infants who are small for gestational age and large for gestational age should have blood sugar screening.

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8 1/4/2021

Breastfeeding Support and Management Objectives of Common Problems in • Recite 3 goals to accomplish regarding the First Week Postpartum breastfeeding support in the first week postpartum. • Describe 3 signs of adequate milk intake in the first 3 days postpartum. • List 3 interventions that support infants and breastfeeding mothers during a delay in lactation in the first week postpartum.

Hospital discharge to first clinic visit See Babies Within 24-72 Hours after Discharge • Teach parents: – How to assess a feeding • When is baby done? • – Nipple pain is NOT normal 24 hours: – Stooling, urine output – If jaundice, poor nursing, sore nipples – Anticipated weight – Primip, feeding OK, breasts are not feeling heavier yet trajectory • 48 hours: – If nursing fine, milk increasing, no jaundice, no soreness • 72 hours – If cesarean birth, nursing fine, milk in at discharge, baby’s weight loss has stabilized

Source: United States Breastfeeding© CommitteeIABLE3 © IABLE 4

Signs of Adequate Intake in the First 3 Days (Before Milk is ‘In’) Reassuring Signs of Adequate Intake After Milk ‘Comes In’ • The baby nurses every few hours • 2 stools a day • 2-3 voids a day • The baby nurses every few hours • Content between feedings • 3-4+ yellow seedy stools/day • Minimal jaundice • Breasts feel fuller • Always wet • Weight loss is not • Baby is content between feedings excessive • Breasts full before feeding, emptier after feeding • Baby begins gaining at least one ounce (30g) per day

1 1/4/2021

Step 1- Weigh the Infant and Plot on Assessing Feeding At the Breast the Growth Curve The 4 Basic Steps

Weigh the Explain Infant for Evaluate Nutritive Describe Proof of Latch and and Signs of Adequate Positioning Nonnutritive Satiation Growth Suck

Step 3- Sit with Parents to Teach Nutritive and Non-Nutritive Sucking A 6 day old healthy term newborn female is in your office for a weight check. The baby is now • Watch the infant feed on the first breast, and point out swallows 12% below birth weight. The baby is nursing for • As the infant relaxes, and there have been NO swallows for 3-4 each feeding. Mom feels that her milk supply minutes, switch infant to the other breast. No need to wait for has not ‘come in’ yet. She identifies that the the infant to unlatch on their own baby does not seem satisfied at the breast. • Point out swallows on the second side What do you recommend? • Once swallows are done for 3-4 minutes on the second side, OK to take infant off the breast • If infant is still hungry, start the process over on the first, then the second breast • Nursing on both sides twice is called Switch Nursing

Dx of Delayed Secretory Activation Delayed Lactogenesis- What • Milk is not ‘in’ to do? – By day 3 for multiparous – By day 5 for primiparous • Nurse the baby first at least 8+/24 hours • No breast fullness/heaviness –Hands-on pumping after nursing • Excessive infant weight loss –Supplement with expressed BM, donor milk or formula • Firm feeding plan, and follow closely

2 1/4/2021

Cup Feeding Finger Feeding Pros Cons Pros Cons • Does not fulfill infant’s suck • Learning curve • Avoids using a bottle • Difficult with larger volumes need – Spillage, slow • Good for small volumes • Needs coordination • Cups are easily available • Not typical in our culture • Active participation • Aspiration and cheap (shot glass) • Overwhelming task for • Cleaning • Easy to clean some • Accessibility

Advantages: Supplementer at the Breast Bottle •Familiar •Fast •Easy to clean Pros Cons •With correct bottle/positioning, can • Saves time • Clumsy, hassle promote positive behaviors • Need extra equipment • Increase breast stimulation Disadvantages: • Avoids artificial nipples • Not easily transportable •Bottle preference possible (fast flow) • Some babies refuse it •Promotes tongue thrusting to slow down fast flow • Not for sleepy babies •Most types flow with ANY mouth movement •Often mouth not open wide- baby “latches” to narrow portion •Parents may view as “giving up”

Best For: • Longer term supplementation of larger volumes

Why Paced Bottle Feeding?

Early ▪ Slows feeding to Postpartum mimic breastfeeding Concerns ▪ Prevents overfeeding ▪ Prevents propping ▪ Encourages socialization during feeding

3 1/4/2021

Baby is Up at Night, Sleepy in the Day Sleepy Baby • Most common reason in the first month for insufficient weight despite an adequate milk supply Parents report that their 8 day • “Living on the letdown” old sleeps much of the day, • Need to be woken for feedings and is hard to wake up to feed. • Will sleep all night in the first 6 weeks At 11 pm, the baby wants to nurse every hour until 3 am. What advice can you give?

Management of the Sleepy Baby Infant Feeds Too Frequently • Stimulate, undress infant • Wake the baby for feedings (not ad lib) Mom, partner, and infant are seen • Use breast compressions while nursing for the 14 day exam. Parents complain that the infant wants to • Feed on both sides twice nurse every 30 min during the day, • Often need to pump and supplement until and at night every 2 hours. They are baby is more effective at the breast exhausted. – Bottles often best method The baby is growing well, an ounce • Maternal avoidance of sedating substances a day. • Frequent follow-up for weight checks How would you evaluate this? • Tends to resolve by 3 weeks-3 months pp What can you suggest? Source: US Breastfeeding Committee • DO NOT assume that posterior tongue tie is the cause

Source: US Breastfeeding Committee © IABLE 21 © IABLE 22

Conclusions

• Early postpartum support during the first week allows the opportunity to instill breastfeeding confidence for families. • Mothers with a delay in lactation need support to protect and support breastfeeding during infant supplementation. • Many early postpartum concerns may lead to inappropriate supplementation. With proper advice, breastfeeding can be supported and protected. • The most common reason for low weight gain in the first month is infant sleepiness.

4 1/4/2021

Objectives Sore Nipples and Sore • Describe 3 common reasons for persistent sore Breasts nipples/breasts in a lactating mother. • List 3 indications to clip an infant lingual frenulum. • Discuss 2 treatment options for nipple vasospasm. • Describe 3 causes of nipple dermatitis. • List 2 interventions for a breast abscess. • Identify 3 common bacteria that are known to cause acute mastitis.

Nipple Pain Can Start Early A transgender father and infant see you at 4 days postpartum. He complains that his nipples are cracked • 11-96% of have nipple pain at some point and sore. Latch hurts quite a bit, and sometimes his • 43% with sore nipples at hospital D/C nipples are bleeding between nursing. He is not sure if he • 73-76% with sore nipples at 3 days pp, with 19- can continue to chestfeed. 26% having cracks Why are his nipples so sore? What would you do to evaluate this father and baby? What are some initial steps to help him?

Latch and Causes of Nipple/Areola Positioning Trauma Suck Vasospasm Dynamics • Mechanical nipple damage Sore – Poor latch or atypical Nipples suck and – Tongue-tie Dermatitis Breasts Trauma – Pump trauma – Bite wound • Inverted/Invaginated Nipples with lysed Infection Pregnancy adhesions

1 1/4/2021

Shallow latch Shallow Latch Can Damage Nipples QUICKLY

Engorgement? Positioning?

Cracked Nipple Moist Wound Healing Treatment • Moist wound covering based on wound • Moist Wound healing care principles • Decrease trauma • No evidence for best topical materials • Treat underlying any skin pathology • Nonstick cover • Assess for deep breast infection – Silver embedded materials • A shell for inverted nipples only if needed to – Foam materials hold edges of wound apart – Ointment/oil with nonstick pad or parchment paper • Antibacterial ointment • Medicinal honey • Coconut/olive oil • Breastmilk • No evidence for benefit with APNO

Can be very thin… Tongue Tie?

Photo: Kathy Leeper MD, IBCLC © IABLE 11 © IABLE 12

2 1/4/2021

Can Have Several Insertions Pediatric Grooved Director ~ 4 inches

Frenotomy Scissors

Photo courtesy of James Murphy, MD

Frenotomy Gauze ~ 1 minute

Indications for Clipping a Frenulum Same baby: Consensus Statement Academy of Otolaryngology-Head and Neck Surgery 2020

Before clipping After

3 1/4/2021

Indications for Clipping a Frenulum Consensus Statement Academy of Otolaryngology-Head and Neck Surgery 2020 Indications for Clipping an Upper Lip Frenulum Consensus Statement Academy of Otolaryngology-Head and Neck Surgery 2020

Otolaryngology- Head and Neck Surgery Feb 2020 19 © IABLE 19 Otolaryngology- Head and Neck Surgery Feb 2020 20 © IABLE 20

Pump Trauma Nipple Blebs

• White/yellow spot on nipple • May or may not be a corresponding plugged duct • Treatment – Often don’t need to be treated – Steroid ointment to reduce inflammation – Keep nipple well-moisturized • Olive oil • Lanolin – Sterile unroofing to improve flow. © IABLE 21 © IABLE 22

A mother and infant see you at a 6 week postpartum Blebs visit. The baby has been nursing well, but latch still hurts. The nipple pain improves somewhat during nursing, but then after nursing mom notices sharp, deep aching and burning sensations in her nipples that radiate into her breasts. What is your differential Diagnosis?

Inadequate latch Candidiasis Vasospasm

Hyperlactation Subacute mastitis/dysbiosis

4 1/4/2021

Hyperlactation Candida Overgrowth

• Reviewed in a later session • Symptoms • Consider as an etiology for/contributor • Burning/sharp nipple pain • Nipple itchiness to breast pain if • Signs • Pain mainly when full • Red, shiny nipple/areolar region • Satellite lesions • Frequent breast fullness • Superficial cracking at base of • Recurrent mastitis nipple • Diagnosis • Stringy milk • Gram stain/culture of • Infant choking at the breast nipple/areolar region • Infant feeds on one side only for short • Rule out dermatitis • Unlikely dx if infant has no periods thrush • High supply when pumping • Treat with topical antifungals or oral for 7-10 days • Do not treat over the phone

Nipple/Areolar Treating Yeast Overgrowth Rashes Often Diagnosed as ‘Yeast Mother Infant Overgrowth’ • Treat if – Mom has symptoms • Treatment based on infant – Rash diagnosed as thrush or diagnosis strong clinical suspicion – Nystatin oral suspension – Infant has thrush – Oral fluconazole • Treatment options: • Do not treat if mom has – Topical nystatin ointment symptoms (not proven yeast), – Topical clotrimazole cream and infant has no thrush – Oral fluconazole 200mg qd x 10 days – Mupirocin oint if not sure

Symptoms of Subacute Mastitis or Mammary Dysbiosis Bacterial Dysbiosis-Exam

• Nipple pain • Painful latch, improves • Possible nipple lesions during feeding – Scabs • Dep breast pain after – Cracks feeding – Blebs • Breasts feel tender – White biofilm • Recurrent plugged ducts • • +/- Nipple scabs Pain on manual expression and breast • Decrease in supply palpation

5 1/4/2021

Management of a Bacterial Vasospasm Dysbiosis

• This is a bacterial-overgrowth situation –Coag-neg staph, staph aureus, gr. B strep, and others • Breast exam and breastmilk culture • Reduce any oversupply • Antibiotics based on culture results

Classic Sx and Signs of Vasospasm of the Treatment of Nipples Vasospasm HEAT breaks the cycle! • Pain during and after • Avoid any nipple trauma feeding • Apply heat immediately after • Persistent burning nursing sensation of nipples – Heating pad on low over bra • Sharp intermittent – Foot warmers over breast pads breast pain • Keep breasts/nipples warm X • Also triggered by cold • Calcium channel blockers • Nipple turns pale-blue- red after nursing or pumping Source: US Breastfeeding Committee

33 © IABLE 33 © IABLE 34

Plugged Ducts Risk Factors for Plugged Ducts

• Symptoms • High Milk Supply • Return to work – Tender localized area • Longer stretches of sleep of fullness and • Irreg feeding/pumping possible lump • Poor pump fit • Change in feeding – Pain radiates to/from positions the nipple during • Restrictive clothing or nursing other external compression – No breast redness or • Stress/fatigue fever • Dysbiosis – Lower supply/breast does not fully drain

6 1/4/2021

Plugged Ducts A mother and infant see you at 2 months postpartum. • Treatment Mom reports that she went to urgent care 3 weeks ago – Rest for a L sided mastitis, associated with fever, chills, and – Frequent drainage breast redness. She was given dicloxacillin 500mg 4 times a day for 10 days. The infection and pain went away. – Heat and gentle massage Today she notices that she has a headache, feels chilled, – Vibration and the R breast is painful with a red spot. – Ultrasound She expresses frustration, and wants to know why this is – Vary nursing positions happening. – If the lump does not resolve in 48 hours, needs a visit What could be her risk factors for another mastitis? – Lecithin 1200mg-2400mg twice a day for prevention Source: US Breastfeeding Committee 37 © IABLE 37 © IABLE 38

Who Develops Acute Mastitis = Inflammation in the Breast Mastitis? • Increased Risk If: • Flu symptoms – <3 months pp • +/- Mild erythema early – 1st Baby • Breast swelling and more – Stress erythema later on • – Incomplete emptying Often preceded by plugged ducts or nipple – Cracked nipple damage – High milk supply • Pumped milk may be – History of mastitis with bloody, clumpy, or have previous children mucous – ?Infant thrush

Source: US Breastfeeding Committee © IABLE 39 © IABLE 40

Deep Crack and Lymphangitis Deep Crack… and Early Mastitis

7 1/4/2021

Blebs Can Be Associated with Mastitis

Organisms: Staph aureus (MSSA) MRSA E coli Gr B Strep Gr A Beta Hemolytic Strep Coag Neg Staph

Mastitis Can Be Bilateral Mastitis Treatment • Breastmilk culture – R/O MRSA • Rest • Hot compresses • Frequent breast drainage • Antibiotics, tx until sx resolve – dicloxacillin 500mg qid, clindamycin 300mg qid, cefdinir 300mg bid • Probiotics • Anti-inflammatories- ibuprofen • If not resolving, r/o inflammatory Breast CA

Complications of Mastitis Abscesses During Lactation

• 8-19% of women • Require drainage have recurrent • Continue episodes of antibiotics, relying mastitis on culture results • Keep breast well- • 3-10% of women drained with mastitis • Baby may nurse if develop abscesses milk is not purulent

8 1/4/2021

Abscess with Small Drain Herpes Simplex on the Breast • Transmission – Often given to moms from nursing toddler with cold sores – Can cause herpes in infant • Management – Avoid direct contact of lesions with infant – Express and discard milk on affected breast – OK to nurse on unaffected side – Cover lesions until scabbed over

Herpes Zoster (Shingles) Nipple Dermatitis on the Breast

• Shingles- can spread • Eczema chickenpox • Management • Psoriasis – Avoid direct contact of lesions with • Irritant dermatitis baby – Express and discard milk on • Allergic affected breast dermatitis – OK to nurse on the other side – Cover lesions until scabbed over • Contact dermatitis

Symptoms/Signs of Treatment of Dermatitis Dermatitis • • Itchiness, pain Identify underlying cause – • Persistent cracking Infant medications/foods – • Redness and/or scaly Topical irritants • Soaps, topical treatments • May start during – pregnancy or any time History of eczema/psoriasis postpartum • Keep moist with an – Commonly starts after 6 oil/lanolin months pp • Topical Steroid • Often diagnosed as ‘yeast’ by others – Triamcinolone 0.1% or other medium strength steroid • Remember Pagets

9 1/4/2021

Conclusions • Because there are several causes of sore nipples, evaluation and management requires a thorough history and physical exam. • The most common cause of cracked nipples is inappropriate latch and/or suck. • Clipping the infant’s lingual frenulum may lead to improved latch and suck skills, and decrease nipple trauma. • Underlying medical problems such as a history of eczema or Raynaud syndrome may be clues for sore nipple etiologies. • There is rare need to wean or pump and dump due to mastitis or abscesses. • Plugged ducts and recurrent mastitis are often due to milk stasis, and appropriate counseling can help to reduce these recurrences.

10 1/4/2021

Objectives Low Milk Production • List 2 reasons for insufficient breast development during pregnancy. • Describe 2 reasons why a woman may have absence of lactation postpartum. • Recite 3 reasons for low milk production. postpartum that are not due to prenatal breast development. • Identify 2 behavioral means of increasing milk production. • Describe 2 indications for using herbs or prescription medications to increase milk production.

Low Milk Supply—Real or Perceived? Perceived Low Milk Supply

I wonder if I have enough milk?! Normal interval growth Feedings are so short now…

Frequent Sleepy, Normal Fussy baby nursing with a Snacker High Suck postpartum marginal Need breast Parental supply changes expectations Pain, GERD, Fear, Other

Growth Spurt

Source: US Breastfeeding Committee © IABLE 3 © IABLE 4

Perceived vs Real Milk Production Poor Weight Gain Does Occur

Weigh the Infant

Gaining Well Not Gaining Well

Insufficient Milk Evaluate To Transfer (plenty of Low Milk Identify Cause of milk expressed Production 30 grams or 1 oz gain a day Infant Sx after feeding) In the first 3-4 mo is optimal!!

1 1/4/2021

Little or No Breast Changes Insulin resistance, Insufficient breast high androgens, in Pregnancy development surgery, radiation, congenital Little Breast Change Milk never hormonal, retained came in placenta, meds postpartum Low Milk Supply

Lack of nipple Insufficient Hormonal stimulation Glandular Tissue Interruption Milk came in but mom lost her milk Lack of breast MOST COMMON emptying CAUSE Acquired Insulin Maternal illness, Congenital (surgery, Resistance, High medication radiation) Androgens, Meds

Insufficient Glandular Tissue Shape Matters More than Size

• Little tissue to develop • Not related to size of breast • Possible causes: – Trauma to the breast bud • chest surgery, chest burn – Breast Surgery • Reduction, lumpectomy – Breast/chest radiation

Hormonal Interference • High Androgens –Obesity –Polycystic Ovarian Syndrome –Diabetes –Pre-eclampsia • Insulin resistance • Meds (aripiprazole) The Breast Journal, Volume 17 Number 4, 2011 391–398 © IABLE © IABLE 12

2 1/4/2021

Milk Never ‘Comes In’ Almost no drops of milk in the first 7-10 days Insulin resistance, Insufficient breast high androgens, development surgery, radiation, Differential Medical congenital Diagnosis Evaluation Milk never Hormonal, retained • Pituitary Insult • Cortisol came in placenta, meds postpartum • Retained • Thyroid function Low Milk Supply placental Lack of nipple • Prolactin level stimulation fragment • Testosterone Milk came in but mom lost her milk • Theca Lutein • HCG Lack of breast Cyst MOST COMMON emptying CAUSE • Medications Maternal illness, medication

Low Milk Production Low Milk Production

Lack of milk removal Lack of milk removal INFANT CAUSES MATERNAL CAUSES

Preterm, weak, low Mechanical tone, illness Reliance on Infrequent Nipple Pump Feedings Shield Use Shallow latch, tongue-tie, cleft, retrognathia, large nipples, positioning, suck dynamics © IABLE 15 © IABLE 16

Oro-Boobular Disproportion Substances that May Decrease Milk Production

• Bromocriptine, cabergoline • Estrogen-containing birth control pills • Long acting progesterone contraceptives • Decongestants- pseudoephedrine • High dose steroids • Epinephrine • Frequent use of sedating antihistamines • Aripiprazole • High dose SSRI • Enalapril • Nicotine • Alcohol • Herbal teas/supplements • Placenta encapsulation

3 1/4/2021

Fullness after 5 Increased hours of no concentration of emptying bioactive factors

Weaning!

Less fullness after 5 hours Decreased rate of milk of no emptying production

Storage Capacity Maternal Illness or Medication

Necessitates more Tolerates longer frequent removal periods without • Sepsis of milk milk removal • Surgery • Pre-eclampsia • Decrease due to illness usually temporary

Exercise and Moderate First Steps to Weight Loss Increase Milk Production • Maximize nipple stim/breast • No data on effect of weight loss on milk emptying production, unless mother is undernourished • 8 times a day • No more than a 5-6 hr break at • Slow, 1lb/½ kg per week likely fine night • Nursing usually more effective • Stay well hydrated than pumping • Moderate exercise not shown to decrease • Add hand expression to pumping • Avoid meds that production decrease production • Lactic acid in breastmilk not shown to deter • Reduce stress/rest nursing or affect baby • Sufficient calories if undernourished Breastfeeding Med 15(6) 2020

4 1/4/2021

Common Plant Based Common Foods Believed to Increase Supply Galactogogues Based on Culture, Little Research

• Stinging Nettle • Goats Rue • Herbs and • Green Leafy • Ginger • Moringa Leaf Spices Vegetables and • Garlic • Shatavari – Garlic, ginger, sprouts • Basil • Torbangun basil, onions, • Fenugreek • Grains- oats, • Black Seed caraway, anise, • Fennel quinoa, barley, rice • Turmeric coriander, dill, • Anise • Dill cumin • Nuts and nut • Blessed Thistle • Alfalfa butters • Milk Thistle • Hops • Brewers yeast • Marshmallow root • Chamomile,

25 marshmallow Mother-food.com

Plant-Based Galactogogues that Decrease Galactogogues that are Blood Sugar/Improve Insulin Sensitivity Phytoestrogens

• Black Seed • Garlic • Fennel • Fenugreek • Coriander • Fenugreek (and increases testosterone) • Fennel • Cumin • Shatavari • Shatavari • Alfalfa • Milk Thistle (Silymarin) • Goats rue • Hops • Milk Thistle (Silymarin) • Alfalfa • Turmeric • Ginger • Dill

Fenugreek Fenugreek Trigonella foenum-graecum Trigonella foenum-graecum • Possible side effects • Phytoestrogen • Infant flatus/abd pain • Improves insulin sensitivity • Maple syrup odor for infant and • Considered possibly safe by the mother FDA in medicinal amounts • Drop in blood sugar if at risk • Legume, cross reacts with • Dose- 500mg-610mg caps of peanuts in allergic people crushed seeds, 2-3 caps 3x/day • Liver toxicity has been reported • Evidence is mixed • May interact with warfarin • Exacerbate asthma Lactmed/Toxnet Dec 2018 • Decrease cholesterol Breastfeeding Med 13(10) 2018 Breastfeeding Med 13(5) 2018 Lactmed, Toxnet 2018 29 © The Milk Mob. 29 30 © The Milk Mob. 30

5 1/4/2021

Goats Rue Shatavari- Asparagus Racemosus Galega officinalis (Wild Asparagus) • Unclear mechanism of action • Metformin derived from this • Root is the active, safe • Improves insulin sensitivity part of plant • Slow increase in volumes • Long hx of use in India • A few poorly designed trials • Side effects- headache, slight risk of a showing effectiveness decrease in milk supply • Most studies were in • Interacts with Lithium combination with other • Dose is 800mg-1000mg herbs 3x/day • Clinically may increase glandular • Studies show mixed tissue results • Risks- hypoglycemia, anti-

Herbal Moringa=Malunggay Combinations • Many different • Used, grown and consumed brands in tropics • Clinically may be less • Leaf portion increases milk effective supply • Less of each herb • Dose is 500mg-1000mg • Most effective for 3x/day good milk producers • Might raise PRL level who need a boost • GI upset common for parent and child

Metoclopramide Domperidone • Increases prolactin levels • Increases prolactin levels • Dopamine antagonist • Dopamine antagonist • Rare neurologic side effects • S/E- fatigue, dizziness, depression, seizures, tremors, tics, tardive • Studies show effectiveness in NICU dyskinesia’ population • Low relative infant dose =4.4% • Dose at 10mg 3-4 times a day • • Contraindications- psychiatric disorders, Relative infant dose 0.04% seizures, risk of serotonin syndrome with other • Contraindications- Long QT serotonin agents • Side effects-abdominal cramps, rash, • Dose = 5-10mg 3-4x/day itching, prolonged QT • At most can double milk volume • Rx interactions- antifungals, Ann Pharmacotherapy Oct 2012 • Limit duration of use erythromycin, anticholinergics, 46; 1392 • Follow women closely for neurologic side effects lithium Breastfeeding Med Nov 2020 • Not FDA approved, not available in USA Ann Pharmacotherapy Oct 2012 46; 1392 © IABLE 35 © IABLE 36

6 1/4/2021

Considerations in Reasons to NOT Use Galactogogue Use Galactogogues • Response depends on one’s ability to make milk • Not as substitutes for optimal – People with high production will have a greater response nursing/pumping • Studies done on those with no risk factors for low • Back to work and pumping less production don’t apply to women who have risk • Increasing breast volume factors without drainage: • • Certain herbs/meds are a better fit for some vs others Increased risk of plugs/mastitis • Situations of NO milk or • Research is generally low quality. Best evidence is minimal drops 1-2 weeks after cultural experience birth • No data on how long herbs take to be effective • Expensive and not effective • Do the work-up!!

When to Consider Galactogogues Case of Early Excessive Weight Loss • Relactating • Ramping up dwindling or • You are seeing a dyad, G1P1 day 4 pp lost production • Healthy male born at 38 weeks, BW 7 lb 1 oz (3203g) • Induced lactation • Adoption, surrogate • Day 4 weight = 6 lb 2 oz (2778g), down 13% • Pump reliance • He is nursing every 2.5 hours, both sides, day and night • Premies • The baby is acting hungry • Late preterm • Infants are not nursing • Mom’s breasts don’t feel full yet • Insufficient glandular tissue- but no evidence (professional opinion)

What Could Be Going On, as NEWT tool: www.newbornweight.org Etiologies of Her Low Supply?

• Possible prenatal issues

• Possible intrapartum/early pp issues

7 1/4/2021

Case of Insufficient Growth at 2 Months • You are seeing a 3 month old in the office for fussiness. • You are seeing female for a 2 month exam • The family is new to town, having seen you • G3P3, Born term NSVD, 40 weeks gest for the first time at 2 months of age for a • Baby’s nursing pattern well child exam. • 4 times from am to supper time • Baby boy JJ was born term, healthy, and • Cluster feeds in evening mom reports that his weight at 2 mo of age • Sleeps 11 hours over night was considered normal, same weight % • Baby is content • In the last month, JJ has been crying more • Mom never worried re feeding issues during the day, and he has been waking up • Baby is happy more often at night to nurse. • She doesn’t feel ‘empty’ • Mom reports that her breasts might feel less • You measure a pre/post feed weight full than they used to. • Baby transfers 95 ml What are possible reasons for a What is the most likely reason drop in the infant weight gain?

Conclusions

• Low milk production can be associated with prenatal, intrapartum, and/or postpartum complications. • Low milk production can occasionally be the first sign of a maternal medical problem. • Galactogogues do not take the place of frequent, effective feeding and/or pumping. • Galactogogues are only effective in the setting of frequent, thorough breast emptying.

8 1/4/2021

Medications and Objectives Breastfeeding • Describe 2 basic principles of how medications enter human milk. • Recite 2 reliable sources of information for medication use while breastfeeding. • List 3 substances that are contraindicated while breastfeeding.

Basic Principles of Meds and A 32 y/o G2P2 comes to you asking if Mothers’ Milk Etanercept (Enbrel) is OK for her to receive twice a week while breastfeeding her 2 week • Volume of distribution old baby. • Medication half-life • Molecular weight What would you advise? • Infant absorption What reference(s) would you use? • Protein binding • Ion trapping • Lipid solubility • Protein binding • Effect on milk production • Effect on the infant

Volume of Distribution Half-Life of Drug

• Meds move from mom’s blood into breastmilk • How long does it hang • More likely to go into breastmilk around? if: – Choose meds that have short half-lifes o Absorbed from mom’s gut • Antidepressants o Drug is fat soluble • Anti-anxiety meds o Little protein binding – Medication is usually gone o Small molecule in 5 half-lives

1 1/4/2021

Molecular Weight Protein Binding

• Larger size hard to diffuse thru alveolar • membrane If protein binding >90%, milk levels low • < 200 Daltons easily pass into the milk • A very important determinant of drug • > 800 Daltons do not penetration • LMH heparins = 2000-8000 daltons • Heparin = 12,000-15,000 daltons • Exception is active transport • Insulin is large but is taken up by alveolar cells • Undergoes cellular regulation like other milk components

Infant Absorption Relative Infant Dose (RID)

• Choose medications that are not well • Calculated as: absorbed from the infant gut – The dose, based on body weight, that the infant receives via breastmilk, as compared to the – IV, IM medications therapeutic dose/body weight for the mother.

Active Transport Systems are RARE • Alveolar Cell Wall Pumps: • No sufficient data comparing infant dose/body weight • Iodine pump: same pump found in thyroid; from medication in breastmilk vs the infant’s therapeutic created to maintain infant’s iodine dose/body weight if the medication was given directly to • Ionic forms of iodides, esp. radioactive iodides infant (i.e.: I -131) concentrate in milk due to this energy • An RID less than 10% is considered acceptable. driven pumping • An RID greater than 25% may be unsafe

Other Medication General Guidelines Factors • Near all meds OK during pregnancy are OK for lactation • Ion trapping • Milk pH is ~7.2, plasma is 7.4 – Decongestants an exception • Basic drugs accumulate in milk • Infant considerations • Lipid solubility – Age of infant • Lipid content of milk varies from 1- 20% – Infant medical problems • Higher lipid content in hind milk • Timing of meds vs feeding • Lipophilic meds have higher milk • OK for infants = OK for lactation levels • Mirtazepine has 2.3 higher levels in hind • Choose the best med in a category milk than foremilk

2 1/4/2021

The List of Unsafe Meds is Short! Possible Decrease in Supply Prolactin Effect • Most chemotherapy for maternal cancer • Enalapril • Most radioactive meds ( such as I-131) • Aripiprazole • Codeine, tramadol • Progesterone • Recreational drugs • Estrogen – Occas marijuana is an exception? • Prednisone • Statins for high cholesterol- low dose likely OK • Meds that increase dopamine • Amiodarone Oxytocin • Prolactin-lower meds such as bromocriptine, cabergoline • Alcohol • Most novel oral anticoagulants (little info) • Smallpox and yellow fever vaccines in non-emergencies Reduce PRL effectiveness Always look up medications to be sure! • Estrogen and Progest

Avoid Meds that Increase Dopamine Alcohol During Breastfeeding • Breastmilk level=blood level • Hops and Barley increase PRL  Cabergoline (Dostinex) – Alcohol may blunt this increased PRL  Pramipexole (Mirapex) • Alcohol level peaks at 30-60 min  Ropinirole (Requip) – Food delays the peak time ↑dopaminergic  Rotigotine (Neupro) • Infant intake decreases by ~20% after 1-2  Selegiline (Eldepryl, Emsam, Zelapar) activity causes a drinks  MAO inhibitor/dopamine agonist for • Safest Rules: Parkinsons, Depression, ADHD ↓prolactin level – No more than 2 drinks a day, but not daily  Levodopa (Dopar, Larodopa, Sinemet) – Each drink over 1-2 hours – Eat food when drinking – Wait to nurse 2-2.5 hours after drinking • 4-5 drinks drops PRL and inhibits oxytocin

Narcotics During Lactation Smoking During Breastfeeding • Newborns who are narcotic naïve • Smokers can • Reduce exposure – most at risk for decreased respirations, sleepiness breastfeed by smoking right – Decreased metabolism • Increased risk of after feeding, not SIDS – Brain sensitivity to sedating effects before • Decreased milk – Metabolism of codeine and tramadol too variable to production • Low dose nicotine assume safety in infant – Dec’d PRL replacement is • Limit round-the-clock maternal opiates to 2-3 days for – Dec’d blood flow to preferred breast pain control • Decreased fat in • Infants exposed to methadone and buprenorphine breastmilk during pregnancy – Ok to continue during breastfeeding – Less NAS

3 1/4/2021

Marijuana During Lactation

• Marijuana (THC) is stored in fat – Baby’s brain and breastmilk are high in fat • Estimated transfer into breastmilk is 0.8% of maternal dose • Unclear how long THC stays in breastmilk • Daily infant exposure may delay motor development • Long term effects of intermittent marijuana exposure unknown • Some studies show a decrease in PRL in mothers smoking marijuana • AAP and ACOG discourage marijuana during breastfeeding

Evidence-Based Medication More Herbal References Resources • herbmed.org-American Botanical Council • Lactmed- thru the National Library – English Translation to German Commission E of Med Monographs • Medications in Mothers’ Milk by • nccam.nih.gov -fact sheets about alternative Tom Hale therapies, consensus reports and databases, • Infant Risk Center - infantrisk.com but no specific lactation info. Free • Mothertobaby.org • https://naturalmedicines.therapeuticresearch. com/– Natural Medicine Comprehensive • E-lactancia.org Database $$$

Academy of Breastfeeding Medicine Conclusions www.bfmed.org Meds During Breastfeeding

• Only international physician-only org • Most medications are safe during breastfeeding. • Protocols: • Pharmacologic properties of medication help. • Use of Antidepressants in Nursing Mothers determine their safety during breastfeeding. • Galactogogues • Contraception and Breastfeeding • Use an evidence-based resource that is kept up to • Analgesia and Anesthesia for the Breastfeeding Mother date. • Breastfeeding and the Drug Dependent Mother • Share medication information resources with • ABM Listserv families.

4 1/4/2021

Which statement is True regarding Which statement is false regarding medications and breastfeeding? smoking cigarettes during breastfeeding?

A. High dose statins should be avoided during A. Smoking cigarettes may reduce the milk supply. lactation. B. Parental smoking increases the risk of infant B. Highly protein-bound medications are more likely Sudden Infant Death Syndrome. to transfer into breastmilk. C. Women who smoke should not breastfeed. D. Low dose nicotine replacements may be used C. Medications that are lipophilic are less likely to during lactation. transfer into breastmilk. E. Smoking immediately after nursing may reduce D. Medicines that raise dopamine will raise the infant’s exposure to cotinine, the prolactin. metabolite of nicotine.

5 1/4/2021

Symptoms, Evaluation, Objectives and Management of • Describe 2 infant symptoms and 2 maternal symptoms of Excessive Lactation hyperlactation. • Describe 2 behavioral management strategies that can be employed to decrease the milk production. • Describe 2 substances that can decrease the milk production.

Symptoms and Signs in Baby Hyperlactation = Over-Production ▪ Struggle during initial let- • Production of excessive milk down with gasping, choking, • Breast discomfort fussiness • Mom compelled to express beyond ▪ Rapid weight gain what the baby is taking (assuming ▪ 1 lb/week normal infant growth) ▪ Excessive gas and • No defined clinical criteria explosive/green stools • No set of “ounces per day” or ▪ Usually refuses second weight gain criteria breast ▪ Baby may refuse to nurse on breast with larger production ABM Clinical Protocol #32 Bfeeding Med 15(3) 2020 © IABLE 3 ABM Clinical Protocol #32 Bfeeding Med 15(3) 2020 © IABLE 4

Symptoms and Signs in Mother Etiology of Hyperlactation

• Breast fullness • Needs to pump to relieve • Mothers induce hyperlactation • Chronic tender breasts • Mothers worry re low production • Routine pumping after nursing, ie to stash milk • Heavy, fast letdown for work/ donate • • Use of galactagogues when unnecessary Sore nipples • Women who only pump and don’t nurse • Baby pinches nipples • Haakaa use • Leads to cracks, fissures, vasospasm, persistent pain • Physiologic • Freq plugged ducts The Guernsey phenomenon Unclear why breasts don’t respond to feedback of • Freq mastitis fullness • Mothers may or may not • Anatomic recognize excessive milk production • Large storage capacity • High storage capacity prevents feeling too full

1 1/4/2021

Pumping Management of Parameters Hyperlactation

 Minimize pumping for first • Behavioral Strategies 3 wks of baby’s life (unless • Block feeding • Decrease/stop pumping in feeding plan) & explain why • Medication/Herb Use  When baby is > 3 wks old, encourage limiting of pumping to 2-4 oz EBM per day for storage

Block Feeding Reduce or Eliminate Pumping • Feed from 1 breast for • If resting side is too a 3-hr block of time, ie full, pump minimally all feeds from noon to to comfort 3pm are from the L, 3 to 6pm from the R • Do not try more than 4 hour blocks • The full breast increases=> • Excessive drop?- • production drops nurse from both Coach moms • This can be tough • Usually noticeable drop sides! in supply by 36 hrs • Gradually reduce pumping times/volumes over days- wks • Just stopping not safe

Sage Tea or Extract Pseudoephedrine • Decongestant • Sage Tea • stimulates alpha- and beta- receptors, causing – 1 tbsp of dried sage into 8 oz of hot water, steep vasoconstriction for 3 minutes, then drink. • Unclear mechanism in decreasing milk production • Sage extract (Herbpharm is one) • ? slight decrease in prolactin levels (13%) – 20-40 drops at one time • 24% drop in milk production after single 60mg dose • Best to use when breasts are relatively empty • Monitor for 6-8 hours to observe effect Dosing • Use just as needed, not regularly Start with 30mg and assess effects, watch for infant fussiness Repeat in 8-12 hrs as needed If 30mg not effective, increase to 60mg Do not prescribe regularly, ONLY as needed

2 1/4/2021

Estrogen Bromocriptine Usually Slows Production and Cabergoline

• Estrogen-containing • Strong dopamine agonists OCPS • Dopamine is the Prolactin • Start with once daily Inhibitory Factor dosing for a week • Cabergoline has fewer side • Typical drop in effects production by day 5-7 • Cabergoline 0.25mg po ONCE, • If milk production begins and observe effect over 3 days to rise again later, can re- • Dose every 3-5 days dose for another week, • or stay on it Be careful what you ask for • Use as VERY last resort! • Useful for fetal demise or other reasons to abruptly wean

Conclusions The parent of a 6 week old baby reports that she needs to pump for comfort 3x/day. She removes 8 oz of milk after breastfeeding the infant in the morning. She also pumps about • Hyperlactation may lead to breastfeeding problems 6 oz after feeding at 1 pm, and she pumps 5 oz after feeding for infants and the lactating parent. the infant before bed. IF she does not pump all of the milk out, • Excessive pumping early postpartum is a common she is constantly uncomfortable and more at risk for plugs. cause of hyperlactation. What would you advise? • Block feeding can be an effective behavioral strategy to decrease milk production. • There are several substances that a lactating parent can take to reduce the milk production.

3 1/4/2021

Objectives Session 10

Pump Technology and • Describe 2 advantages to manual expression and 2 Human Milk Storage advantages to pump expression. • Identify 3 factors to determine proper fitting of breast shield size for a breast pump. • Explain to a new mother how to use her new breast pump. • Describe to a family how long expressed breastmilk may be safely stored at room temperature, in the refrigerator, and in the freezer.

Expressing Breastmilk Ideal Situations for Manual Expression

• The first week postpartum • Engorgement • Low milk supply • No pump available • Infrequent need • Preference • Cultural norm

Advantages to Manual Advantages to Pump Manual Breast Expression Expression Women always have their hands with Expression might be faster Pumps them

Only parts to wash are hands Improved comfort if manual expression • No electricity used hurts • Vacuum is created by squeezing a handle or Can be done anywhere, no need for Can be done hands free if using an electric lever electricity pump • Most are single sided Costs nothing Easier for women with physical limitations • Mother has control over duration of each Increases milk supply beyond pumping Increases milk supply cycle and frequency of cycles Increases fat concentration of breastmilk

No nipple trauma

1 1/4/2021

The Haakaa Milk Collector Battery or Electric Powered Breast Pumps • Soft, silicone • Apply to the breast after squeezing • Draws milk during a letdown Easier Proper use Proper fit • Use on the other breast when than a imperative needed to to protect pumping/nursing on one side clothes milk prevent • Only use if infant won’t nurse washing production injury! from that breast or is done on machine! that side • No stealing from the infant! • Can cause trauma due to high negative pressure and wide opening Pump Expression Video © IABLE 8

✓ Stim mode Control Options for Electric or Battery ✓ Suction control Operated Breast Pumps ✓ Control over cycle rate

• Stimulation/massage mode Electric Breast Pump • Stimulates let-down w/fast, light suction Speed/rate of • Not all pumps have this suction cycles Degree of suction • Some pumps automatically start on them, others don’t pressure • Amount of suction • Most if not all pumps allow suction control • Ideal suction at -150 to -200mmHg during expression mode • Rate of cycles • Some allow fast vs slow rate of pumping

✓ Stim mode ✓ Suction control ❑ No control over cycle rate ✓ Stim mode ✓ Suction control ❑ No control over Options for single/double pumping cycle rate

Control over vacuum, not rate

Stimulation phase

2 1/4/2021

✓ Stim mode ❑ No Stim mode ✓ Suction control ✓ Suction control ✓ 3 pre-set cycle rates ✓ Control over cycle rate 3 pre-set cycle rates

Stimulation mode

3 pre-set cycle rates

Wearable Pumps ✓ Stim mode ✓ Suction control ❑ No control over cycle Pros Cons rate

Convenient Can spill

Limited flange sizes Quiet Limited volume

Rechargeable Expensive

Most are standard Must be Fitting 24mm size Cleaned well, INTACT, Breast Shields Good Seal Nipple should and in PLACE Not become stuck in shaft

Center the Nipple in the Shield Duckbills are essential for vacuum Comfort and No nipple trauma are KEY

3 1/4/2021

Variety of Pumping Tips Shield Sizes Size # of Parts • Wash hands with soap Ease of Use to Clean and water Versability Portability • Find a comfortable with Bottle place to pump Sizes Does Sound Insurance Options for Pay for It? • Start w/low suction or “stimulation” phase, if Pump needed Is it Cycles Multiuser? • Increase to highest comfortable vacuum • Ideally achieve -150-200mm hg • Manual expression sometimes helpful Factors to Consider When Choosing a Pump © IABLE 21 © IABLE 22

Freq/Duration of Single Sided or Double Sided pumping? Pumping • Pump every 3 hours In general, double pumping results in an extra milk ejection • Average duration = 12-20 and more milk expressed for time spent over single pumping minutes • Average session = 2-3 let- downs • High production – Mothers limit volume expressed • IF pumping takes 25+ minutes, check flange size and vacuum setting

4 1/4/2021

CDC Guidelines for Cleaning Pump Parts Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol 2009

Grp 1= 2 x/day n=15 Grp 2= 2-5 x/day n=18 Grp 3= >5 x/day n=16

*Mean daily pumping for Day 1-14 = 6x in all groups

Mean daily volumes (MDV) of expressed milk over the course of the 8-week study of three groups as defined by frequency of hand expression during the first three postpartum days. Statistical comparisons using analysis of variance were performed only between Groups I, II and III. P<0.05 *vs Group I, vs Groups I and II. (Morton J, et al)

CDC Guidelines for Cleaning Pump Parts: Sanitizing: Esp for <3 mo infant

• One of the following is recommended: – Boil for 5 minutes, remove with tong – Steam in a microwave bag or plug-in steam system – Dishwasher on sanitize cycle – Bleach • 1 tsp of bleach in 16 cups of water – Submerge completely and soak for 2 minutes • Do not rinse, to avoid re-contamination – Bleach will break down as it dries and is safe • Dry on a clean paper towel or unused dish towel

Using Expressed Milk Conclusions • Fresh – Heat in warm water • Individuals vary regarding • Frozen optimal means of milk – Defrost in a warm water bath expression. or overnight in refrigerator – Use within 24 hours after • Mothers should be taught thawed proper use and care of – Use within a few hours after it pumps to avoid trauma and is warmed low supply. • Never reheat in a microwave!! • Mothers need guidance on milk storage and reheating.

5 1/4/2021

Choose the correct statement Which statement would be appropriate advice for a mother who plans to pump regarding breastmilk expression: her breastmilk? A. Double pumping will typically yield more milk in A. Freshly expressed breastmilk may be stored in less time than pumping on each side separately. the refrigerator for up to 36 hours. B. Adding manual expression to pumping might B. Freshly expressed breastmilk is safe at room increase milk volume expressed. temperature for up to 2 hours maximum. C. A mother with a healthy term infant does not need to routinely sterilize her pump parts by boiling. C. Pump parts may be washed in warm soapy water, rinsed, then air dried. D. Defrosting frozen milk slowly in the refrigerator leads to less fat loss as compared to heating in a D. Breastmilk has been proven to be highly warm water bath. nutritious after being frozen for 2 years. E. All of the above

6 1/4/2021

Methods of Weaning from Breastfeeding, Objectives Basic Concepts of Re-lactation, Induced Lactation, and Tandem Nursing • Describe 3 reasons why women wean prematurely. • Describe 2 ways that mothers can decrease the frequency of pumping or nursing in order to wean. • Describe 2 ways to encourage a child over age 2 to wean. • Define tandem nursing, re-lactation and induced lactation.

The Meaning of Weaning

• Addition of complementary foods • Substituting formula for breastmilk or breastfeeding

• Decrease frequency of nursing, but not pumping

• Actively and continually decreasing the number of Weaning breastfeeds or pumpings per day, until done Source: US Breastfeeding Committee

Mother-led Weaning The Decision to Wean

• Sometimes weaning is a health recommendation • Usually mothers make the decision to wean • Mothers should not coerced by others to Source: United States Breastfeeding Committee wean • Wean by dropping feedings • Wean by stopping nursing and just pump

1 1/4/2021

Dropping Weaning by Just Feedings Pumping

• Mother drops one feeding, and gives formula or stored milk • Take the baby off the breast, and just pump • She pumps slightly to comfort as needed • Gradually increase interval of time between pumping • Once comfortable, drop another feeding at another time sessions, and only pump to comfort of day • After dropping last pumping, may need to pump • When down to last feeding, may need to pump a day or several days later two later

Which Weaning Method is Preferred? Breast Comfort During Weaning • Cool compresses • Always pump to comfort, avoid fully emptying • Medications to reduce • Traveling • Mother who just nurses supply: • Working long hours • Slow wean/partial weaning • Sage, peppermint • Rapid weaning • Toddler/older child • Pseudoephedrine • Oversupply • Contraception with • Baby refuses to nurse estrogen

12 Weaning Breastfeeding During Toddlers Pregnancy • No statistics on frequency in the USA • Start with a nursing routine • Milk supply drops during pregnancy • Most nursing infants wean by 2nd • Start by dropping the easiest trimester nursing times • No evidence for increased risk of preterm birth in low risk mothers • Distract with playing, toys, treats • Possible increased risk of low birth • Separation from toddler weight • Change routines at home • Possible increased risk of maternal • nutritional compromise Anticipatory guidance for • Important for mother to receive children over 2 nutritional eval and recommendations

Women and Birth June 2017

2 1/4/2021

Tandem Nursing Induced Lactation

• Mother nurses infant/toddler during • Initiating lactation without pregnancy and beyond pregnancy • Mom nurses both infant • Adoption/surrogacy and toddler for as long as • Partner giving birth desired • Toddler often nurses after • Typical preparation: the baby • Hormones, often oral • Toddler can help maintain contraceptive pills supply • Galactogogues • Toddler stays healthier • Typically no concerns about • Frequent pumping infant growth

Re-Lactation A mother of a 13 month old is interested in weaning. She is nursing her toddler in the morning, before naps in the morning and afternoon, and before bed. She still feels like she has to pump at work because Source: United States Breastfeeding Committee after 6 hours she feels full. • Initiate breastfeeding after weaning How would you advise her to wean the toddler, and • Adoption • Maternal illness stop pumping at work? • Infant intolerance to formula or ill infant • Lost supply due to mismanagement • Change of heart • Supply donor milk to relative/friend • For women with a h/o good supply, expect ~6-8 weeks to re-establish milk supply © IABLE 15 © IABLE 16

Conclusions

• Women appreciate guidance on weaning strategies. • It is common for women to tandem nurse. • Women can induce lactation without birthing. • A mother who loses her milk supply can often recover it with hard work over time.