BREASTFEEDING 101 FOR PEDIATRIC PRACTICES Jennifer A. Hudson, MD Medical Director, Newborn Services Greenville Health System SC Chapter of AAP, July 2018 Introduction Disclosures • I have no commercial interests or relevant relationships to disclose Objectives • Utilize basic strategies to support breastfeeding couplets in the outpatient setting • Observe and assess a breastfeeding session using a World Health Organization framework Why breastfeeding is important How breastfeeding works Assessing a breastfeed Observing a breastfeed Listening and learning Breast conditions Breastfeeding Counselling: A Training Course. World Health Organization. Breastfeeding Rates The American Academy YOU ARE HERE of Pediatrics recommends exclusive breastfeeding for 6 months. CDC Breastfeeding Report Card, 2016 Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice. Breastfeeding and the Use of Human Milk. AAP, 2012 Those not breastfed experience more… minor, major, acute and chronic …health problems The Surgeon General’s Call to Action to Support Breastfeeding, 2011 National Goals Baby-Friendly 47.5% 23.7% Why Women Don’t Low education Formula Lack of role marketing models Lack of Work or experience school Hospital Embarrassed practices Modern Poor support lifestyle No confidence Formula • Inherent weaknesses – Nutrient degradation, expiration – Powder not sterile, requires clean water – Susceptible to manufacturing and storage errors source: weatherflow.com WHO Code Why breastfeeding is important How breastfeeding works Assessing a breastfeed Observing a breastfeed Listening and learning Breast conditions Breastfeeding Counselling: A Training Course. World Health Organization. Mammary Structures • Alveoli – Secretory acinar units – Grouped into lobules – Lobules drain into ductules – Ductules drain into ducts – Ampulla = small reservoir – Lactiferous ducts transport milk to nipple • Myoepithelial cells – Contract to eject milk Mammary Structures • Surrounding skin – Hair – Apocrine sweat glands – Sebaceous glands • Areola mammae – Montgomery tubercles • Hypertrophied sebaceous glands • Lactiferous gland • Papilla mammae (nipple) – Muscular projection – 2 dozen lactiferous ducts Milk Secretion • Transcellular pathways – Secretory pathway for proteins (casein and lactalbumin), sugar (lactose) and salts – Lipid pathway for short and long chain FA (synthesized and stored) – Endocytosis/exocytosis for maternal immunoglobulin A, other plasma proteins • Paracellular pathway – Bioactive cells (leukocytes) Lactogenesis Stage I • Pregnancy (week 16 to postpartum day 3) – Increase in breast size, alveolar diameter, blood flow – Increased serum levels of plasma lactose and lactalbumin – Alveoli become distended with colostrum – Milk secretion inhibited by high placental progesterone levels – After parturition, colostrum secretion begins Breast changes with pregnancy Pregnancy: breast weight increases 2-3x baseline Lactating: breast weight increases 3-4x baseline Source: thepregnancyzone.com Lactogenesis Stage II • Placenta is expelled at parturition • Progesterone withdrawal initiates lactogenesis II – Removes inhibition at the cellular receptor level • Further increase in lactose concentrations is associated with increased synthesis of milk components From Czan KC, Henderson JJ, Kent JC et al: Hormonal control of the lactation cycle. In: Hale TW and Hartmann PE, editors: Textbook of • Transitional milk secretion Human Lactation, Amarillo, TX, 2007, Hale Publishing LP postpartum days 3-14 Lactogenic hormones • Prolactin The “Let-Down” Reflex – Synthesized and secreted by anterior pituitary – Found in brain, mammary glands, placenta – Primary hormone of milk production and maintenance – Release spikes stimulated by infant suckling • Supportive metabolic hormones – Thyroid hormones (TSH, TRH) Source: studyblue.com – Parathyroid hormone – Insulin – Cortisol – Growth hormone Galactokinesis The “Let-Down” Reflex • Oxytocin – Released by posterior pituitary – Promotes nurturing behavior, bonding, reduced stress, calm – Released in surges with nipple stimulation and other sensory input (tactile, visual, aural stimuli from infant) Source: studyblue.com Signs of an active letdown reflex Squeezing or tingling sensation Milk ejection from opposite breast during feed Flowing milk if baby releases during feeding Pelvic cramping during feeds Slow and deep sucks and swallowing by baby Galactopoiesis (Maintenance) • Recovery after parturition – Suckling promotes oxytocin release – Promotes uterine contraction and involution – Decreased postpartum hemorrhage and anemia – More rapid weight loss postpartum • Lactational amenorrhea and anovulation – Complex hormonal interactions, can last 24 months – Delays fertility, promotes child spacing • Psychologic effects – Bonding, mental health, stress reduction • Risk reduction – Breast and ovarian cancer – Osteoporosis, obesity Hugyourbaby.org Post-lactation Regression • Lack of milk extraction (incomplete/infrequent) – Gradual (months) or rapid (days-weeks) wean • Overall maternal prolactin levels decrease • Engorgement of alveoli – Compresses surrounding blood vessels, reducing flow – Diminishes delivery of oxytocin to myoepithelial cells – Reduced milk production with engorgement and lower prolactin – Secretions in alveoli and ducts reabsorbed – Alveoli collapse and glandular elements return to resting state – Apoptosis and remodeling return breast to pre-pregnancy state Kmberggren.com Milk Composition • Varies by time of day • Mature milk • Maternal diet • Foremilk – high water content, • Stage of lactation protein, vitamins, lactose • Individual differences • Hindmilk – high fat content Why breastfeeding is important How breastfeeding works Assessing a breastfeed Observing a breastfeed Listening and learning Breast conditions Breastfeeding Counselling: A Training Course. World Health Organization. Attachment Attachment • Results of poor attachment • Causes of poor attachment – Pain and damage to nipple – Use of bottles before breastfeeding established – Poor milk removal – Maternal inexperience • Engorgement – Functional problems • Unsatisfied baby, crying • Small or weak baby • Jaundice, weight loss, temperature • Maternal breast anatomy instability • Engorgement – Reduced milk production • Late start • Failure of lactation – Lack of skilled support • Community • Poorly trained health care providers Positioning Assisting a Breastfeeding Why breastfeeding is important Local breastfeeding situation How breastfeeding works Assessing a breastfeed Observing a breastfeed Listening and learning Breast conditions Breastfeeding Counselling: A Training Course. World Health Organization. • How is breastfeeding going? • Are you having any difficulties? • What are you worried about? • Tell me about his wet and dirty diapers. • How is your baby sleeping at night? • It sounds like you are feeling… Why breastfeeding is important Local breastfeeding situation How breastfeeding works Assessing a breastfeed Observing a breastfeed Listening and learning Breast conditions Breastfeeding Counselling: A Training Course. World Health Organization. Mammary Development • Morphogenic problems – Accessory breast – mammary tissue outside the two major glands aafp.org – Amastia – congenital absence of breast and nipple – Amazia – nipple without breast tissue – Hyperadenia – mammary tissue without nipple – Hypoplasia – breast underdevelopment – Polythelia (or hyperthelia) – accessory nipple(s) grupos.emagister.com without breast tissue – Symmastia – webbing between breasts realself.com Flat or Inverted Nipples • Build confidence – difficult at beginning, be patient, bf from breast not nipple • Encourage STS and exploration • Help try different positions • Help make the nipple stand out before feeding – hand stimulation, pump • If attachment is problematic, teach expression and cup feeding Engorgement Ankyloglossia N=797 ENT Peds LC ST Frequently causes feeding problems 30% 10% 69% Recommend surgery? 53% 21% Sometimes causes speech problems 60% 23% - 50% Recommend surgery? 74% 29% Sometimes causes social distress 67% 21% Recommend surgery? 69% 19% Messner AH, Lalakea ML. Ankyloglossia: controversies in management. Int. J. Pediatr. Otorhinolaryngol, 2000. • AAP: no position statements or guidelines • AA Otolaryngology: no position statements or guidelines • Academy of Breastfeeding Medicine – All neonates should be assessed for tongue-tie – Conservative management may be sufficient – If frenotomy is deemed necessary, should be performed by trained physician Best Evidence • Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound Geddes et al, Pediatrics 2008 – 24 dyads, average infant age 33 days – Ultrasound milk transfer improved after frenotomy • Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance. Power, Murphy, Arch Dis Child 2015 – Wide variation in prevalence 0.02-10.7% – Hazelbaker Assessment Tool for lingual frenulum function – 316 infants reviewed in 5 quality RCTs – No major complications of frenotomy – optimal timing of intervention 2-3 weeks – 50% of BF infants required no intervention Ankyloglossia Actions • Lactation consultants and providers should collaborate before suggesting tongue-tie to new mothers • For severe cases, consider frenotomy during birth hospitalization – LC, provider, family