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Breastfeeding MythBusters Julie K. Prussack, MD Northern Michigan Family Medicine Update June 27, 2019 Disclosures None Objectives 1. Identify common breastfeeding myths. 2. Support breastfeeding dyads in common experiences and struggles including low milk supply, feeding expressed breastmilk, maternal alcohol use, maternal diagnostic imaging, and maternal anesthesia. 3. Access InfantRisk Center, LactMed, and KellyMom resources. Myth #1 Formula is equivalent to breastmilk. Truth #1 Breastmilk is has many nutritional and health benefits, tailored for each specific child. WIC Supplemental Nutrition Branch. California Department of Health Services. March 2005. Excess Health Risks with Not Breastfeeding Excess Outcome Risk (%) For full-term infants Otitis media 100 Atopic dermatitis 47 Gastrointestinal infection 178 Hospitalization for lower respiratory tract diseases 257 Asthma, with family history 67 Asthma, no family history 35 Childhood obesity 32 Type 2 diabetes mellitus 64 Acute lymphocytic leukemia 23 Acute myelogenous leukemia 18 Sudden infant death syndrome 56 For pre-term infants Necrotizing enterocolitis 138 For never breastfeeding mothers Breast cancer 4 Ovarian cancer 27 The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011. URL: https://www.ncbi.nlm.nih.gov/books/NBK52680/ Excess Outcome Risk (%) For full-term infants Otitis media 100 Atopic dermatitis 47 Gastrointestinal infection 178 Hospitalization for lower respiratory tract diseases 257 Asthma, with family history 67 Asthma, no family history 35 Childhood obesity 32 Type 2 diabetes mellitus 64 Acute lymphocytic leukemia 23 Acute myelogenous leukemia 18 Sudden infant death syndrome 56 For pre-term infants Necrotizing enterocolitis 138 For never breastfeeding mothers Breast cancer 4 Ovarian cancer 27 Myth #2 Eating *this* will increase your milk supply. Truth #2 The best way to increase milk supply is to directly feed or express milk. Establishing milk supply • Skin-to-skin immediately after birth • Latch within the first hour • “Empty” breasts at least 8-12 times daily Baby tracking app, SmallNest, reported that on average, parents of 2,000 U.S. and Canadian babies reported 16-18 feeds per 24 hours ABM clinical protocol #5: peripartum breastfeeding management for the healthy mother and infant at term, revision 2013. Breastfeeding Medicine. Vol. 8, No. 6, 2013. URL: https://www.bfmed.org/protocols Increasing milk supply • Assess latch and transfer • Continue to drain breasts, including overnight when prolactin is highest • Medications: metoclopramide, domperidone (not FDA approved) • Hydrate and eat to thirst/hunger • Limited evidence for herbs and supplements ABM clinical protocol #9: use of galactogogues in initiating or augmenting maternal milk production, second revision 2018. Breastfeeding Medicine. Vol. 13, No. 5, 2018. URL: https://www.bfmed.org/protocols Myth #3 Baby needs more breastmilk. Truth #3 An infant’s milk intake stabilizes or decreases as they grow. Newborn stomach size How much breast milk does a baby need? Medela. https://www.medelabreastfeedingus.com/article/169/how-much-breast- milk-does-a-baby-need From 1 month to 6 months • Infants typically need 19-30 ounces per day • Average of 1-1.25 ounces per hour • If 8 feedings, bottles of 3-4 ounces per feed • After 6 months, with introduction of solids, intake may gradually decrease to 14-19 ounces per day at 1 year • Can use milk calculator at: https://kellymom.com/bf/pumpingmoms/pumping/milkcalc/ Bonyata, K. How much breast milk will my baby need? Kellymom.com. Updated 1/14/18. URL: https://kellymom.com/bf/pumpingmoms/pumping/milkcalc/ But baby wants more milk! • Breastfeeding offers more than just nutrition • Can overfeed with the bottle • Encourage paced bottle feeding with slow flow nipple The Milk Mob. Institute for Advancement of Breastfeeding & Lactation Education. URL:http://lacted.org/libr-iable-samples/ Resources for parents and caregivers http://www.nancymohrbacher.com/articles/2013/12/3/for-the-caregiver- of-a-breastfed-baby.html https://kellymom.com/bf/pumpingmoms/employed-moms/childcare- breastfed-baby/ Myth #4 You need to pump & dump. Truth #4 There is often no need to “pump & dump” for anesthesia, imaging, alcohol, or medications. Anesthesia Wanderer et al. Anesthesia & Breastfeeding: More Often Than Not, They Are Compatible. Infographic. Anesthesiology: October 2017, Vol.127, A15. Imaging • Radiographic studies do not make milk radioactive! • Mammograms can be done, although with decreased sensitivity. Best done immediately after draining breasts. • Per American College of Radiology, it is safe to continue breastfeeding after iodinated or gadolinium-based contrast agents. Manual on Contrast Media. American College of Radiology. Version 10.3, 2018. URL: https://www.acr.org/- /media/ACR/Files/Clinical-Resources/Contrast_Media.pdf American College of Radiology “Because of the very small percentage of iodinated or gadolinium-based contrast medium that is excreted into the breast milk and absorbed by the infant’s gut, we believe that the available data suggest that it is safe for the mother and infant to continue breast- feeding after receiving such an agent… [If the mother chooses to “pump & dump,”] There is no value to stop breast feeding beyond 24 hours.” Manual on Contrast Media. American College of Radiology. Version 10.3, 2018. URL: https://www.acr.org/- /media/ACR/Files/Clinical-Resources/Contrast_Media.pdf Alcohol in Breast Milk • Alcohol is found in the breast milk in approximately the same concentration as in the blood, and similarly leaves the breast milk as it is metabolized by the mother • Legal limit to drive 0.08%=percent alcohol in breast milk at legal limit • Percent alcohol in apple juice: 0.06-0.66% • Percent alcohol in non-alcoholic beer: <0.5% Gorges et al. Estimates of Ethanol Exposure in Children from Food not Labeled as Alcohol-Containing. J Anal Toxicol. 2016 Sep; 40(7): 537–542. Alcohol in Breast Milk • Highest concentration at 30- 60 min. after drinking • On average, one drink is metabolized completely in 2 hours (nomogram by Motherisk: https://www.ncbi.nlm.nih.gov/p mc/articles/PMC2213923/pdf/1 1852608.pdf) Alcohol in Breast Milk • Thomas Hale (2017): “…mothers who ingest alcohol in moderate amounts can generally return to breastfeeding as soon as they feel neurologically normal.” • Alcohol does decrease oxytocin release and therefore inhibit let-down reflex and production • Studies have shown that weight, linear growth, and psychomotor development can be affected by moderate drinking in breastfeeding mothers Hale, Thomas. Medications and Mothers’ Milk, 2017 edition. Springer Publishing, 2017: 348-350. Medication Safety • InfantRisk Center at Texas Tech University • (806) 352-2519 8AM- 5PM Central Time • InfantRisk.org • InfantRisk App ($9.99) • MommyMeds App ($3.99) Medication Safety • LactMed • https://toxnet.nlm.nih.gov/ newtoxnet/lactmed.htm • LactMed App (Free) L1 L2 L3 L4 L5 Compatible Limited Data No Data - Limited Data Hazardous -Probably Probably - Possibly compatible compatible hazardous Tylenol Sertraline Oxycodone Codeine Amiodarone Ibuprofen Benadryl Bupropion Marijuana Isotretinoin Amoxicillin Flagyl Doxycycline Chantix Kombucha Loratadine Guaifenesin Nicotine Tizanidine Fluorouracil Dextrometh- Methylphen- Hormonal Colchicine Methotrexate orphan idate Contraception Metformin Prednisone Sumatriptan Glimepiride Tamoxifen Myth #5 You cannot breastfeed while pregnant. Myth #5 It is generally safe to breastfeed in low-risk pregnancies. Breastfeeding during pregnancy • Nipple stimulation does release oxytocin, but in a similar or lesser amount than with sexual activity • Oxytocin receptors are sparse until 38 weeks and are also blocked by progesterone • Only a few small observational studies have been done, but there is no evidence to suggest an increase in miscarriage or preterm delivery Flower, Hilary. A New Look at the Safety of Breastfeeding During Pregnancy. KellyMom.com, 2013. URL: https://kellymom.com/pregnancy/bf-preg/bfpregnancy_safety/ Breastfeeding during pregnancy Can be complicated by: • Nursing aversion • Nipple sensitivity • Decreased milk supply • Change in milk taste/composition • Self-weaning AAFP Breastfeeding Position Paper “Breastfeeding during a subsequent pregnancy is not unusual. If the pregnancy is normal and the mother is healthy, breastfeeding during pregnancy is the woman’s personal decision. If the child is younger than two years, the child is at increased risk of illness if weaned.” Breastfeeding, Family Physicians Supporting (Position Paper). American Academy of Family Physicians, 2014. URL: https://www.aafp.org/about/policies/all/breastfeeding-support.html AAFP Breastfeeding Position Paper “Breastfeeding the nursing child during pregnancy and after delivery of the next child (tandem nursing) may help provide a smooth transition psychologically for the older child.” Breastfeeding, Family Physicians Supporting (Position Paper). American Academy of Family Physicians, 2014. URL: https://www.aafp.org/about/policies/all/breastfeeding-support.html More Myths… • Most infants sleep through the night by 6 months. • Formula will help my infant sleep through the night. • Supplemental formula will help my infant gain weight better than supplemental breast milk. • Maternal dietary fiber makes babies more gassy/fussy. • You cannot make enough milk by exclusively pumping. • Smoking mothers should not breastfeed. • People with a history of breast surgery cannot breastfeed. • Transgender and adoptive parents cannot breastfeed..
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