6/8/2020

OVERVIEW

• Economic benefits of breastfeeding • Maternal benefits of breastfeeding • Infant benefits of breastfeeding • Maternal risk factors • Infant risk factors BREASTFEEDING BENEFITS, RISKS, Presented by: Ashley Denker, MSN, • Contraindications for breastfeeding CONTRAINDICATIONS RNC-MNN, IBCLC

THERE IS NO EQUAL SUBSTITUTE ECONOMIC BENEFITS

“Human milk is species specific, and all substitute If 90% of U.S. mothers complied with the feeding preparations differ from it, making human recommendation to exclusively breastfeed for 6 milk uniquely superior for infant feeding.” AAP, 2012 months: •Savings of $13 billion annually •Decrease healthcare system costs by $2.45 billion •Eliminates formula costs of $4 to $10 per day

(AAP, 2012; WHO, 2020)

ECONOMIC BENEFITS MATERNAL BENEFITS

Globally: • Psychological Benefits •Save the lives of 800,000 children each year • Postpartum Recovery •Save $300 billion • Health Benefits •Every $1 invested in breastfeeding generates $35 in economic returns

(WHO, 2020) (LAWRENCE & LAWRENCE, 2016)

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MATERNAL BENEFITS MATERNAL BENEFITS

Psychological: Postpartum Recovery: Reduced Health Risks of: •Maternal Hormones •Return to pre-pregnancy state •Breast cancer and ovarian cancer •Maternal Empowerment & quicker •Osteoporosis Fullfillment •Oxytocin release •Rheumatoid Arthritis •Increased Infant Interaction •Cardiovascular Disease •Decreased risk of postpartum •Type 2 Diabetes depression and anxiety

(LAWRENCE & LAWRENCE, 2016) (LAWRENCE & LAWRENCE, 2016)

MATERNAL BENEFITS INFANT BENEFITS •Species & Age Specific Breast & Ovarian Cancer: •Nutritional Advantages •Cumulative breastfeeding duration of > 12 months results in a 28% decrease •Decreased Comorbities •Each year of breastfeeding results in a 4.3% reduction in breast •Infection Prevention cancer •Immunologic Protection Type 2 Diabetes: •4-12% decreased risk in mothers without gestational diabetes •Allergy Prophylaxis diagnosis •Psycho/Social/Cognitive Benefits

(AAP, 2012) •SIDS Prevention

INFANT BENEFITS – SPECIFICITY INFANT BENEFITS – SPECIFICITY

Species Specific: Gestational Age Specific: •Nutrients uniquely tailored to baby •Preterm milk contains higher levels of •Constantly changing protective factors including immunoglobulins, fatty acids, and cytokines. •Lower rates of NEC, sepsis, severe retinopathy, metabolic syndrome •Enhanced neurodevelopment

(AAP, 2012; LAWRENCE & LAWRENCE, 2016; USBC, 2020) (AAP, 2012; LAWRENCE & LAWRENCE, 2016; USBC, 2020)

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INFANT BENEFITS - NUTRITIONAL INFANT BENEFITS - NUTRITIONAL

•Highly, efficient bioavailability and utilization •Nutrient to nutrient •Contains cholesterol, DHA, & taurine essential for brain interaction growth and development •Ligands bind to micronutrients •Enzymes contribute to digestion •Iron almost completely absorbed compared with only •Lactoferrin binds to iron 10% of the iron in formula •Proteins •Healthy eating habits

(LAWRENCE & LAWRENCE, 2016) (LAWRENCE & LAWRENCE, 2016; USBC, 2020)

INFANT BENEFITS – COMORBITIES INFANT BENEFITS – COMORBITIES

•Cardiovascular Disease •Obesity •Reduced risk of hypertension •15-30% reduction in adolescent and adult obesity if any •Decreased risk of atherosclerosis breastfeeding occurs •Lower LDL levels •Additional 4% reduction associated with each month of •Diabetes breastfeeding •30% reduction of type 1 diabetes mellitus after exclusively breastfeeding for 3 months •40% reduction of type 2 diabetes mellitus

(AAP, 2012; LAWRENCE & LAWRENCE, 2016) (AAP, 2012; LAWRENCE & LAWRENCE, 2016)

INFANT BENEFITS – INFECTION PROTECTION INFANT BENEFITS – IMMUNOLOGIC PROTECTION

Leukocytes, antibodies Decreased risk of: Decreased risk of: and additional •Respiratory Tract Infections •Leukemia antimicrobial factors •RSV Bronchiolitis •Celiac Disease protect against infection •Otitis Media •Inflammatory Bowel Syndrome •Gastrointestinal Infections •Crohn’s Disease

(AAP, 2012; LAWRENCE & LAWRENCE, 2016) (AAP, 2012; LAWRENCE & LAWRENCE, 2016)

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INFANT BENEFITS – ALLERGY PROPHYLAXIS INFANT BENEFITS – PSYCHO/SOCIAL/COGNITIVE

•Decreased incidence of eczema, atopic dermatitis, and •More mature, secure, assertive, and progress farther on the asthma developmental scale •Exclusive breastfeeding for 3-4 months results in •Greater rapid visual acuity development • 27% reduction in risk in low-risk infants •Higher intelligence test scores, teacher ratings and educational • 42% reduction in infants with positive family history achievements •Enhanced lung volume and function •Decreases risk of abuse and neglect

(AAP, 2012; LAWRENCE & LAWRENCE, 2016) (AAP, 2012; LAWRENCE & LAWRENCE, 2016)

INFANT BENEFITS – SIDS RISK FACTORS

“21% of the US infant “Prior to discharge, mortality has been anticipation of breastfeeding problems attributed, in part, to the should be assessed based increased rate of SIDS in on maternal and infant risk infants who were never factors.” breastfed.” •Risk factors have a dose effect!

(AMERICAN ACADEMY OF PEDIATRICS, 2012; USBC 2020) (EVANS ET AL., 2014)

MATERNAL RISK FACTORS – MEDICAL HISTORY MATERNAL MEDICATION USE

•Most mediations are safe for use during breastfeeding •Extremes of age •Healthcare providers should consult lactation resources •Maternal Obesity for individual medication information • U.S. National Library of Medicine (Formerly LactMed) •Maternal medication use • Infantrisk.com (Dr. Thomas Hale) •Inappropriate advice may lead to mothers discontinuing breastfeeding unnecessarily •Weigh the risks of drug exposure through milk and the risk of interrupting or stopping lactation

(EVANS ET AL., 2014; LAUWERS & SWISHER, 2016; LAWRENCE & LAWRENCE, 2016) (AAP, 2013; CDC, 2019)

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MEDICATION CONTRAINDICATIONS MATERNAL RISK FACTORS – MEDICAL HISTORY

•Live attenuated vaccines contraindicated Significant medical problems: •Radiopharmaceuticals contraindicated • Untreated hypothyroidism, pituitary problems (Sheehan’s syndrome), diabetes, hypertension, cystic fibrosis and PCOS •Nuclear Regulatory Commission •Acute medical conditions •Lithium is no longer contraindicated Psychosocial problems: • Sleep deprivation, anxiety, depression, PTSD, and lack of social support for breastfeeding Maternal history of abuse

(CDC, 2019) (EVANS ET AL., 2014; LAUWERS & SWISHER, 2016; LAWRENCE & LAWRENCE, 2016)

MATERNAL RISK FACTORS - PSYCHOSOCIAL MATERNAL RISK FACTORS – REPRODUCTIVE HISTORY

Depression and Anxiety: •Primiparity •Decrease oxytocin •Infertility Breastfeeding challenges • •Conception by assisted reproductive technology •Bonding attachment Breastfeeding problems •Early cessation of exclusive breastfeeding • •Early weaning •Low milk supply •Antenatal administration of betamethasone

(LAUWERS & SWISHER, 2016) LAUWERS & SWISHER, 2016; LAWRENCE & LAWRENCE, 2016)

MATERNAL RISK FACTORS – A & P MATERNAL RISK FACTORS – LDRP EXPERIENCE • Previous breast surgery – Always ask! • Prolonged labor • Previous breast abscess • Long induction or augmentation of labor • Lack of noticeable breast enlargement during puberty or pregnancy • Use of medication during labor • Flat, inverted, or very large nipples • Unplanned c-section • Variation in breast appearance (marked asymmetry, hypoplastic or tubular) • Postpartum Complications • Hemorrhage • Hypertension, preeclampsia, eclampsia • Infection

(EVANS ET AL., 2014; WILSON-CLAY & HOOVER, 2005) (EVANS ET AL., 2014)

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MATERNAL FACTORS – FINANCIAL NEEDS MATERNAL FACTORS – PLANS & INTENTIONS

Breastfeeding is considered “well established” after 6 weeks Does she •Does she plan to use medication during labor? intend or •Does she intend to breast and bottle feed (with PBM or formula) need to return before 6 weeks of age? •Does she plan on using pacifiers and/or artificial nipples/teats to school or before 6 weeks of age? work? •Does she plan on using hormonal contraception before 6 weeks?

(EVANS ET AL., 2014)

MATERNAL RISK FACTORS – RED FLAGS INFANT RISK FACTORS

•No signs of milk “coming in” by 72 hours postpartum • Medical •Mother is unable to hand express milk • Anatomy & Physiology •Need for breastfeeding aid or appliances at the time of discharge • LDRP Experience •Requires special feeding plan • Environmental

(EVANS ET AL., 2014; LAUWERS & SWISHER, 2016; LAWRENCE & LAWRENCE, 2016) (USBC, 2020)

INFANT RISK FACTORS – MEDICAL/A&P INFANT RISK FACTORS – MEDICAL/A&P

• Low birth weight, SGA, IUGR Oral anatomic Neurologic problems: • Premature or late preterm abnormalities: •Genetic disorders •Cleft lip and/or palate Hypertonia • LGA • •Macroglossia •Hypotonia • Postterm > 41 weeks •Micrognathia (mandibular • Multiples hypoplasia) • Difficulty latching to one or both breasts •Ankyloglossia (tongue tie) • Ineffective or un-sustained suckling

• Persistent sleepiness (EVANS ET AL., 2014; LAUWERS & SWISHER, 2016; LAWRENCE & LAWRENCE, 2016) (EVANS ET AL., 2014)

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INFANT RISK FACTORS – MEDICAL/A&P INFANT RISK FACTORS - LDRP

Medical problems: Excessive weight loss: • Stressful delivery •Hypoglycemia •> 7-10% of birth weight in the • Birth trauma Infection first 48 hours of life • • Born after long epidural •Jaundice Less than 2 hours of skin to skin •Respiratory distress • with mother immediately after •Hypothermia birth •Prematurity

(EVANS ET AL., 2014) (USBC, 2020)

INFANT RISK FACTORS - ENVIRONMENTAL CONTRAINDICATIONS TO BF - MATERNAL

•Breast pump deficiency NICU: 3 Categories: •Formula Supplementation •Maternal infant separation • Should NOT breastfeed or feed expressed breastmilk •Lack of established, effective •Medical interventions • Should temporarily NOT breastfeed and should NOT breastfeeding prior to discharge preventing skin to skin feed expressed breastmilk •Inability to latch/refusal to latch & and/or breastfeeding transfer milk at time of discharge • Should temporarily NOT breastfeed but CAN feed expressed breastmilk •Discharge < 48 hours of age •Early pacifier use (in term infants)

(EVANS ET AL., 2014; LAUWERS & SWISHER, 2016; LAWRENCE & LAWRENCE, 2016)

CONTRAINDICATIONS TO BF - MATERNAL CONTRAINDICATIONS TO BF - MATERNAL A mother should temporarily NOT breastfeed and should A mother should NOT breastfeed or feed expressed NOT feed expressed breastmilk if she is: breastmilk if she is: •Infected with untreated brucellosis •Infected with HIV (U.S. vs international) •Taking certain medications, while the drug remains in her body at •Infected with human T-cell lymphotropic virus type I or II a harmful level to baby •Using an illicit street drug, such as PCP, cocaine, or cannabis •Undergoing diagnostic imaging with radiopharmaceuticals •Suspected or confirmed Ebola virus disease •Active HSV infection with lesions present on the breast Breastmilk should be expressed and discarded to maintain adequate supply.

(CDC, 2019) (CDC, 2019)

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CONTRAINDICATIONS TO BF - MATERNAL CONTRAINDICATIONS TO BF - INFANT

A mother should temporarily NOT breastfeed but CAN feed Infant is diagnosed with galactosemia expressed breastmilk if she has: •A rare genetic metabolic disorder in which the infant is unable to •Untreated, active tuberculosis metabolize lactose •Active varicella infection that developed within 5 days prior to – 2 •Duarte’s variant can breastfeed with close monitoring of days following delivery galactose levels •Formula recommendation

(AAP, 2012; CDC, 2019; LAUWERS & SWISHER, 2016) (CDC, 2019; LAUWERS & SWISHER, 2016)

MATERNAL DIET MATERNAL DIET

Recommendation: balanced diet similar to the non-lactating Caffeine intake: postpartum mother along with a few additions •In a single cup of coffee, infant’s plasma level & milk level is low •Increase Kcal by about 500 •Has a dose effect •Avoid diets/medications that promise rapid weight loss •Varies infant to infant •Eat a wide a variety of foods daily •Infant s/s: irritability, fussiness, short sleep cycles •Drink to thirst

(LAWRENCE & LAWRENCE, 2016) (LAUWERS & SWISHER, 2016)

MATERNAL SUBSTANCE USE MATERNAL SUBSTANCE USE Alcohol Nicotine Cannabinoids • Human milk metabolizes • Does transfer to the • THC is highly protein bound, “It is suggested instead that the mother be alcohol close to the same infant via breastmilk lipid soluble, and has a low encouraged to breastfeed while, at the same time, it rate as the body • Considerable transfer of molecular weight is strongly encouraged that she abstain completely • Breastfeed right before chemicals via second-hand • Easily transfers to human milk consumption smoke • Is stored in lipid-filled tissues, from using marijuana as well as other drugs, alcohol, • Occasional use timed • Nicotine replacements including the brain and tobacco.” around breastfeeding does (patch/gum) are • Insufficient data to assess the not appear to have harmful acceptable when effects of exposure during BF (AAP, 2018, p. 10) effects on the baby. breastfeeding • Infant s/s: tremors, • Infant s/s: drowsiness, • Infant s/s: fussiness, exaggerated startle reflex, weakness, failure to thrive, diarrhea, shock, vomiting, high pitched cry, decreased slowed brain growth. tachycardia, restlessness arousal, poor feeding (AAP 2013/2018; LAUWERS & SWISHER, 2016)

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REFERENCES REFERENCES

American Academy of Pediatrics (2018). Marijuana use during pregnancy and breastfeeding: implications for neonatal and childhood outcomes. Pediatrics, 142(3), e20181889. doi 10.1542/peds.2018-1889 Lauwers, J. & Swisher, A. (2016). Counseling the nursing mother: A lactation consultant’s guide (6th ed.). Burlington, MA: Jones & Bartlett Learning. American Academy of Pediatrics (2013). Clinical report: The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics, 132(3), e796-809. doi 10.1542/peds.2013-1985 Reece-Stremtan, S., Campos, M., Kokajko, L., & The Academy of Breastfeeding Medicine. (2017). ABM clinical protocol #15: Analgesia and anesthesia for the breastfeeding mother, Revised 2017. Breastfeeding Medicine 12(9), American Academy of Pediatrics (2012). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 1-7. doi: 10.1089/bfm.2017.29054.srt 129(3), 827-841. Doi 10.1542/peds.2011-3552 Sriraman, N. K., Melvin, K., Meltzer-Brody, S., & The Academy of Breastfeeding Medicine. (2015). ABM clinical Centers for Disease Control and Prevention (2019). Breastfeeding. Retrieved from protocol #18: Use of antidepressants in breastfeeding mothers. Breastfeeding Medicine, 10(6), 290-299. doi: https://www.cdc.gov/breastfeeding/index.htm 10.1089/bfm.2015.29002 Evans, A., Marinelli, K. A., Taylor, J. S., & The Academy of Breastfeeding Medicine. (2014). ABM clinical protocol #2: Unicef (2018). The global breastfeeding collective. Retrieved from Guidelines for hospital discharge of the breastfeeding term newborn and mother: “The going home protocol,” revised https://www.unicef.org/nutrition/index_98470.html 2014. Breastfeeding Medicine, 9(1), 3-8. Doi 10.1089/bfm.2014.9996 United States Breastfeeding Committee (2020). Landscape of breastfeeding support image gallery. Retrieved from Hale, T. W. (2020). Drug entry into human milk. Retrieved from https://www.infantrisk.com/content/drug-entry- http://www.usbreastfeeding.org/p/cm/ld/fid=177 human-milk World Health Organization (2020). Breastfeeding. Retrieved from https://www.who.int/health- Lawrence, R. A. & Lawrence, R. M. (2016). Breastfeeding: A guide for the medical profession (8th ed.). Philadelphia, PA: topics/breastfeeding#tab=tab_1 Elsevier.

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