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Introduction

This course is based around a number of cases that reflect day-to-day interactions of mothers with their medical practitioners. The clinically relevant, evidence-based information can then easily be applied within the context of a normal medical practice to provide effective, integrated management of women who are pregnant or breastfeeding.

However, medical practitioners do not support breastfeeding women in isolation and ideally women receive assistance and correct and consistent information from a number of different sources. Following initial assessment and management, referring mothers with breastfeeding difficulties to other health professionals who have more expertise and fewer time constraints, such as lactation consultants (IBCLCs), is often appropriate. In addition, lay breastfeeding support groups such as the Australian Breastfeeding Association (ABA) provide invaluable support and encouragement to breastfeeding women and are also an important referral option.

Before beginning this course take time to complete the pretest quiz. This will give you an indication of your breastfeeding knowledge at this point in time. A similar, but different quiz, at the end of the course will enable you to (hopefully) see an improvement in your knowledge base.

1.0 Case Study A (Joanne)

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?

Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.

What information would you give?

Topic 1.2: What information to give
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.

Why do breastfeeding alternatives have different effects?

Topic 1.3: Effects of Breastfeeding alternatives
These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.

What are mothers' common and valid concerns about breastfeeding?

Topic 1.4: Common breastfeeding concerns
Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.

Would you examine her breasts at this visit?

Topic 1.5: Breast examination
Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.

What are the contraindications to breastfeeding?

Topic 1.6: Contraindications to breastfeeding
There are very few conditions when women should be discouraged from breastfeeding, including active tuberculosis, HIV, human T-cell leukaemia virus Type 1, brucellosis, some medications, illicit drug use and classic galactosaemia and some inborn errors of metabolism in the infant.

What conditions may be related to poorer lactation outcomes?

Topic 1.7: Conditions related to lactation outcomes
Common problems are previous lactation failure, hormonal problems and obesity.

Joanne's sister-in-law developed hyperthyroidism when she had been breastfeeding her last baby and was told that she would have to wean so that she could commence taking medication. Joanne asks you whether it is common for women to have to wean to be treated for medical conditions. What would you tell her about medication use in breastfeeding women?

Topic 1.8: Medications
There are very few medical conditions for which a mother needs to cease breastfeeding so that she can be adequately treated. In nearly all situations a mother can continue to breastfeed while she is on medication.

1.1 Discussing breastfeeding

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?

Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.

Would you discuss breastfeeding at this visit?

Yes. While it is ultimately the mother who makes a decision regarding the method of infant feeding, she should make an informed decision with evidence-based information. Many women decide before or early in their pregnancy how they will feed their infant and the earlier they decide that they will breastfeed, the more likely they are to initiate and continue to breastfeed.1,2

Intention to breastfeed,2,3 and intended length of breastfeeding 2,4 are the most powerful predictors of duration of breastfeeding. Additionally, there is a link between a doctor providing breastfeeding information, support and encouragement to women during the antenatal period and the rate of breastfeeding initiation 5,6,7 and duration 6,8,9. Therefore, it is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.10

The positive influence of doctors and other health professionals on breastfeeding initiation and duration is only effective if there is overt support and encouragement. Neutrality is perceived by mothers as simply disguised indifference to how the baby is fed and has a similar effect on breastfeeding initiation and duration as overtly negative views.7,11,12)

Attending antenatal breastfeeding education – either as a separate class or as part of an antenatal education course, also increases breastfeeding initiation 13,14 and duration 15,16. The inclusion of specific segments on correct positioning and attachment of the baby at the breast reduces the incidence of nipple pain and trauma.15 Providing women with a list of classes in their area, and encouraging them to attend, is recommended.

Notes

  1. # Hegney D et al. (2003) The Toowoomba infant feeding support service project: Report on phase1 - A longitudinal needs analysis of breastfeeding behaviours and supports in the Toowoomba region.
  2. # Scott JA et al. (2001) Factors associated with breastfeeding at discharge and duration of breastfeeding
  3. # Heath A-LM et al. (2002) A longitudinal study of breastfeeding and weaning practices during the first year of life in Dunedin, New Zealand
  4. # diGirolamo A et al. (2005) Intentions or experience? Predictors of continued breastfeeding
  5. # Lu MC et al. (2001) Provider encouragement of breast-feeding: evidence from a national survey
  6. # Li L et al. (2004) Factors associated with the initiation and duration of breastfeeding by Chinese mothers in Perth, Western Australia
  7. # Bentley ME et al. (1999) Sources of influence on intention to breastfeed among African-American women at entry to WIC
  8. # Taveras EM et al. (2003) Clinician support and psychosocial risk factors associated with breastfeeding discontinuation
  9. # Utaka H et al. (2005) Breastfeeding experiences of Japanese women living in Perth, Australia
  10. # Brodribb W et al. (2007) Identifying predictors of the reasons women give for choosing to breastfeed.
  11. # DiGirolamo AM et al. (2003) Do perceived attitudes of physicians and hospital staff affect breastfeeding decisions?
  12. # Counsilmann JJ et al. (1983) Bivariate analyses of attitudes towards breast-feeding
  13. # Deshpande AD et al. (2000) Breast-feeding education and support: association with the decision to breast-feed
  14. # Giugliani ER et al. (1994) Effect of breastfeeding support from different sources on mothers' decisions to breastfeed
  15. # Duffy EP et al. (1997) Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates.
  16. # Pugin E et al. (1996) Does prenatal breastfeeding skills group education increase the effectiveness of a comprehensive breastfeeding promotion program?

1.2 What information to give

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?

Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.

What information would you give?

Topic 1.2: What information to give
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.

What information would you give?

Ask whether she has thought about how she will feed her baby, and her views about breastfeeding. Most women say they will "breastfeed if they can" or think they should breastfeed but feel uncertain and anxious. They may see breastfeeding as a superior product, with formula feeding being seen as an adequate and valid alternative method of infant feeding1 with little understanding of the differences between the two.

Disadvantages of Breast Milk Substitutes

When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding:

(Please click on any point for further details.)

  • are more expensive for the family and the community2
    • costs of formula, bottles, teats/artificial nipples, etc and medical costs
    • costs to community calculated to be at least $1-2 million in Australian Capital Territory each year3 and $U.S. 3.6 billion/ year in the USA4
  • are usually less convenient
    • preparation and storage of alternative feeding products
    • being caught out without sufficient formula
    • needing to find places and ways of keeping formula sterile and utensils clean when travelling
  • risk contamination during
    • the manufacture phase
    • the preparation phase5,6
  • lack the same hormonal responses in the mother
    • fertility returns immediately
    • Breastfeeding encourages attachment and bonding between the mother and her infant.7,8
  • lack the same levels of nutritional components
    • ie. essential amino acids and types of proteins, fatty acids and other nutritional components tailored to suit the developing human infant.9 (See Case 3 for further information)
  • lack immunological components that provide protection from a number of diseases and adverse outcomes in infants and their mothers10,11 such as ...
    • infection (otitis media, gastrointestinal infection, lower respiratory tract infections)
    • allergy (atopic dermatitis, asthma)
    • chronic disease (Type 1 and Type 2 diabetes, childhood leukaemia, SIDS, coeliac disease)
    • necrotising enterocolitis (NEC)
    • poorer cognitive development
    • maternal type 2 diabetes
    • maternal breast and ovarian cancer
    • maternal rheumatoid arthritis
    • All these effects are evident in developed as well as developing countries. Two extensive reviews10,11 published in 2007 evaluated the methodological rigour of studies comparing the effect of breastfeeding and formula feeding on a number of outcomes. These reviews and other studies published since their data were collected are able to quantify the risk for formula fed infants and their mothers.
  • increase the likelihood of acute otitis media
    • Formula fed infants are twice as likely to develop acute otitis media as infants exclusively breastfed for 3-6 months (OR 2)10 and are more likely to suffer from recurrent otitis media12. Additionally, infants breastfed for 4-6 months are nearly twice as likely (OR 1.95) to develop otitis media by the time they are two years old as infants breastfed for more than 6 months13.
  • increase the likelihood of gastrointestinal infection
    • The adjusted odds ratio of formula fed infants developing non-specific gastrointestinal infection is approximately 2.7.10,14 In recent published research from the United Kingdom14 exclusive breastfeeding could have prevented 53% of hospital admissions for gastrointestinal illness each month in the first eight months of life. The risk of hospital admission doubles for each month after weaning.
  • increase the likelihood of lower respiratory tract infections (LRTI)
    • In Ip’s10 meta-analysis there would have been a reduction of 72% in hospital admissions for LRTI if all infants were exclusively breastfed for 4 months (OR 3.75). The odds ratio for infants contracting pneumonia if breastfed for between four and six months rather than > 6 months was 4.27.13
  • increase the likelihood of atopic dermatitis
    • For children under school age the odds ratio for those formula fed, compared to those exclusively breastfed for 3 months, developing atopic dermatitis was 1.47. This was even more evident for children from atopic families (OR 1.72)10. However, the effect does not appear to persist into later childhood or adulthood15.
  • increase the likelihood of asthma
    • Although studies appear to give conflicting reports and are difficult to evaluate, formula feeding appears to increase the incidence of wheezing within the first four years of life (OR 1.43) especially for those with a family history of atopy (OR 1.66)10,16. Similar to the findings with atopic dermatitis, it is unlikely that the effect persists into adolescence and adulthood10,16.
  • increase the likelihood of Type 1 diabetes
    • Formula feeding, compared to breastfeeding for at least 3 months appears to increase the risk of developing Type 1 diabetes (OR 1.23-1.43). However, exclusivity of breastfeeding and other confounders were not always addressed10,17.
  • increase the likelihood of Type 2 diabetes
    • Similarly, formula fed infants are more likely to develop Type 2 diabetes than those breastfed (OR 1.64).18
  • increase the likelihood of childhood leukaemia
    • Infants formula fed or breastfed for less than 6 months had a higher incidence of developing Acute Lymphoblastic Leukaemia (ALL) (OR 1.32) and Acute Myeloblastic Leukaemia (AML) (OR 1.18) in childhood10,19. There is some evidence that other childhood cancers may also be affected20.
  • increase the likelihood of obesity
    • There appears to be a small increase in obesity and overweight in children and adults who were not breastfed as infants (OR 1.32 – 1.07). This effect seems to be dose related ie the effect increases with increasing duration of breastfeeding11 with one study finding a reduction of 4% in the risk of overweight for each month of breastfeeding.21
  • increase the likelihood of SIDS
    • A meta-analysis of studies using a precise definition of SIDS and adjusting for known confounders found that formula fed infants were more likely to die of SIDS than infants who had been breastfed at all (OR 1.56)10.
  • increase the likelihood of coeliac disease
    • Being breastfed at the time of the introduction of gluten reduced the incidence of coeliac disease by 52%. Additionally, reducing lengths of breastfeeding increase the risk of the infant developing coeliac disease22.
  • increase the likelihood of NEC
    • The absolute risk difference for developing NEC between premature infants receiving breast milk or formula is 5%. However, any advantage is still clinically important in these fragile infants10.
  • increase the rate of infant mortality
    • The odds ratio of a formula fed infant dying in the first 12 months in the USA compared to an infant who was ever breastfed is 1.2723. This equates to approximately 720 post-neonatal deaths in the USA each year.
  • affect cognitive development
    • Even when many confounding variables have been accounted for, children who had been breastfed as infants have intelligence scores approximately 4.9 points higher than children who had been formula fed11. A 2006 paper24 and subsequent review10 suggest that this difference is a function of maternal intelligence rather than a function of breast milk or breastfeeding. However, another study, adjusting for maternal cognitive ability and other confounders found a difference of 5.6 and 6.3 points in two different populations. They also found that the association between breastfeeding and cognitive development was modified by a gene involved in fatty-acid metabolism.25
  • increase the likelihood of maternal Type 2 diabetes
    • In women without gestational diabetes a shorter duration of breastfeeding (or no breastfeeding) was related to an increased risk of developing Type 2 diabetes26.
  • increase the likelihood of breast and ovarian cancer
    • For every year a woman breastfeeds she reduces her risk of developing breast cancer by 4.3%10. Additionally, women who have breastfed for at least 12 months reduce their risk of ovarian cancer by 28%10.
  • increase the likelihood of other diseases where there is some data
    • septicaemia and meningitis, urinary tract infection27

Odds ratio of disease incidence with breast or formula-feeding

Odds ratio of disease incidence with breast or formula-feeding

Notes

  1. # Wiessinger D (2004) Watch your language
  2. # Cattaneo A et al. (2006) Infant feeding and cost of health care: a cohort study
  3. # Smith JP et al. (2002) Hospital system costs of artificial infant feeding: estimates for the Australian Capital Territory
  4. # Weimer J (2001) The Economic Benefits of Breastfeeding: A Review and Analysis
  5. # Walker M (1993) A fresh look at the risks of artificial infant feeding
  6. # Giovannini M et al. (2008) Enterobacter sakazakii: an emerging problem in paediatric nutrition.
  7. # Kennell JH et al. (1998) Bonding: Recent observations that alter perinatal care
  8. # Klaus MH (1998) Mother and infant: Early emotional ties
  9. # Lawson M (2007) Contemporary aspects of infant feeding
  10. # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries
  11. # Horta B et al. (2007) Evidence on the long-term effects of breastfeeding
  12. # Lubianca Neto JF et al. (2006) Systematic literature review of modifiable risk factors for recurrent acute otitis media in childhood
  13. # Chantry CJ et al. (2006) Full breastfeeding duration and associated decrease in respiratory tract infection in US children
  14. # Quigley MA et al. (2007) Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study
  15. # Pesonen M et al. (2006) Prolonged exclusive breastfeeding is associated with increased atopic dermatitis: a prospective follow-up study of unselected healthy newborns from birth to age 20 years
  16. # Greer FR et al. (2008) Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas
  17. # Rosenbauer J et al. (2007) Early nutrition and risk of Type 1 diabetes mellitus - a nationwide case-control study in preschool children.
  18. # Owen CG et al. ( 2006) Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence
  19. # Kwan ML et al. (2004) Breastfeeding and the risk of childhood leukemia: a meta-analysis
  20. # Ortega-Garcia JA et al. (2008) Full breastfeeding and paediatric cancer
  21. # Harder T et al. (2005) Duration of breastfeeding and risk of overweight: a meta-analysis
  22. # Akobeng AK et al. (2006) Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies
  23. # Chen A et al. (2004) Breastfeeding and the risk of postnatal death in the United States
  24. # Der G et al. (2006) Effect of breast feeding on intelligence in children: prospective study, sibling pairs analysis, and meta-analysis
  25. # Caspi A et al. (2007) Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism
  26. # Stuebe AM et al. (2005) Duration of lactation and incidence of type 2 diabetes
  27. # Hanson LA (2004) Protective effects of breastfeeding against urinary tract infection

1.3 Effects of Breastfeeding alternatives

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?

Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.

What information would you give?

Topic 1.2: What information to give
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.

Why do breastfeeding alternatives have different effects?

Topic 1.3: Effects of Breastfeeding alternatives
These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.

Why do breastfeeding alternatives have different effects?

These effects are due in part to the presence in breastmilk of substances and systems that act against infections and inflammation.

Secretory IgA (SIgA) Secretory IgA is manufactured in the breast and acts against pathogens to which the mother has been exposed. Stimulated lymphocytes migrate from Peyer’s patches in the mothers gut and similar lymphoid tissue in the bronchial tree to the breast and produce SIgA in reaction to the pathogens present in the infant's environment (entero-mammary and broncho-mammary pathways). There are high concentrations of SIgA in colostrum to provide protection for the infant postpartum; by 4 months the infant consumes 75mg/Kg/day of SIgA. SIgA prevents the adhesion of bacteria and viruses to epithelial cells as well as neutralising viruses and bacterial toxins. Other antibodies (IgG, IgM and IgE) are also present in breast milk.
Leukocytes Similar to SIgA, leukocyte numbers are highest in colostrum, and fall to approximately 104 – 2x105 in mature milk1. The majority of cells are macrophages (85%) and small lymphocytes and play a role in protecting the breastfed infant and the breast by destroying pathogens by phagocytosis2. Macrophages and lymphocytes in breastmilk produce other active agents (SIgA, lactoferrin, complement, prostaglandins). They are also able to enter the infant’s circulation3.
Lactoferrin Lactoferrin is an iron binding glycoprotein that has a bactericidal effect on gram +ve and -ve bacteria as well having antiviral and antifungal capacity.
Carbohydrates Carbohydrates - in particular oligosaccharides, glycoproteins and glycolipids promote the growth of non-pathogenic bacteria in the infant’s gut as well as preventing the attachment of bacteria and other pathogens to the epithelial lining of the gut and other mucosal surfaces.
Fatty Acids Fatty Acids affect certain bacteria, viruses and parasites. They also enhance the development of the nervous system2. It is hypothesised that the fatty acid composition of breastmilk is responsible for the differences in cognitive development between those breastfed and those formula-fed,4 and may also impact on the development of allergic disease2.
Lysozyme, α lactalbumin, complement, cytokines, growth factor, nucleotides Lysozyme, α lactalbumin, complement, cytokines, growth factor, nucleotides present in breastmilk have all been shown to have an active role against pathogens2,3.

Notes

  1. # Xanthou M et al. (1995) Human milk and intestinal host defense in newborns: an update
  2. # Hanson L (2004) Immunology of Human Milk: How breastfeeding protects babies
  3. # Hanson LA (2007) The role of breastfeeding in the defense of the infant
  4. # Caspi A et al. (2007) Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism

1.4 Common breastfeeding concerns

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?

Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.

What information would you give?

Topic 1.2: What information to give
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.

Why do breastfeeding alternatives have different effects?

Topic 1.3: Effects of Breastfeeding alternatives
These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.

What are mothers' common and valid concerns about breastfeeding?

Topic 1.4: Common breastfeeding concerns
Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.
Pregnant woman eating

What are mothers' common and valid concerns about breastfeeding?

Common and valid concerns often held by mothers include:

  • uncertainty regarding their chances of success
  • how they can return to paid work and continue to breastfeed
  • whether their partner will feel left out if they breastfeed
  • embarrassment about breastfeeding in public

Women may think they should not breastfeed

  • if they smoke
  • have an occasional alcoholic drink
  • eat 'junk food'

Exploring these and other concerns and providing information, reassurance and other resources is useful in allaying anxiety and preparing the parents for their changing role. For example:

Encourage acquiring knowledge and support networks

Breastfeeding is a learned art; many women do not find it easy especially in the first few weeks. Having a realistic idea of the needs and behaviours of infants, especially those that are breastfed, enables parents to adjust their expectations and goals for this time of their life accordingly. It will also help them to determine when they need to seek assistance from a trained professional, community resources or family and friends to provide physical, emotional and informational support. Developing support networks such as these prior to the infant's birth is very beneficial.

Discuss the most appropriate outcome depending on individual circumstances

Many women continue to breastfeed while they are in the paid workforce, however, the longer a return to work is delayed the better established breastfeeding will be. Work options (e.g. part-time, job share, working from home, flexible working hours), child care options (e.g. on-site child care, a child care centre near the work place, individual care that allows for the infant to be brought to the mother for breastfeeding)1 and feeding options (e.g. expressed breastmilk; formula when separated, breastfeed when together2; or complementary foods if baby >6 months) can be explored.

Encourage both parents to develop their own unique roles

Feeding is only one part of infant care and, while fathers are unable to breastfeed, they can play an important role in the other aspects of caring for their children. While bathing, playing or settling their child a father begins to develop a unique relationship that is not dependent on supplying food. It is often a joyful experience as the infant becomes more interactive and responsive. By being aware of the reasons why breastfeeding is important and providing physical and emotional support for the mother the father also contributes to successful breastfeeding outcomes.

Support breastfeeding with confidence, anywhere the mother and baby may be

Learning to breastfeed takes time. Many new mothers feel awkward and uncomfortable, and apprehensive about breastfeeding away from home until their baby is able to attach to the breast and breastfeed easily. If mothers feel more comfortable, breastfeeding can be done very discretely with clothing that lifts from the waist, or a wrap or shawl draped across the breastfeeding infant. Parenting rooms are also becoming more common as are venues designated 'breastfeeding friendly'. Regardless, a woman's right to breastfeed in a public place is protected by law in most parts of the World.

Assist women to quit smoking and limit alcohol intake while breastfeeding, but it's better to be breastfed than formula fed even if the mother smokes.

While nicotine and alcohol enter breastmilk, any adverse effects in the infant are much smaller than the adverse effects of alternatives to breastmilk.

Women who smoke are less likely to initiate breastfeeding,3 and breastfeed for a shorter duration4. Their infants are exposed to nicotine and other substances through the air they breathe and their skin regardless of the method of infant feeding. Breastfeeding significantly modifies the effect of smoking on the risk of respiratory tract infections in the infant5. It is recommended that women stop smoking during pregnancy and lactation. However, it is more detrimental for an infant of a mother who continues to smoke to be formula fed than breastfed.

Alcohol passes readily into milk with levels peaking 30-60 minutes after ingestion. As the mother metabolises the alcohol, levels in milk reduce in parallel to maternal plasma levels. By 2 hours following the ingestion of one standard drink there is minimal amounts of alcohol in breastmilk. The effects of alcohol on the breastfed infant are dependent on the amount and frequency of maternal ingestion with social drinking having a minimal impact6.

Discuss healthy eating for maternal well-being

Maternal nutrition. For the vast majority of women their diet has little effect on the volume and adequacy of the breast milk they produce, although a well balanced diet is recommended for the woman's health and well being. Women who are poorly nourished, or have a specific deficiency (eg vegan mothers may become Vitamin B12 deficient and produce milk that is Vitamin B12 deficient) may need to supplement their diet, or supplement their breastfed infant7.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Hawkins SS et al. (2007) The impact of maternal employment on breast-feeding duration in the UK Millennium Cohort Study
  2. # McVeagh P (2001) Breastfeeding - help!
  3. # Donath SM et al. (2004) The relationship between maternal smoking and breastfeeding duration after adjustment for maternal infant feeding intention
  4. # Giglia R et al. (2006) Maternal cigarette smoking and breastfeeding duration.
  5. # Woodward A et al. (1990) Acute respiratory illness in Adelaide children: breast feeding modifies the effect of passive smoking
  6. # McAfee G ( 2007) Drugs of abuse and breastfeeding.
  7. # Hopkinson JM (2007) Nutrition in lactation

1.5 Breast examination

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?

Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.

What information would you give?

Topic 1.2: What information to give
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.

Why do breastfeeding alternatives have different effects?

Topic 1.3: Effects of Breastfeeding alternatives
These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.

What are mothers' common and valid concerns about breastfeeding?

Topic 1.4: Common breastfeeding concerns
Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.

Would you examine her breasts at this visit?

Topic 1.5: Breast examination
Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.

Would you examine her breasts at this visit?

Yes and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal' and allows the identification of any variations that may require planning of appropriate postpartum help.

Breasts are composed of both glandular and adipose tissue supported by a loose connective tissue network. Under hormonal influences during pregnancy (e.g. human placental lactogen, oestrogen, progesterone, prolactin, growth hormone) the glandular component of the breast increases with growth and branching of the ductal system, an increase in lobule formation and alveolar differentiation1,2.


© Health e-Learning

While there are great variations in breast size, breast tissue usually lies from the 2nd to the 6th rib and comprises between 15 and 20 lobes that differ in size and intertwine within the breast. Breast milk is stored in the alveoli of the lobes, ducts from the many alveoli joint to form a mean of 9 ducts (range 4 – 18) opening onto the nipple2,3.


© S.Cox IBCLC

Nipples also vary greatly in size (from less than 12 mm to more than 23 mm)4 and shape. Most protrude from the surface of the areola and become erect in response to tactile, thermal and sexual stimulation5. The nipple is surrounded by the areola that also varies in size and pigmentation with pigmentation increasing during pregnancy. Modified lactiferous ducts and sebaceous glands on the areola (known as Montgomery's follicles) become more prominent during pregnancy. These follicles produce a secretion containing anti-inflammatory factors that helps lubricate the nipple and prevent infection2,5.

Click on graphic for a larger image. .
© Ramsay DT, Hartmann RL, Hartmann PE

Major ducts in the lactating breast are small (mean diameter 2mm), easily compressible and lie superficially. Recent work indicates that milk is not stored in the ducts and the 'lactiferous sinuses' often depicted lying beneath the nipple/areola in schematic diagrams of lactating breasts do not exist1,2.
The breast is innervated by branches of the 2nd to 6th intercostal nerves that contain sympathetic and sensory fibres5 with the lateral cutaneous branches of the 3rd – 5th intercostal (usually the 4th) nerves being responsible for the sensory innervation of the nipple and areolar area2. Milk production, however, is independent of nerve stimulation1.

What anatomical variations would give rise to concerns?

Picture Description Advice
Asymmetrical Breasts

Image © S.Cox IBCLC

Abnormal appearance Breasts that are markedly asymmetric, are widely spaced with a narrow base, appear to have a large areola with little breast substance may be an indication of insufficient glandular tissue in the breast. Some women will also note no or minimal increase in breast size during pregnancy. While breast milk production will commence, these women often have difficulty producing sufficient breast milk for their infants to grow at an adequate rate. Careful follow-up postpartum (at least within 72 hours of hospital discharge and at least weekly thereafter until breastfeeding is well established) will enable an accurate assessment of the mother’s capacity to produce breast milk.
Scarred Breasts

Image © B.Ingle IBCLC

Scars indicating a history of breast surgery Identifying the reasons for breast surgery, the type of surgery performed and the position of any scars will enable an assessment of the impact the surgery may have on future breastfeeding. Breast reduction surgery often causes difficulties with breastfeeding due to a reduction in glandular tissue, interruption of the ductal system, and damage to the nerve supply to the nipple. While breast augmentation is less likely to cause problems, note needs to be taken of the reasons for the augmentation in the first place (eg hypoplastic breasts). Periareolar incisions may damage the sensory nerve supply to the nipple/areola complex and interrupt the afferent arm of the let down or milk-ejection reflex.
Inverted Nipple

Image © Goldfarb Breastfeeding Clinic

Flat or inverted nipples Occasionally nipples do not protrude but appear to be on the same plane, or below the plane of the areola (flat or inverted nipples). Gently compressing the areola will help distinguish between nipples that appear flat or inverted, but protrude with stimulation, and nipples that become more inverted with stimulation. Infants may have difficulty attaching to these nipples, breast drainage may be poor and the nipples may become painful and cracked. Although nipples often increase in size during pregnancy1 and become more protractile and elastic, by identifying flat and inverted nipples in the antenatal period strategies to increase the likelihood of successful breastfeeding can be instituted immediately postpartum. (See Case 4 for further information).

Notes

  1. # Geddes DT (2007) Gross anatomy of the lactating breast
  2. # Geddes DT (2007) Inside the lactating breast: The latest anatomy research
  3. # Going JJ et al. (2004) Escaping from Flatland: clinical and biological aspects of human mammary duct anatomy in three dimensions
  4. # Wilson-Clay B et al. (2002) The Breastfeeding Atlas
  5. # Brodribb W (2004) Breastfeeding Management

1.6 Contraindications to breastfeeding

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?

Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.

What information would you give?

Topic 1.2: What information to give
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.

Why do breastfeeding alternatives have different effects?

Topic 1.3: Effects of Breastfeeding alternatives
These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.

What are mothers' common and valid concerns about breastfeeding?

Topic 1.4: Common breastfeeding concerns
Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.

Would you examine her breasts at this visit?

Topic 1.5: Breast examination
Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.

What are the contraindications to breastfeeding?

Topic 1.6: Contraindications to breastfeeding
There are very few conditions when women should be discouraged from breastfeeding, including active tuberculosis, HIV, human T-cell leukaemia virus Type 1, brucellosis, some medications, illicit drug use and classic galactosaemia and some inborn errors of metabolism in the infant.

What are the contraindications to breastfeeding?

There are very few conditions when women should be discouraged from breastfeeding

Active tuberculosis

Infants of mothers with active tuberculosis are at increased risk of infection whether they are breastfed or not. When a mother is initially diagnosed with active TB and is thought to be infectious, it is recommended that she be separated from her infant for as short a time as possible - until she is having adequate anti-tuberculous treatment and the infant is receiving prophylaxis. The mother can continue to provide breastmilk for her infant during the period of separation as long as she does not have tuberculous mastitis1,2.

HIV

Because of the risk of transmission of HIV from mother to infant via breastmilk, WHO recommends that when replacement feeding is

  • acceptable,
  • feasible,
  • affordable,
  • sustainable, and
  • safe

it is recommend that HIV-infected mothers avoid all breastfeeding.

If the available replacement feeding does not meet all of these criteria, exclusive breastfeeding is recommended during the first months of life.3 This recommendation is supported by the NHMRC in Australia4. In Australia most women with HIV would be advised not to breastfeed.

Human T-cell Leukaemia Virus Type 1

This retrovirus is endemic in the Caribbean, South America, sub-Saharan Africa and parts of Japan and is associated with the development of adult T cell leukaemia/lymphoma and a progressive neuropathy. As well as being transmitted via sexual contact and with blood and blood products, it is also transmitted via breastmilk – the longer the exposure to breastmilk the greater the risk of transmission1.

Brucellosis

Brucella sp. can probably be transmitted via breastmilk although active infection in the infant has not been demonstrated. Breastmilk can be expressed and discarded until the mother has had 48-72 hours of appropriate treatment1.

Medications

There are very few situations where the need for medications results in an absolute contraindication for breastfeeding. In most instances there are alternative medications that are compatible with breastfeeding. Drugs that are absolutely contraindicated (until not detectable in breastmilk) are antimetabolites and radiopharmaceuticals used in therapeutic doses.

Illicit drug use

Illicit use of drugs such as cocaine and PCP (angel dust) by a mother are known to have a detrimental effect on her breastfed infant and are absolutely contraindicated during lactation. There is limited or no data on the effect of other illicit drugs on breastfed infants. Considering the frequent concomitant use of illicit drugs, the uncertainty of dose and purity of the drugs and impairment of the mother, there must be concern about women who continue to use illicit drugs while breastfeeding5,6.

Classic galactosaemia and some inborn errors of metabolism in the infant

7
These are very rare and require specialist assessment and treatment.

Conditions that are NOT a contraindication to breastfeeding.

Hepatitis B

The rate of vertical transmission of Hepatitis B via breast milk is low, even though viral DNA has been recovered from breastmilk. With passive and active immunization of the infant soon after birth the transmission rate is similar regardless of the infant feeding method. Infection with hepatitis B is not a contraindication for breastfeeding1,2,8.

Hepatitis C

Studies have not demonstrated an increase in vertical transmission in infants who have been breastfed and therefore there is no contraindication for women who are HCV antibody positive to breastfeed7,9. Because of the theoretical risk of transmission through blood, it is recommended that mothers with cracked or bleeding nipples express and discard milk from the affected breast until the nipples have healed1,2,9.

Pregnancy

There is no reason for a mother to wean her child if she becomes pregnant again. There is no evidence that continued breastfeeding has adverse effects on a normal pregnancy, the growing foetus or older child. Many women experience nipple tenderness during the first trimester and a gradual reduction in milk supply encourages many children to wean during this time. However, some continue to breastfeed throughout the pregnancy and are tandem fed with the new baby10

Notes

  1. # Lawrence RM (2005) Transmission of infectious diseases through breast milk and breastfeeding
  2. # Buescher ES (2007) Human milk and infectious disease
  3. # World Health Organization (2003) HIV and infant feeding: guidelines for decision makers
  4. # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers
  5. # McAfee G ( 2007) Drugs of abuse and breastfeeding.
  6. # Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession
  7. # Gartner LM et al. (2005) Breastfeeding and the use of human milk
  8. # Gartrell N (2005) Not tonight dear, the kids have earaches. What happens to a lesbian couple post-partum?
  9. # MacDonald M et al. (2003) Preventing transmission of hepatitis C
  10. # Lawrence RA (2005) Reproductive function during lactation

1.7 Conditions related to lactation outcomes

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?

Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.

What information would you give?

Topic 1.2: What information to give
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.

Why do breastfeeding alternatives have different effects?

Topic 1.3: Effects of Breastfeeding alternatives
These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.

What are mothers' common and valid concerns about breastfeeding?

Topic 1.4: Common breastfeeding concerns
Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.

Would you examine her breasts at this visit?

Topic 1.5: Breast examination
Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.

What are the contraindications to breastfeeding?

Topic 1.6: Contraindications to breastfeeding
There are very few conditions when women should be discouraged from breastfeeding, including active tuberculosis, HIV, human T-cell leukaemia virus Type 1, brucellosis, some medications, illicit drug use and classic galactosaemia and some inborn errors of metabolism in the infant.

What conditions may be related to poorer lactation outcomes?

Topic 1.7: Conditions related to lactation outcomes
Common problems are previous lactation failure, hormonal problems and obesity.

What conditions may be related to poorer lactation outcomes?

Previous lactation failure
Only a small proportion of women are physically unable to breastfeed. However, many more initiate breastfeeding but wean before they originally intended due to unexpected and insurmountable problems. There is no reason to suspect similar difficulties occurring in a subsequent lactation unless there are fundamental anatomical or hormonal problems. Identifying the reasons for a previous early weaning enables strategies be instituted to prevent or overcome the problems.
Hormonal problems
An interplay of hormones is necessary to prepare the breasts for lactation and to initiate and maintain lactation after the infant is born. Women with hormonal conditions such as hypothyroidism, diabetes and endocrine disorders that lead to difficulty conceiving may experience difficulty initiating lactation.
Obesity
Women who are obese or overweight are less likely to be breastfeeding at any time postpartum than their normal weight counterparts1.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Oddy WH et al. (2006) The association of maternal overweight and obesity with breastfeeding duration

1.8 Medications

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?

Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.

What information would you give?

Topic 1.2: What information to give
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.

Why do breastfeeding alternatives have different effects?

Topic 1.3: Effects of Breastfeeding alternatives
These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.

What are mothers' common and valid concerns about breastfeeding?

Topic 1.4: Common breastfeeding concerns
Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.

Would you examine her breasts at this visit?

Topic 1.5: Breast examination
Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.

What are the contraindications to breastfeeding?

Topic 1.6: Contraindications to breastfeeding
There are very few conditions when women should be discouraged from breastfeeding, including active tuberculosis, HIV, human T-cell leukaemia virus Type 1, brucellosis, some medications, illicit drug use and classic galactosaemia and some inborn errors of metabolism in the infant.

What conditions may be related to poorer lactation outcomes?

Topic 1.7: Conditions related to lactation outcomes
Common problems are previous lactation failure, hormonal problems and obesity.

Joanne's sister-in-law developed hyperthyroidism when she had been breastfeeding her last baby and was told that she would have to wean so that she could commence taking medication. Joanne asks you whether it is common for women to have to wean to be treated for medical conditions. What would you tell her about medication use in breastfeeding women?

Topic 1.8: Medications
There are very few medical conditions for which a mother needs to cease breastfeeding so that she can be adequately treated. In nearly all situations a mother can continue to breastfeed while she is on medication.

Joanne's sister-in-law developed hyperthyroidism when she had been breastfeeding her last baby and was told that she would have to wean so that she could commence taking medication. Joanne asks you whether it is common for women to have to wean to be treated for medical conditions. What would you tell her about medication use in breastfeeding women?

There are very few medical conditions for which a mother needs to cease breastfeeding so that she can be adequately treated. Within most classes of drugs, or drugs used to treat a specific condition some are better options for breastfeeding women than others. In nearly all situations a mother can continue to breastfeed while she is on medication. Medications that are absolute contraindications to breastfeeding have been mentioned above.

Has the infant already been exposed in-utero? An infant is exposed to much higher levels of a medication in-utero than through breast milk.
Is the medication necessary? Can a topical or local preparation be used rather than an oral or parenteral preparation?
How much of the drug would the infant receive in a day? What is the relative infant dose? As a rough guide a relative infant dose of 10% is deemed to be compatible with breastfeeding.

Consider the following:

  • dose and timing of maternal administration of the medication
  • molecular weight – large molecules (eg heparin) are less likely to diffuse into the milk compartment than smaller molecules (eg lithium)
  • lipid solubility – drugs that are lipophilic diffuse more readily across cell membranes and into the milk compartment
  • pH and pKa Because breast milk has a slightly higher pH than plasma, drugs that are weak bases (such as erythromycin, beta blockers) will tend to accumulate in milk, while drugs that are weak acids (sulphonamides, barbiturates) have minimal transfer into milk
  • protein binding – drugs that are heavily protein bound are less likely to transfer into milk
  • ctive transport – some drugs are preferentially transported into milk
Is this medication used in infants?
What is its oral bioavailability? Medications given parenterally to the mother are unlikely to be absorbed by the infant no matter how much is present in breast milk.
How effective will the infant be excreting what has been absorbed? Newborns have 33% of the adult capacity for drug excretion while a 7 month old has a similar capacity to an adult. Infants who are premature or sick have reduced capacity.
Are there other drugs that will be just as effective but are potentially a safer option for a breastfeeding woman?

The amount of drug transferred into milk will depend on the dose, timing and formulation of the medication

  • Medications given once a day should be taken around the feed just prior to the infant's longest sleep.
  • Medications taken more frequently should be taken around the time of a feed (authorities differ whether just before or just after is most appropriate) to allow for drug peaks to fall prior to the next breast feed.
  • Expressing and discarding milk will not necessarily reduce the amount of the medication in milk. In most instances the concentration of a drug in milk mirrors that in maternal plasma. As the mother metabolises the drug the milk level will fall.

Obtaining correct and up-to-date information

Recommendations that a mother should not breastfeed while taking a specific medication are common when limited data is available.

Generic sentences such as “"Drug A is excreted into breast milk and caution should be used when administered to breastfeeding women"” or “"Alternative feeding arrangements should be considered"” are often encountered in product information sheets although recommendations often vary between different references.

A recent survey of 10 frequently used sources of information regarding breastfeeding and medication use found wide disparity in the recommendations between the sources for 14 medications1.

Using a reference or source with expertise in evaluating the risks of medications in breastfeeding women is essential. The following list is not inclusive, but contains resources that have reputable information and recommendations.

  • Click Externalhere[link: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT] to go to the Drugs and Lactation Database. The LactMed database in the menu on the left will be selected. Enter the name of drug or condition you wish to treat. This database will provide information on the drug's transfer into breast milk, adverse effects in infants, and other drugs with a similar action that may be more appropriate to use in breastfeeding women.
  • Medications and Mothers' Milk (Hale Publishing 2006)
  • Dr Thomas Hale's ExternalBreastfeeding and Medications Forums[link: http://neonatal.ama.ttuhsc.edu/lact/medicationforumspage.html]
  • Drug information centres at the local women's hospital
    • Queensland – Queensland Drug Information Centre, 07 3636 7098;
    • New South Wales – MotherSafe, 02 9382 6539 (1800 647 848 NSW country);
    • Victoria – Drug Information Centre, Royal Women's Hospital, 03 9344 2277;
    • South Australia – Women's and Children's Hospital, 08 8161 7222;
    • Western Australia – Women's and Children's Health Services, 08 9340 2723;
    • ACT – Drug Information Canberra Hospital, 02 0624 4333

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Akus M et al. (2007) Lactation safety recommendations and reliability compared in 10 medication resources

2.0 Case Study B (Joanne)

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO[link: http://www.who.int/en/] and ExternalUNICEF[link: http://www.unicef.org/] summarise the maternity practices needed to support and encourage breastfeeding.

Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding

Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?

Topic 2.2: Birthing Factors that Affect Breastfeeding
Labour analgesia and near-term birth
Topic 2.3: Management After Birth
Place Rosie in skin-to-skin contact; Encourage breastfeeding on demand; Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day; Give Rosie no food or drink other than breastmilk, unless medically indicated; Give Rosie no artificial teats or dummies; Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.

Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?

Topic 2.4: Poor Attachment
Investigate whether there an underlying reason; Maximize breastfeeding opportunities; Protect the milk supply; Feed the baby; Nipple shields may be useful.

Because Rosie has not been feeding well, the hospital staff are concerned that she may develop hypoglycaemia. Is hypoglycaemia likely to occur in a healthy term breastfed neonate?

Topic 2.5: Hypoglycaemia
Healthy full-term infants do not develop symptomatic hypoglycaemia simply as a result of underfeeding.

On day three, just before Rosie and Joanne are to go home, Joanne mentions that Rosie looks jaundiced and asks if it is due to her breastmilk. What is the relationship between jaundice and breastfeeding?

Topic 2.6: Relationship between Jaundice and Breastfeeding
In the early days jaundice in a breastfed infant may be due to inadequate breastfeeding. Breast milk jaundice usually begins after day five, is associated with increasing milk volumes and is thought to be due to as yet unidentified substance in breast milk. It rarely requires investigation or treatment.

2.1 Preparation Before Birth

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO[link: http://www.who.int/en/] and ExternalUNICEF[link: http://www.unicef.org/] summarise the maternity practices needed to support and encourage breastfeeding.

Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO[link: http://www.who.int/en/] and ExternalUNICEF[link: http://www.unicef.org/] summarise the maternity practices needed to support and encourage breastfeeding.

Every facility providing maternity services and care for newborn infants should:

  1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
  2. Train all health care staff in skills necessary to implement the policy.
  3. Inform all pregnancy women about the benefits and management of breastfeeding.
  4. Help mothers initiate breastfeeding within a half-hour of birth.
  5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infant.
  6. Give newborn infants no food or drink other than breastmilk, unless medically indicated
  7. Practice rooming-in - allow mothers and infants to remain together – 24 hours a day.
  8. Encourage breastfeeding on demand.
  9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
  10. Foster establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Step 3Inform all pregnant women about the benefits and management of breastfeeding

Joanne should be encouraged to access breastfeeding information and support within her local community. Women who feel they have sufficient knowledge and information about breastfeeding before their babies are born are more likely to continue to breastfeed1,2. Some studies have found no effect of antenatal breastfeeding education on breastfeeding initiation or duration 3,4especially if breastfeeding initiation rates are already high. Others have found a positive relationship between antenatal breastfeeding education and breastfeeding initiation 5,6 and duration7,8 particularly if breastfeeding skills are also taught9,10. Individual sessions with a lactation consultant or other qualified person appear more beneficial than a non-individualised instruction8. Therefore, it is the breastfeeding information and support received during the antenatal period to prepare mothers that is important rather than attendance at a specific class. McLeod1 suggests that as well as creating realistic breastfeeding expectations and providing consistent and relevant breastfeeding information, antenatal breastfeeding preparation also needs to include “quality ongoing support from partners, family, friends, professionals and the community”.

There is no evidence that antenatal nipple preparation, including the use of creams or ointments prevents nipple tenderness or damage in the postpartum period and is therefore not necessary11,12 although some women find gentle breast massage during their pregnancy enables them to become more familiar with handling their breasts.

Notes

  1. # McLeod D et al. (2002) Factors influencing continuation of breastfeeding in a cohort of women
  2. # Chezem J et al. (2003) Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: effects on actual feeding practices
  3. # Lavender T et al. (2005) Breastfeeding expectations versus reality: a cluster randomised controlled trial
  4. # Forster D et al. (2004) Two mid-pregnancy interventions to increase the initiation and duration of breastfeeding: a randomized controlled trial
  5. # Deshpande AD et al. (2000) Breast-feeding education and support: association with the decision to breast-feed
  6. # Giugliani ER et al. (1994) Effect of breastfeeding support from different sources on mothers' decisions to breastfeed
  7. # Su LL et al. (2007) Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial
  8. # Mattar CN et al. (2007) Simple antenatal preparation to improve breastfeeding practice: a randomized controlled trial
  9. # Duffy EP et al. (1997) Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates.
  10. # Pugin E et al. (1996) Does prenatal breastfeeding skills group education increase the effectiveness of a comprehensive breastfeeding promotion program?
  11. # Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review
  12. # Hewat RJ et al. (1987) A comparison of the effectiveness of two methods of nipple care

2.2 Birthing Factors that Affect Breastfeeding

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO[link: http://www.who.int/en/] and ExternalUNICEF[link: http://www.unicef.org/] summarise the maternity practices needed to support and encourage breastfeeding.

Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding

Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?

Topic 2.2: Birthing Factors that Affect Breastfeeding
Labour analgesia and near-term birth

Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?

Labour Analgesia

Infants, whose mothers are given analgesia during labour, are at greater risk of a delay in appropriate breastfeeding behaviours and some studies suggest poorer long-term breastfeeding outcomes1. Early and prolonged skin-to-skin contact as well as consistent and skilled assistance throughout the postpartum period facilitates breastfeeding and negates some of these negative effects.

Pethidine (meperidine), the opiate most widely used for obstetric analgesia in Australia, and its metabolite norpethidine accumulate and are excreted slowly in the infant. Given during labour, especially 2-3 hours prior to delivery, pethidine is known to cause neonatal sedation and respiratory depression2. Additionally, its use has been associated with the infant being unable to effectively root, latch and feed soon after delivery3,4 and to have a lower sucking frequency for as long as three days after birth5. Other opiates, such as Morphine, do not have an active metabolite and their effect on breastfeeding behaviours, when used during labour, are not as well documented. However, their impact on maternal and neonatal sedation and respiratory depression remains a concern2. Short acting opiates such as Fentanyl may be an effective alternative6.

Studies investigating the effects of epidural analgesia on breastfeeding do not give a clear cut answer in part because there is a wide variation in the doses and drugs used. Additionally, the effects may be confounded by the addition of other analgesia during labour (such as pethidine), the length of the labour and the reason for the epidural1. Some studies indicate that adding opiates, such as high doses of epidural fentanyl, to local anaesthetic agents may affect breastfeeding in the short and long term7,8, although others found no effect of epidurals on breastfeeding success9.

Near-term Birth

Although 37 weeks gestation is classified as ‘term’ many infants born at this gestational age do not act in the same way as term infants. As well as having greater difficulty maintaining stable respirations, body temperature and blood glucose levels they also have higher metabolic needs and lower energy stores. Immature sucking and rooting reflexes as well as a lack of awake/alert periods may result in poor milk transfer, ineffective breast stimulation and incomplete breast emptying leading to poor weight gain and an insufficient milk supply. These factors may result in hypoglycaemia, jaundice, failure to thrive and readmission to hospital10,11.

Therefore Joanne and Rosie need careful monitoring during their hospital stay to ensure good breast drainage and adequate milk intake (urine and stool output, weight and development of jaundice). Joanne may need to express after feeds, and the colostrum or milk fed to Rosie by syringe, dropper, cup or spoon. They also need early follow-up (48 hours) after hospital discharge to ensure problems have not developed10,11.

Factors affecting breastfeeding in the near-term infant

Factors affecting breastfeeding in the near-term infant

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

[link: http://www.bfmed.org/Resources/Download.aspx?filename=Protocol_10.pdf]

Academy of Breastfeeding Medicine Protocol[link: http://www.bfmed.org/Resources/Download.aspx?filename=Protocol_10.pdf]

Click on the icon and read the Academy of Breastfeeding Medicine Protocol: Breastfeeding the Near-term Infant.

Notes

  1. # Montgomery A et al. (2006) ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother.
  2. # Mattingly JE et al. (2003) Effects of obstetric analgesics and anesthetics on the neonate : a review
  3. # Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed
  4. # Nissen E et al. (1995) Effects of maternal pethidine on infants' developing breast feeding behaviours
  5. # Hafstrom M et al. (2000) Non-nutritive sucking by infants exposed to pethidine in utero
  6. # Hale TW (2007) Anesthetic and analgesic medications: Implications for breastfeeding
  7. # Beilin Y et al. (2005) Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study
  8. # Jordan S et al. (2005) The Impact of Intrapartum Analgesia on Infant Feeding
  9. # Halpern SH et al. (1999) Effect of Labor Analgesia on Breastfeeding Success
  10. # Meier PP et al. (2007) Increased lactation risk for late preterm infants and mothers: evidence and management strategies to protect breastfeeding
  11. # Wight NE (2003) Breastfeeding the borderline (near-term) preterm infant

2.3 Management After Birth

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO[link: http://www.who.int/en/] and ExternalUNICEF[link: http://www.unicef.org/] summarise the maternity practices needed to support and encourage breastfeeding.

Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding

Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?

Topic 2.2: Birthing Factors that Affect Breastfeeding
Labour analgesia and near-term birth
Topic 2.3: Management After Birth
Place Rosie in skin-to-skin contact; Encourage breastfeeding on demand; Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day; Give Rosie no food or drink other than breastmilk, unless medically indicated; Give Rosie no artificial teats or dummies; Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.

Steps 4-9 of the Ten Steps to Successful Breastfeeding outline the optimal management of mothers and their infants from birth to encourage and support breastfeeding.

Step 4 - Place Rosie in skin-to-skin contact

Although Step 4 states

Help mothers initiate breastfeeding within a half-hour of birth, it is now interpreted as Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed.
1

Ideally Rosie will be placed prone, skin-to-skin on her mother’s abdomen or chest immediately following birth and left for at least the first hour or until she has attempted to breastfeed. Rosie can be quickly dried, and a blanket or other covering placed over mother and infant to maintain body temperature. Routine administration of medications (e.g. Vitamin K) and assessment and weighing of the infant can either be postponed until after this time, or performed with the infant undisturbed2.

Many infants are awake and alert in the first two hours after birth and when left skin-to-skin with their mothers go through an ordered series of innate prefeeding movements with most finding the breast and begin to feed within the first hour or so.3,4 Early suckling has been associated with increased breastfeeding duration and the ability to breastfeed.5

A recent Cochrane review6 has also shown that early skin-to-skin contact of healthy term infants:

  • Increases the likelihood of a successful first breastfeed;
  • Reduces the time to the first effective breastfeed;
  • Increases breastfeeding rates at hospital discharge, at four months and six months;
  • Encourages better thermal regulation by the infant;
  • Improves cardio-respiratory stability in late pre-term infants;
  • Increases blood glucose levels;
  • Reduces crying; and
  • Reduces maternal pain from engorgement on day 3

Additionally, mothers are less anxious on day 3, are more confident handling their infant by hospital discharge and are more likely to exhibit maternal attachment behaviours.6

The benefits of skin-to-skin contact and early breastfeeding are of even greater importance for infants who are at risk for breastfeeding difficulties such as those born late preterm or whose mothers were given analgesia (particularly opiates) during labour. Women who give birth by caesarean section under epidural or spinal anaesthetic can also hold their infants skin-to-skin either in the operating theatre or in the recovery room. Extra assistance may be required from maternity staff.

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Step 5 - Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie

Breastfeeding is a natural process; however, it is not instinctive behaviour for mothers. Therefore, even when they have attended antenatal classes, mothers benefit from skilled support and assistance when learning how to breastfeed. Consistent and appropriate help in the postpartum period increases breastfeeding initiation and duration and should be a normal part of maternity care.7,8 In particular helping women to ensure good positioning and attachment of the infant to the breast, teaching them about early feeding cues and expected course of breastfeeding in the first few days and weeks is important.

When an infant is unable to breastfeed (e.g. due to illness of the infant or mother or prematurity) or the infant and his or her mother are separated, the mother requires assistance to initiate and maintain lactation. The infant can then receive breast milk in the short term, and a normal breastfeeding relationship can be established when conditions permit. Mothers benefit from being shown how to express milk (both by hand and pump) as well as being given information regarding expression routines and the safe collection and storage of breast milk.

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Step 6 - Give Rosie no food or drink other than breastmilk, unless medically indicated

Practices that interfere with the natural rhythm of the infant’s appetite and feeding cues will have a negative effect on the establishment of lactation and on breastfeeding duration. Normal, healthy, term infants allowed unlimited access to the breast do not need water, glucose water or infant formula routinely9.

Their use affects the infant’s desire to feed at the breast – reducing prolactin release and breast emptying, adversely affecting milk supply10, and breastfeeding rates at four and 16 weeks11. Additionally, giving infant formula changes the gut environment and increases the risk of infective and atopic disease5. In some situations (eg. a delay in lactogenesis ll and subsequent excessive weight loss) supplemental feeding is medically indicated but steps to protect and increase the mother’s milk supply should also be undertaken.

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Step 7 - Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day

Rooming-in 24-hours a day enhances the mother’s ability to watch and learn about her infant so that she is aware of these early feeding cues and responds to her infant accordingly. This close contact also conditions the milk-ejection reflex resulting in the release of oxytocin and hence availability of milk, three to ten minutes before a feed- just as the infant begins to stir.12

Rooming-in has been associated with more frequent feeding, greater weight gain,13 and longer duration of breastfeeding.14 Additionally, mothers who room-in tend to look at, touch and talk to their infants in more intimate ways.15 Rooming-in does not affect the amount or quality of a mother’s sleep.13

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Step 8 - Encourage breastfeeding on demand

During the first breastfeed after birth most infants will take between 0 and 5 mls of colostrum. This volume gradually increases as the milk changes from colostrum to mature milk over the first week or so.16 The increase in volume is instigated by a drop in progesterone levels following the delivery of the placenta. Subsequently the amount of milk produced is regulated by prolactin release and breast emptying, both dependent on the number and length of breastfeeds – a reflection of the infant’s appetite.

On average, infants will breastfeed between 3-8 times in the first 24 hours, and then between 5 -10 times a day until day 7,16 however, there is considerable variation in the number and length of breastfeeds between infants and between days with the same infant. Unrestricted access to the breast in the early days of breastfeeding allows for this variation, assists with the regulation of milk supply, provides milk for the infant according to his or her needs, results in lower weight loss or better weight gains and improved breastfeeding rates.5,13 Breastfed infants require no additional supplements or water, even in hot weather, until they are six months old.

Feeding the infant 'on demand', that is when he or she displays early feeding cues such as hand to mouth movements, rooting, mouthing or body movement in light sleep provides unrestricted access to the breast. There is no evidence that breastfeeding 'on demand' increases the extent or duration of nipple tenderness.

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Step 9 - Give Rosie no artificial teats or dummies

Dummy or pacifier use, especially before breastfeeding is well established has also been linked with a shorter breastfeeding duration5,10. This problem is more pronounced when the dummy or pacifier is used as an alternative to quieten an infant rather than breastfeeding him or her. Infants also use a different sucking action with bottle teats (artificial nipples) or dummies than when breastfeeding. There is concern that some infants are unable to adjust their sucking actions between the different modalities and using teats or dummies may exacerbate sucking difficulties at the breast17. Therefore dummies and artificial teats should not routinely be used for infants who are breastfed.

Recent studies suggest that the risk of SIDS is reduced in infants who use a dummy while going to sleep, especially if the infant has an unsafe sleep environment (e.g. sleeping prone or with a mother who smokes)18. This finding needs to be balanced against evidence that SIDS risk is reduced in breastfed infants19, and dummy use has an impact on breastfeeding success. The American Academy of Pediatrics20 and UNICEF UK Baby Friendly Initiative21 recommend that parents who wish to use a dummy to settle their infant to sleep not do so until breastfeeding is well established – at around four weeks. Other points to note are: it is preferable that dummies not be used at other times; not all infants will accept a dummy and many will not retain the dummy for the whole of the sleep period21. There is no evidence that forcing an infant to take a dummy, or replacing it if it has fallen out of the sleeping infant’s mouth is beneficial18,20.

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Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # World Health Organization (2006) Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Intergrated Care
  2. # Academy Of Breastfeeding Medicine Protocol Committee (2003) ABM clinical protocol #5: Peripartum breastfeeding management for the healthy other and infant at term.
  3. # Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed
  4. # Matthiesen AS et al. (2001) Postpartum maternal oxytocin release by newborns: Effect of infant hand massage and sucking
  5. # Philipp BL et al. (2004) The Baby-Friendly way: the best breastfeeding start.
  6. # Moore ER et al. (2007) Early skin-to-skin contact for mothers and their healthy newborn infants
  7. # World Health Organization Evidence for the 10 Steps to Successful Breastfeeding
  8. # Forster D et al. (2007) Breastfeeding initiation and birth setting practices: A review of the literature
  9. # AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk
  10. # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
  11. # Szajewska H et al. (2006) Effects of brief exposure to water, breast-milk substitutes or other liquids on the success and duration of breastfeeding: A systematic review
  12. # McNeilly A et al. (1983) Release of oxytocin and prolactin in response to suckling
  13. # Child and Adolescent Health and Development (CAH) (1998) Evidence for the ten steps to successful breastfeeding
  14. # Scott JA et al. (2001) Factors associated with breastfeeding at discharge and duration of breastfeeding
  15. # Prodromidis M et al. (1995) Mothers touching newborns: a comparison of rooming-in versus minimal contact
  16. # Kent JC (2007) How breastfeeding works
  17. # Wilson-Clay B (1996) Clinical use of silicone nipple shields
  18. # Hauck FR et al. (2005) Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis
  19. # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries
  20. # American Academy of Pediatrics (2005) The changing concept of Sudden Infant Death Syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk
  21. # UNICEF UK Baby Friendly Initiative (Accessed April 28, 2008) UNICEF UK Baby Friendly Initiative statement on dummy use

2.4 Poor Attachment

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO[link: http://www.who.int/en/] and ExternalUNICEF[link: http://www.unicef.org/] summarise the maternity practices needed to support and encourage breastfeeding.

Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding

Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?

Topic 2.2: Birthing Factors that Affect Breastfeeding
Labour analgesia and near-term birth
Topic 2.3: Management After Birth
Place Rosie in skin-to-skin contact; Encourage breastfeeding on demand; Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day; Give Rosie no food or drink other than breastmilk, unless medically indicated; Give Rosie no artificial teats or dummies; Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.

Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?

Topic 2.4: Poor Attachment
Investigate whether there an underlying reason; Maximize breastfeeding opportunities; Protect the milk supply; Feed the baby; Nipple shields may be useful.

Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?

Investigate whether there an underlying reason
Investigate whether there an underlying reason why Rosie is having difficulty staying attached to the breast. Infants born to primiparous women, particularly if they have received analgesia during labour, are less likely to breastfeeding effectively than other infants up to day 3, although this difference is not significant by day 7.1 Other causes of ineffective breastfeeding may have more long lasting effects and need to be addressed as soon as possible.
For example flat or inverted nipples (See Case Study 1 and Case Study 4) or conditions that affect the infant’s ability to create and maintain intraoral negative pressure such as ankyloglossia (See Case Study 4), a cleft palate, respiratory dysfunction or neurological or muscular problems require individual and specific treatment to ensure breastfeeding progresses well.
Maximize breastfeeding opportunities
Encourage skin-to-skin contact to capitalize on any innate reflex behaviours. Teach Joanne how to watch for early feeding cues and encourage her to assist Rosie to the breast whenever she displays these cues.
Protect the milk supply
Encourage Joanne to express colostrum at least eight times a day if Rosie is not effectively feeding. Hand expression is often easiest when small amounts of colostrum are being collected, but an electric breast pump may be more effective as milk supply increases.
Feed the baby.
Give Rosie expressed colostrum/milk with cup, spoon, dropper or syringe. By day three infants consume on average 408ml/24 hours 2(approximately 50ml per feed for 8 feeds a day). If Rosie is still not feeding at the breast by that time and Joanne is unable to express enough to satisfy Rosie she may need to be supplemented with an alternative milk such as banked human milk or infant formula.
Nipple shields may be useful
By providing a firmer surface for non-latching infants, especially if the nipples are flat or inverted.3 However, it is preferable to wait until at least day 3 by which time the milk supply has increased before suggesting their use.

Most infants are interested in attempting to breastfeed by 24 hours postpartum. Therefore, infants who are not interested require further evaluation to exclude other conditions such as sepsis, respiratory distress, hypoglycaemia, hypothermia or continued effects from maternal drug administration. However, the premise of feeding the baby and protecting the milk supply remain.

Notes

  1. # Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss
  2. # Saint L et al. (1984) The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum
  3. # Wilson-Clay B (1996) Clinical use of silicone nipple shields

2.5 Hypoglycaemia

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO[link: http://www.who.int/en/] and ExternalUNICEF[link: http://www.unicef.org/] summarise the maternity practices needed to support and encourage breastfeeding.

Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding

Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?

Topic 2.2: Birthing Factors that Affect Breastfeeding
Labour analgesia and near-term birth
Topic 2.3: Management After Birth
Place Rosie in skin-to-skin contact; Encourage breastfeeding on demand; Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day; Give Rosie no food or drink other than breastmilk, unless medically indicated; Give Rosie no artificial teats or dummies; Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.

Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?

Topic 2.4: Poor Attachment
Investigate whether there an underlying reason; Maximize breastfeeding opportunities; Protect the milk supply; Feed the baby; Nipple shields may be useful.

Because Rosie has not been feeding well, the hospital staff are concerned that she may develop hypoglycaemia. Is hypoglycaemia likely to occur in a healthy term breastfed neonate?

Topic 2.5: Hypoglycaemia
Healthy full-term infants do not develop symptomatic hypoglycaemia simply as a result of underfeeding.

Because Rosie has not been feeding well, the hospital staff are concerned that she may develop hypoglycaemia. Is hypoglycaemia likely to occur in a healthy term breastfed neonate?

Healthy full-term infants do not develop symptomatic hypoglycaemia simply as a result of underfeeding.1

Healthy full term neonates are able to adapt from an intrauterine environment where their energy needs are supplied, to an extrauterine environment where they regulate their own glucose levels within a short period of time. Blood glucose levels fall within the first hour and begin to rise soon after, becoming stable 2-3 hours after birth whether the infant has been fed or not. Assuming normal glycogen and adipose stores, infants produce energy by gluconeogenesis, glycogenolysis and ketogenesis.

Skin-to-skin contact and early and frequent breastfeeding helps protect infants at risk from hypoglycaemia. Feeding breast milk not only provides an exogenous source of energy, but also enhances gluconeogenesis and the production of ketone bodies that can be used by the brain to protect neurological function. However, variables such as gestational age, age since birth, and other energy needs affect the infant’s ability to provide sufficient energy to maintain normal function.

Which infants are at risk and should be monitored?

  • There is no evidence that routinely measuring blood glucose in a healthy, full-term infant is helpful, and it may be potentially harmful for establishing breastfeeding.
  • Any infant who becomes symptomatic should be tested and treated according to the result.
  • Infants at risk for hypoglycaemia such as those who:
    • Are premature or small for gestational age;
    • Have suspected inborn errors of metabolism or endocrine disorders, infections, hypothermia or respiratory distress; or
    • Suffered perinatal stress (including hypoxia or low APGAR score)
    should have their blood glucose checked approximately 2 hours after birth.
  • Infants of mothers who have diabetes or other conditions with hyperinsulinaemia are at greater risk of hypoglycaemia and should have their blood glucose checked within 30-60 minutes of birth.
  • While bedside blood glucose monitors are useful screening tools, plasma glucose levels should be confirmed by the laboratory.
  • Plasma glucose levels are 15% higher than whole blood levels.
  • Monitoring before a feed should continue until the levels are normal and stable.

About Hypoglycaemia

Hypoglycaemia is hard to define in the neonate because of the lack of a significant correlation between blood (or plasma) glucose levels, symptoms of hypoglycaemia, and long term neurological sequelae. Some neonates are asymptomatic but have extremely low plasma glucose levels while symptoms of hypoglycaemia such as irritability, tremor, lethargy, hypotonia, high pitched cry, cyanosis, hypothermia, seizures, vasomotor instability, apnoea, poor or inadequate sucking2,3 are often non-specific and may be the result of other pathological conditions.

Therefore there is no standard definition of hypoglycaemia that can be applied universally to neonates3 with therapeutic operational thresholds being more suitable indicators for intervention.

Operational thresholds for plasma glucose levels:

  • Asymptomatic infants at risk for hypoglycaemia > 2 hours old - < 2.0 mmol/L (36ml/dL)
    • Breastfed infants may have a slightly lower threshold.
    • In the first two hours after birth levels may be as low as 1.6mmol/L (28mg/dL)
  • Symptomatic infants at any age - < 2.5mmol/L (45mg/dL)
  • The therapeutic target is to maintain plasma glucose levels above 2.5mmol/L (45mg/dL)

Treatment

Asymptomatic infants with plasma glucose > 1.4mmol/L

  1. Continue breastfeeding every 1-2 hours or feed 3-5 ml/Kg of expressed breast milk or substitute nutrition (not glucose water).
  2. Monitor plasma levels prior to each feed until levels are stable and above the treatment threshold.
  3. If plasma glucose levels remain low, the infant is not able to suck or tolerate oral feeds commence IV glucose therapy

Symptomatic infants or infants with plasma glucose < 1.1 - 1.4mmol/L

  1. Initiate IV glucose therapy – do not rely on nasogastric or oral feeding.
  2. Adjust rate of glucose infusion so that plasma glucose levels in symptomatic infants are be maintained > 2.5mmol/L.
  3. Once the infant is stable encourage frequent breastfeeding.
  4. Monitor plasma levels prior to each feed until levels are stable and above the treatment threshold.
[link: http://www.bfmed.org/Resources/Download.aspx?filename=hypoglycemia.pdf]

Academy of Breastfeeding Medicine Protocol[link: http://www.bfmed.org/Resources/Download.aspx?filename=hypoglycemia.pdf]

Click on the icon and read the protocol for diagnosis and management of hypoglycemia published by the Academy of Breastfeeding Medicine.

Notes

  1. # Wight NE et al. (2006) ABM Clinical protocol #1 Guidelines for glucose monitoring and treatment of hypoglycemia in breastfed neonates
  2. # Wight NE (2006) Hypoglycemia in breastfed neonates
  3. # Eidelman AI (2001) Hypoglycemia and the breastfed neonate

2.6 Relationship between Jaundice and Breastfeeding

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO[link: http://www.who.int/en/] and ExternalUNICEF[link: http://www.unicef.org/] summarise the maternity practices needed to support and encourage breastfeeding.

Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding

Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?

Topic 2.2: Birthing Factors that Affect Breastfeeding
Labour analgesia and near-term birth
Topic 2.3: Management After Birth
Place Rosie in skin-to-skin contact; Encourage breastfeeding on demand; Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day; Give Rosie no food or drink other than breastmilk, unless medically indicated; Give Rosie no artificial teats or dummies; Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.

Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?

Topic 2.4: Poor Attachment
Investigate whether there an underlying reason; Maximize breastfeeding opportunities; Protect the milk supply; Feed the baby; Nipple shields may be useful.

Because Rosie has not been feeding well, the hospital staff are concerned that she may develop hypoglycaemia. Is hypoglycaemia likely to occur in a healthy term breastfed neonate?

Topic 2.5: Hypoglycaemia
Healthy full-term infants do not develop symptomatic hypoglycaemia simply as a result of underfeeding.

On day three, just before Rosie and Joanne are to go home, Joanne mentions that Rosie looks jaundiced and asks if it is due to her breastmilk. What is the relationship between jaundice and breastfeeding?

Topic 2.6: Relationship between Jaundice and Breastfeeding
In the early days jaundice in a breastfed infant may be due to inadequate breastfeeding. Breast milk jaundice usually begins after day five, is associated with increasing milk volumes and is thought to be due to as yet unidentified substance in breast milk. It rarely requires investigation or treatment.

On day three, just before Rosie and Joanne are to go home, Joanne mentions that Rosie looks jaundiced and asks if it is due to her breastmilk. What is the relationship between jaundice and breastfeeding?

Unconjugated or indirect bilirubin, derived from the breakdown of haem (mainly red blood cells), is normally bound to albumin and transported to the liver where it is metabolised to conjugated (or direct) bilirubin. Direct bilirubin is excreted via the biliary tree into the small intestine, where it is broken down by bacteria to form urobilinogen. However, urobilinogen and conjugated bilirubin may be converted back to unconjugated bilirubin and resorbed into the portal circulation.

Unconjugated bilirubin is fat soluble and can enter the skin and brain if not bound to albumin causing the yellow colouration of skin and sclera (jaundice) and bilirubin encephalopathy (kernicterus). Jaundice usually appears on the head and progresses caudally with increasing levels of bilirubin.1

Infants are at risk for increased bilirubin levels postpartum because of an imbalance in bilirubin production and bilirubin elimination due to:

  • An increase in red cell destruction
  • An increase in enterohepatic circulation of bilirubin because of:
    • an increased load in the intestine (meconium)
    • a lack of bacteria to breakdown conjugated bilirubin
    • higher levels of B-glucuronidase - the enzyme that converts urobilinogen and conjugated bilirubin to unconjugated bilirubin
  • Immaturity of the enzyme systems in the liver to transport bilirubin into the liver and metabolise it to conjugated bilirubin
  • Lower levels of albumin to transport unconjugated bilirubin and less tight binding.

Early onset jaundice (within the first 24-48 hours) or raised levels of conjugated bilirubin are nearly always due to a pathologic process and needs investigation and appropriate treatment regardless of the feeding method.

Even so, bilirubin levels in most infants begin to rise after birth usually peaking around 95µmol/l (5.5mg/dl) around day 4 (physiological jaundice).2 These levels drop rapidly by day 5 and then more slowly so that by day 11 bilirubin levels in formula fed infants reach the adult range of less than 25.5µmol/l (1.5mg/dl).1 Bilirubin levels in normal breastfed infants are reported to be higher than formula fed infants during the first week and can take from three and up to 15 weeks to reach adult levels.1,3 Jaundice is more pronounced in infants with Asian origins as well as those born before term.1

Higher than average levels of bilirubin in breastfed infants arise from increased enterohepatic circulation of bilirubin, although there appears to be different mechanisms for elevated levels within the first week and later.

  • Before day five, higher bilirubin levels are usually the result of inadequate breastfeeding — enterohepatic circulation is increased because of the delayed passage of meconium, few bacteria are present to break down conjugated bilirubin, and there is a starvation effect. Breastfed infants who feed frequently, have little weight loss and experience early, frequent passage of stools have similar bilirubin levels to formula-fed infants. Conversely, when breastfeeding is less than optimal, infants are at increased risk of developing jaundice and reaching bilirubin levels requiring active treatment. Therefore, how effectively the infant is breastfeeding, the presence (or absence) of jaundice, the age of the infant and the gestational age need to be considered when arranging appropriate follow-up following discharge from hospital.4,5 For example, a 48-hour-old infant who is sleepy, not feeding well and is slightly jaundiced probably needs reassessment within 24–48 hours of discharge.
  • With increasing volumes of transitional and mature milk after day 5, a rise in bilirubin levels may be due to breast milk jaundice.3 An as yet unidentified substance in human milk is thought to increase bilirubin enterohepatic circulation. Bilirubin levels will often plateau around 170–200 µmol/l (10–12mg/dl) and rarely rise above 300 µmol/l (17–18mg/dl).

Prolonged mild jaundice in a well and thriving breastfed infant is most likely due to breast milk jaundice. However, rare pathological conditions may also present with prolonged jaundice and appropriate investigations should be undertaken especially if:

  • the level of jaundice is maintained or increases,
  • the bilirubin level is unusually high (>300 µmol/l),
  • the infant is unwell in any way, or.
  • the stools are pale.

These is no need to withhold breast milk from the infant to confirm the diagnosis of breast milk jaundice. In the rare situation where bilirubin levels due to breast milk jaundice are at a level requiring treatment, supplementing the infant with an elemental formula or substituting elemental formula for breastfeeds for a 24-hour period is usually sufficient to reduce it to a satisfactory level.3

Would there be any concern about Rosie developing jaundice at this time?

As Rosie was born near-term and did not feed well for at least the first 24 hours she is at increased risk of developing clinically apparent jaundice and may require further monitoring. It would be appropriate to check her bilirubin level before discharge and arrange close follow-up.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

[link: http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B114/1/297]

American Academy of Pediatrics Clinical Practice Guideline[link: http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B114/1/297]

Click on the icon and read the AAP Guidelines: "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation"

Notes

  1. # Gartner LM et al. (2001) Jaundice and breastfeeding
  2. # Sarici SU et al. (2004) Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns
  3. # Gartner LM (2007) Hyperbilirubinemia and breastfeeding
  4. # AAP Subcommittee on Hyperbilirubinemia (2004) Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation
  5. # Bhutani VK et al. (2004) Diagnosis and management of hyperbilirubinemia in the term neonate: for a safer first week

3.0 Case Study C (Joanne)

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.

You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?

Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.

Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?

Topic 3.3: Contraception
Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.

Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.

Topic 3.4: Milk composition
The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant.

Is there any concern about a slowing of growth around this time?

Topic 3.5: Slowing of growth
Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.

Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?

Topic 3.6: Introducing solids
Breast milk alone is sufficient for growth and development until the infant is around six months of age. Appropriate complementary foods from that time will provide extra energy (especially protein) and micronutrients such as iron and zinc.

What recommendations would you give Joanne about the appropriate time to wean Rosie from the breast?

Topic 3.7: Weaning
There is no set maximum time for breastfeeding to continue although the minimum recommended time for weaning is 12 months (NHMRC, AAP) or two years (WHO). Gradual weaning is ideal.

3.1 Early problems

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.

Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Breast fullness is a physiological response to the initiation of copious milk production, and is a function of increased vascularity, increased milk production and increased oedema due to increased vascularity and milk production1. Breast fullness is associated with some tenderness and pain beginning around day two and peaking by day five2.

Breast engorgement is an exaggeration of the physiological process, with breasts becoming swollen, hard and very painful, and the nipple being flattened by underlying breast fullness. The skin of the breast is often red and shiny and the mother may be slightly febrile (38°C). The baby is often unable to latch well, resulting in painful, cracked nipples and poor milk drainage. With severe engorgement, the breasts may extend from the clavicle to the lower rib cage and from the midaxillary to the midsternal line.1

Breast Engorgement


© S.Cox IBCLC

Early and frequent emptying of the breast reduces the incidence of engorgement3, while predisposing factors for engorgement include:

  • delay with the first breastfeed;
  • infrequent feeding;
  • time-limited feeds;
  • late maturation of milk; and
  • supplementary feeds4

Management of engorgement focuses on ensuring good breast drainage and maternal comfort (5,6), and includes the following points:

Click on some of the bullet points below for more detail:

  • Ensure frequent feeding
    • most neonates require between eight and twelve feeds a day.
  • Soften the areola
    • By expressing a small amount of milk before a feed so that the infant is able to latch more easily. The amount of milk expressed will depend on the individual woman and degree of engorgement.
  • Position the infant at the breast to ensure effective latch and breast drainage.
  • Allow the infant to drain the first breast well before offering the second side.
    • Some studies suggest feeding from only one breast at each feed while expressing small amounts of milk from the other breast for comfort 7.
  • Express by hand or pump until the breasts are soft if the infant is not feeding well at the breast.
    • When the infant has fed well but the breast is still full and painful, only express until the breasts feel more comfortable.
  • Warm compresses and massage before a feed encourage milk flow.
  • Cool/cold compresses after a feed result in vasoconstriction, reduction of oedema and a degree of pain relief.
    • Cold cabbage leaves are as effective as cold packs 8.
  • Breast support from a well-fitting bra or firm t-shirt assists some women.
    • Breast binding is not recommended 9.
  • Anti-inflammatory medications and other analgesics provide some pain relief.

[link: http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening]

Reverse pressure softening for areolar oedema[link: http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening]

Some women, especially those who receive large amounts of IV fluids during labour, have oxytocin augmentation of labour, or use high suction electric breast pump early postpartum, develop pitting oedema of the breast and areola. In these situations, a technique of reverse pressure softening reduces the oedema surrounding the nipple so that the infant can attach/latch more easily. Click on the icon to be read how this is performed.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession
  2. # Hill P et al. (1994) The occurrence of breast engorgement
  3. # Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.
  4. # Moon J et al. (1989) Engorgement: contributing variables and variables amenable to nursing intervention
  5. # Brodribb W (2004) Breastfeeding Management
  6. # Mass S (2004) Breast pain: engorgement, nipple pain and mastitis
  7. # Evans K et al. (1995) Effect of the method of breastfeeding on breast engorgement, masitits and infantile colic
  8. # Roberts KL (1995) A comparison of chilled cabbage leaves and chilled gelpaks in reducing breast engorgement
  9. # Swift K et al. (2003) Breast binding... is it all that it's wrapped up to be?

3.2 Risk of SIDS

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.

You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?

Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.

You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?

As well as needing to breastfeed frequently, in the first few weeks of life infants have short sleep cycles and do not have a distinct day–night pattern (1,2). Therefore, it is normal for infants to wake frequently at night. Some studies have found that nearly two-thirds of infants aged 10–12 months continued to wake regularly at night3. Many families also bed-share (adults and infants sharing the same sleep surface) and bed-sharing has been associated with increased breastfeeding duration (4,5).

Studies investigating risk factors for SIDS have often not clearly defined the sleep environment with no distinction made between safe bed-sharing and co-sleeping (where the infant is in close physical and/or social relationship with another person), and unsafe practices. A recent meta-analysis suggests that there may be a relationship between SIDS and bed-sharing with mothers who smoke and also for young infants (less than eight to eleven weeks old4), although further studies with better definitions of bed-sharing are needed to give a better understanding of risk factors.

There is evidence that infants sleeping on a separate sleep surface in the parents' room have a reduced risk of SIDS compared with infants sleeping in another room6. Some authorities suggest placing the infant's cot alongside the mother's bed so that she can easily communicate with and access the infant.

Information about safe sleeping environments for parents who wish to bed-share include the following points (7,6):

  • Bed-sharing is not recommended if either of the parents smoke, have consumed alcohol or drugs, are obese or extremely fatigued.
  • Sleeping on soft mattresses, waterbeds, couches, recliners or sofas is not safe for infants – use a firm mattress without soft bedding, doonas or pillows near the infant.
  • Ensure there are no gaps between the mattress and wall or headboard, or other gaps where the infant can get trapped or wedged.
  • Pets should not be on/in the bed with the infant. If other children are in the bed, there should be an adult between the child and the infant.
  • The infant should not be dressed too warmly – adult bed coverings and body heat provide significantly more heat than if the infant is sleeping alone.
  • Infants should always be placed supine to sleep, although they will usually be on their side to breastfeed.

Most families will bed-share with their infant or child at some time, even though it may not be on a regular basis. Therefore, all parents should be aware of how to make the sleep environment as safe as possible.

Notes

  1. # Peirano P et al. (2003) Sleep-wake states and their regulatory mechanisms throughout early human development
  2. # de Weerd AW et al. (2003) The development of sleep during the first months of life
  3. # Armstrong K et al. (1994) The sleep patterns of normal children
  4. # Horsley T et al. (2007) Benefits and harms associated with the practice of bed sharing
  5. # Ball HL (2003) Breastfeeding, bed-sharing, and infant sleep
  6. # McCoy R et al. (2008) Clinical protocol #6: Guideline on co-sleeping and breastfeeding
  7. # Brodribb W (2004) Breastfeeding Management

3.3 Contraception

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.

You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?

Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.

Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?

Topic 3.3: Contraception
Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.

Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?

As long as Joanne remains amenorrhoeic and is fully or nearly fully breastfeeding, the chance of her becoming pregnant in the first six months postpartum is less than 2 percent – a similar failure rate to many other methods of contraception 1.

Suckling of the infant inhibits maternal release of hypothalamic GnRH, which controls the release of LH and FSH – hormones necessary for the development and maturation of the ovarian follicle. This effect is dependent on the total sucking stimulus rather than the frequency or length of feeds2. Once follicular growth occurs, there also appears to be a feedback mechanism so that ovulation is inhibited, and if ovulation does occur before six months postpartum it is usually accompanied by an inadequate luteal phase, especially prior to the first menses2. When the suckling stimulus decreases, especially after the introduction of supplementary feeds or solids, GnRH is released and ovulation occurs.

After extensive observational and controlled trials in both developed and developing countries, the conditions under which this suppression of fertility could be used as an effective form of contraception were codified in 1991. The resulting contraceptive method (Lactational Amenorrhoea Method) consists of three criteria:

  • amenorrhoea (return of menses indicated by bleeding for two consecutive days, or a bleed like a menses after day 56);
  • exclusive or full breastfeeding (no regular supplementation or solids; breastfeeding frequently on demand); and
  • less than six months postpartum.

When any of the three criteria are no longer applicable another method of contraception should be employed as pregnancy rates increase3. The percentage of women whose menses return prior to six months varies considerably (26.5–69.5%)4, perhaps reflecting different cultural expectations of the frequency and length of breastfeeds and the introduction of other fluids and foods.

LAM algorithm


© Health e-Learning

Further studies suggest that the pregnancy rate when LAM is continued for up to 12 months with the addition of solid foods is still quite small, although the incidence of an adequate luteal phase with ovulation before the first menses increases3.

Non-hormonal forms of contraception, such as condoms, diaphragms and some forms of IUDs, have little or no effect on lactation and are the methods of choice when another form of contraception in addition to, or instead of, LAM is required.

Studies of progesterone-only contraceptive methods (mini-pill, progesterone-containing IUDs, depo or implants) used during lactation also show minimal effect on lactation, although some women report a reduction in milk supply. Therefore, these methods should be used cautiously in women who have, or are at risk of having, problems maintaining an adequate milk supply. There is also a theoretical risk of disturbing the initiation of lactation if progestogens are prescribed early in the postpartum period as lactogenesis II is triggered by a drop in progesterone levels.

Contraceptives containing oestrogen are known to cause a reduction in milk supply and should preferably not be used during lactation. If it is the most suitable contraceptive method for a woman, delaying its introduction until six months postpartum is recommended (1,3).

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Labbok MH et al. (2005) Clinical protocol #13: Contraception during breastfeeding
  2. # McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women
  3. # Labbok M (2007) Breastfeeding, Birth Spacing and Family Planning
  4. # (1999) World Health Organization task force on methods for the natural regluation of fertility

3.4 Milk composition

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.

You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?

Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.

Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?

Topic 3.3: Contraception
Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.

Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.

Topic 3.4: Milk composition
The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant.

Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.

Breastmilk is a complete food and drink for infants until six months of age. The composition of breastmilk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infants.

Breastmilk Composition

Carbohydrates

Lactose
Breastmilk contains the highest lactose concentration of any mammalian milk (approximately 68g/L), providing up to 40 percent of the infant's energy requirements1. Lactose is synthesised in the breast and is one of the most stable components of breastmilk, being independent of maternal diet. The osmotic effect of lactose in the alveoli is the main determinant of breastmilk volume2. As well as being broken down to galactose and glucose by lactase found in the brush borders of the small intestine, lactose also enhances calcium absorption. Galactose and glucose are absorbed and provide energy for the infant, especially the rapidly developing brain. Galactose is also used to produce galactolipids – important in the development of the central nervous system (3,2).
Oligosaccharides, glycoproteins and glycolipids
These molecules encourage the growth of non-pathogenic bacteria such as Lactobacillus bifidus in the infant's gut and provide the basis for important components of the central nervous system3. Oligosaccharides also appear to provide alternate binding sites for pathogenic bacteria and reduce the adherence of bacteria to epithelial cells. Some oligosaccharides are absorbed and excreted in the urine and may be the mechanism for the reduced incidence of urinary tract infections in breastfed infants1.

Protein and non-protein nitrogen

Non-protein nitrogen
This comprises up to 25 percent of the nitrogen found in breastmilk and consists of more than 200 nitrogenous compounds, including free amino acids, nucleotides, carnitine and urea – some of which appear to be essential for metabolism and growth. Nucleotides also stimulate the growth of Lactobacillus bifidus and inhibit the growth of pathogenic bacteria in the gut (1,4).
Protein
Protein levels in breastmilk are approximately 9g/L, the lowest level among mammalian species, reflected in the human infant's slow growth. Casein contains a number of peptides that bind calcium, phosphorus and magnesium and are insoluble in the low pH of the stomach, forming a curd. Casein enables the delivery of calcium and phosphorus as well as other amino acids to the infant (3,4). In contrast, the whey portion of the milk contains the following soluble proteins:
  • α-lactalbumin, the most common whey protein, appears to have a mainly nutritional role, providing amino acids necessary for growth and development of the infant, although it also has anti-infective properties. α-lactalbumin is also involved in lactose synthesis in the breast4.
  • Immunoglobulins (especially IgA), lactoferrin and lysozyme are bacteriostatic and bactericidal to many bacteria, protozoa, viruses and fungi. Lactoferrin binds iron in milk and enhances iron absorption by the infant.
  • Carrier proteins for vitamins and hormones – for example Vitamin B12 binding protein and corticosteroid-binding protein.
  • Enzymes such as bile-salt stimulated lipase and amylase.
  • Other active components such as epidermal growth factor, insulin, insulin-like-growth factor and relaxin5.
There is some evidence that women who have protein-deficient diets, particularly if there are deficiencies in other dietary components, have a reduction in total protein and non-protein nitrogen in their breastmilk. There is not data to date to indicate whether there is an adverse effect on infant growth or development1.

Fat

The fat content of human milk is approximately 40 g/L6 but varies (35 and 45 g/L) between women, between breastfeeds for the same woman and within a breastfeed1. Fats provide between 45 and 55 percent of the total energy needs of the infant as well as providing essential fatty acids and a mechanism for the delivery of fat-soluble vitamins1. The majority of fats (98–99%) are in the form of triglycerides – 85 percent of which are medium and long chain fatty acids. These include essential fatty acids linoleic and alpha-linolenic acid as well as the omega-3 and omega-6 LCPUFAs arachindonic acid and docosahexaenoic acids, important for the development of the nervous system and membrane structure. Small amounts of phospholipids (integral for myelinization and development of the retina) and cholesterol are also present (1,6).

Medium chain fatty acids are synthesised in the breast while other fats are primarily derived from dietary sources. When the maternal diet is unable to provide the fats needed, long chain fatty acids are derived from the breakdown of maternal fat stores. Therefore the composition of fat in human milk, but not the concentration, will vary depending on maternal diet. Cholesterol levels are not affected by the maternal diet or blood levels6.

Fat concentration in breastmilk rises throughout the feed. However fat content is closely related to the degree of breast fullness with fat concentration being lowest when the breasts are full, and highest when the breasts are well drained. A milk sample with a fat content of more than 10 percent indicates that the breast is well drained7. For a woman with a large milk storage capacity whose infant does not drain the breast at each feed, the fat concentration at the beginning of one feed may be higher than the fat concentration at the end of another feed8. As a reflection of breast drainage, fat content is higher in the day and evening than in the morning and night8.


© J.Kent, Biochemistry & Molecular Biology, UWA

This is a series of sample from an expression collected in 10mL fractions. The samples are, in order from left to right, a foremilk sample (hand-expressed), a stimulation sample (the first milk removed by the breast pump), 7 samples collected during the expression, and a final sample hand-expressed after theexpression. the initial sample is 5.6% cream (fat) and the final is 18.3% cream (fat).

Breastmilk contains bile-salt stimulated lipase that assists lingula, gastric and pancreatic lipase to digest milk fats1.

Vitamins

Women with adequate vitamin intake and stores produce milk that is also has adequate vitamin concentrations. Increasing vitamin intake in these women does not necessarily increase milk vitamin concentrations. However, if the maternal vitamin status is low, milk vitamin concentrations also tend to be low and the infant may become deficient. Maternal supplementation in most of these situations rapidly returns milk concentrations to normal. Two vitamins require special mention.

Vitamin D
Vitamin D levels in breastmilk are not adequate to completely supply the needs of the infant, with sunlight being the natural source of Vitamin D for infants and their mothers. When direct sun exposure is restricted (e.g. climatic conditions, cultural clothing or to protect skin from solar damage) or skin colour reduces the effect of sun exposure, mothers and their infants may become Vitamin D deficient. Those most at risk of Vitamin D deficiency are dark-skinned women, women who are veiled and those who live in high latitudes where sun exposure, especially in winter, is limited. Some countries recommend supplementing all breastfed infants with Vitamin D9 while others recommend women at risk be monitored and their infants supplemented when necessary10.
Vitamin B12
Women with pernicious anaemia, on a strict vegan diet that is deficient in Vitamin B12 or with other causes of Vitamin B12 deficiency will produce milk that is also deficient in the vitamin. The infants may develop irreversible neurological sequelae if not diagnosed and supplemented11.

Minerals

In contrast to vitamins, mineral levels in milk are usually independent of maternal intake. Binding proteins and other transfer factors present in breastmilk enhance the absorption by the infant of minerals and other trace elements so that even apparent low concentrations of specific minerals have a high bioavailability. In contrast, infant formulas often have high mineral concentrations (up to 100 times that of breastmilk) to compensate for their low bioavailability12.

Calcium
Calcium levels in breastmilk are 25–30 g/L and appear to be independent of maternal dietary calcium intake (12,13). Lactose and citrate in breastmilk aid calcium absorption. During the early months of lactation, there is a reduction in maternal bone mineralisation, particularly of the trabecular bones such as the spine and hip, although this is reversed later in lactation and after breastfeeding ceases. This demineralisation is not related to maternal calcium intake – calcium supplementation does not prevent or reduce the effect14. There is no evidence that breastfeeding has a detrimental effect on long-term bone mineralisation or is a risk factor for the development of osteoporosis. Women who become pregnant during or soon after lactation remineralise their bones in early pregnancy13.
Iron
Breastmilk appears to have very low iron levels (0.2-0.4mg/L), but its bioavailability is high so that term infants, who have laid down iron stores before birth, do not require additional sources of iron until around six months of age. Breastmilk concentrations appear to be independent of maternal iron status12. Lactoferrin binds iron in breastmilk and is thought to play a role in its absorption although other factors are also relevant. Vitamin C is known to increase iron absorption12. Phylates, present in cereals, interfere with the absorption of iron. As infant cereals (often supplemented with iron) are often the first weaning foods, this may be a reason why breastfed infants given solids before six months are more likely to be iron deficient at nine months than infants exclusively breastfed for at least six months12. Iron supplementation of infants who are not iron deficient appears to increase episodes of diarrhoea15.
Iodine
Iodine concentration in breastmilk varies depending on maternal iodine status. Although iodine is concentrated in breastmilk, in areas where iodine deficiency is prevalent and goitre formation common, iodine deficiency in breastfed infants can occur16. The use of iodised salt and other iodine supplements by the mother, where appropriate, ensures maternal iodine sufficiency and adequate iodine intake for the infant17.

Changes in milk composition

Over time
The concentration of various components of breastmilk changes over the course of lactation. Compared with mature milk (outlined previously), colostrum has higher concentrations of protein (especially immunoglobulins), sodium and chloride and lower concentrations of lactose, potassium, calcium and citrate7. Many of these differences are due to the closure of the tight junctions between the lactocytes with the onset of lactogenesis II. Lactose levels remain relatively stable over the course of lactation. However, fat content falls during the first four months of lactation, but rises again until 12 months while protein concentration decreases until six months and then remains stable18. While most micronutrient levels stay constant over time, there is a gradual fall in zinc, copper, Vitamin A and potassium levels. None of these variations reduces the overall nutritional value of breastmilk consumed by the infant – infant growth is related to milk volume consumed and not the concentration of particular macronutrients7. During weaning, breastmilk returns to a more colostral composition with higher concentrations of immunoglobulins, sodium and chloride19.
Length of gestation
The milk produced by mothers who have delivered prematurely differs from milk produced by mothers delivered at term. In particular, there are higher concentrations of protein, mainly IgA and lactoferrin, as well has increased levels of calcium, phosphorus and zinc3. While fat levels are similar, there is a higher proportion of medium chain fatty acids in pre-term milk6.

Milk yield

Milk production remains at a similar level from the end of the first month until the sixth month of lactation. Although the amount of milk needed for adequate growth varies considerably (440–1220 ml/day) most women will produce between 710 and 803 mls/day8. Volume of milk produced at the end of the first week postpartum is predictive of milk production at six weeks20. From six months, with the addition of solid foods to the infant's diet, milk production gradually falls, although many women still produce over 500mls of breastmilk a day at 12 months21.

Notes

  1. # Picciano MF (2001) Nutrient Composition of Human Milk
  2. # Czank C et al. (2007) Human milk composition - carbohydrates
  3. # Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession
  4. # Czank C et al. Human milk composition - nitrogen and energy content
  5. # Walker M (1993) A fresh look at the risks of artificial infant feeding
  6. # Czank C et al. (2007) Human milk composition - fat
  7. # Kent JC (2007) How breastfeeding works
  8. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
  9. # AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk
  10. # Munns C et al. (2006) Prevention and treatment of infant and childhood vitamin D deficiency in Australia and New Zealand: a consensus statement
  11. # Rasmussen SA et al. (2001) Vitamin B12 deficiency in children and adolescents
  12. # Lonnerdal B (1997) Effects of milk and milk components on calcium, magnesium, and trace element absorption during infancy
  13. # Prentice A (2003) Micronutrients and the bone mineral content of the mother, fetus and newborn
  14. # Kovacs CS (2005) Calcium and bone metabolism during pregnancy and lactation
  15. # Allen LH (2005) Multiple micronutrients in pregnancy and lactation: an overview
  16. # Semba RD et al. (2001) Iodine in human milk: perspectives for infant health
  17. # Zimmermann MB (2007) The impact of iodised salt or iodine supplements on iodine status during pregnancy, lactation and infancy
  18. # Mitoulas LR et al. (2002) Variations in fat, lactose and protein in human milk over 24 h and throughout the first year of life
  19. # Hartmann PE et al. (1985) Variations in the yield and composition of human milk
  20. # Hill PD et al. (2005) Comparison of milk output between mothers of preterm and term infants: the first 6 weeks after birth
  21. # Kent JC et al. (1999) Breast volume and milk production during extended lactation in women

3.5 Slowing of growth

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.

You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?

Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.

Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?

Topic 3.3: Contraception
Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.

Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.

Topic 3.4: Milk composition
The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant.

Is there any concern about a slowing of growth around this time?

Topic 3.5: Slowing of growth
Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.

Is there any concern about a slowing of growth around this time?

Infant growth is highest in the first few months postpartum and then begins to slow so a decrease in the rate of growth at this age is normal. Additionally, after three months of age breastfed infants gain weight at a slower rate than formula-fed infants, so that by six months they are lighter1 and this is maintained until at least twelve months2.

Most growth charts in use were developed in the United States from cross-sectional data of cohorts of infants who were mainly formula-fed, or contained a mixture of formula-fed and breastfed infants. On these charts, breastfed infants often began to deviate from a specific percentile after four to five months although they continued to thrive otherwise. In 2006 the WHO released new growth standards based on longitudinal data of healthy breastfed infants and children from seven countries. These charts reflect how well-nourished breastfed infants 'should' grow rather than the actual growth in a given population. In comparison to the CDC charts commonly used, the mean weight in the WHO standards is higher for the first six months but is lower from 6 to 32 months3. WHO standards for infant BMI are also available to allow for difference in growth parameters between different racial groups.

Notes

  1. # Dewey KG et al. (1992) Growth of breast-fed and formula-fed infants from 0 to 18 months: The DARLING study
  2. # Dewey KG et al. (1993) Breast-fed infants are leaner than formula-fed infants at 1 y of age: the DARLING study
  3. # de Onis M et al. (2007) Comparison of the WHO Child Growth Standards and the CDC 2000 Growth Charts

3.6 Introducing solids

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.

You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?

Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.

Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?

Topic 3.3: Contraception
Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.

Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.

Topic 3.4: Milk composition
The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant.

Is there any concern about a slowing of growth around this time?

Topic 3.5: Slowing of growth
Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.

Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?

Topic 3.6: Introducing solids
Breast milk alone is sufficient for growth and development until the infant is around six months of age. Appropriate complementary foods from that time will provide extra energy (especially protein) and micronutrients such as iron and zinc.

Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?

A systematic review commissioned by WHO and released in 2001 found that in most circumstances growth and nutrition of infants exclusively breastfed until six months was no different from those who had complementary foods added to their diet at four months1. In addition, there appeared to be an increase in gastrointestinal illness in infants exclusively breastfed for three instead of six months2. A recent United States study also suggests that the incidence of otitis media and respiratory infection is higher when infants are introduced to complementary foods at four months rather than six months3. The WHO, the NHMRC in Australia, the AAP and bodies throughout the world recommend, at a population level, that infants be exclusively breastfed for the first six months of life(4,5,6). Infants who are at risk of becoming deficient in micronutrients such as iron (e.g. premature infants who have limited iron stores) benefit from medicinal supplements rather than the early introduction of solids7.

After six months, breast milk alone may not provide enough energy (especially protein) for adequate growth, and deficiencies in some micronutrients such as iron and zinc may occur. Therefore, nutrient-rich foods with adequate iron content are the most appropriate solid foods at this age. In developed countries, infants aged six to eight months require approximately 130kcal/day from two or three meals of complementary food. This increases to three or four meals plus one or two nutritious snacks to provide 310 kcal/day at nine to 11 months and 580 kcal/day at 12 to 23 months. Although foods at six months tend to be pureed, mashed or semi-solid, by eight months most infants can manage finger food and by 12 months should be eating the same foods as the rest of the family7. If possible, meats should be introduced early as good sources of protein and micronutrients8. Low-fat products are not appropriate for infants or toddlers.

Notes

  1. # Kramer M et al. (2002) The optimal duration of exclusive breastfeeding. A systematic review.
  2. # Kramer M et al. (2003) Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding
  3. # Chantry CJ et al. (2006) Full breastfeeding duration and associated decrease in respiratory tract infection in US children
  4. # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers
  5. # AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk
  6. # World Health Organization (2003) Global Strategy for Infant and Young Child Feeding
  7. # Dewey KG (2002) Guiding Principles for Complementary Feeding of the Breastfed Child
  8. # Krebs NF et al. (2007) Complementary feeding: clinically relevant factors affecting timing and composition

3.7 Weaning

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.

You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?

Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.

Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?

Topic 3.3: Contraception
Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.

Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.

Topic 3.4: Milk composition
The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant.

Is there any concern about a slowing of growth around this time?

Topic 3.5: Slowing of growth
Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.

Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?

Topic 3.6: Introducing solids
Breast milk alone is sufficient for growth and development until the infant is around six months of age. Appropriate complementary foods from that time will provide extra energy (especially protein) and micronutrients such as iron and zinc.

What recommendations would you give Joanne about the appropriate time to wean Rosie from the breast?

Topic 3.7: Weaning
There is no set maximum time for breastfeeding to continue although the minimum recommended time for weaning is 12 months (NHMRC, AAP) or two years (WHO). Gradual weaning is ideal.

What recommendations would you give Joanne about the appropriate time to wean Rosie from the breast?

There is no set maximum time for breastfeeding to continue although the minimum recommended time for weaning is 12 months. The WHO recommends breastfeeding for at least two years, with continued breastfeeding for as long as the mother and infant wish1, while the NHMRC recommends continued breastfeeding for at least the first 12 months and then for as long as the mother and infant wish2. Katherine Dettwyler, an anthropologist who has studied the natural weaning age of primates, suggests that without social constraints human children would naturally wean aged between two and a half and seven years3. Breast milk continues to provide immunological benefits to the infant/child until weaning4, and adequate growth is maintained when appropriate complementary foods are given in addition to breastfeeding5.

Gradual weaning, regardless of the age of the infant or child, is ideal. When the child is older, other foods and fluids gradually replace breastfeeds as a source of nourishment so that the child may only be breastfeeding night and morning. These feeds can then be dropped one at a time by providing other foods or distractions at the time. If the child or infant is younger and breastfeeding constitutes all or most of their nourishment, a more structured weaning process is usually required. First, one breastfed is replaced by infant formula. The mother may experience breast engorgement because of this change in feeding routines. A second breastfeed is replaced when the mother feels ready, but it is ideal to wait at least a few days. A similar process continues until the infant is not having any breastfeeds.

Rapid or immediate weaning is not recommended

Rapid or immediate weaning is not recommended unless there is no alternative. It is often physically and psychologically very distressing for both the mother and infant. The mother will also experience painful engorgement and is at increased risk of mastitis. Beyond the immediate postpartum period, lactation suppression medications such as cabergoline have reduced effectiveness.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # World Health Organization (2003) Global Strategy for Infant and Young Child Feeding
  2. # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers
  3. # Dettwyler KA (2004) When to wean: biological versus cultural perspectives
  4. # Goldman A et al. (1983) Immunologic components in human milk during the second year of lactation
  5. # Buckley KM (2001) Long-term breastfeeding: nourishment or nurturance?

4.0 Case Study D (Sally)

Key Points - Case Study D

Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?

Topic 4.1: Initial assessment
To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.

Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.

Topic 4.2: Milk production
Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.

What may cause inadequate growth in breastfed infants such as Emily?

Topic 4.3: Causes of inadequate infant growth
The main reasons for inadequate growth in a breastfed infant are: reduced milk intake due to suboptimal feeding patterns or routines; low milk supply; difficulty transferring milk; and increased energy expenditure in the infant.

How could Sally increase her milk supply?

Topic 4.4: Increasing milk supply
To increase a mother's milk supply correct any underlying problems, if possible, and increase breast drainage. Encourage adequate rest and a balanced diet. Some women require galactagogues. Some infants who are malnourished at presentation, or do not respond to effective, frequent feeding, may need supplementation with donor breast milk or infant formula.

4.1 Initial assessment

Key Points - Case Study D

Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?

Topic 4.1: Initial assessment
To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.

Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?

Assessment would need to include information relating to the adequacy of breast milk intake, breast or nipple problems and maternal confidence, and physical examination of the infant.

Questions about breast or nipple problems and maternal confidence

Breast and nipple concerns

Although the nipples may have been tender in the first week, tenderness usually subsides by 10 to 14 days postpartum, with some latch-on tenderness remaining7. Breasts feel fuller before a feed and softer after the infant has fed.

Take note if the:

  • nipples are sore and cracked;
  • breasts are soft most of the time; or
  • breasts are hard and painful.

Confidence

Is the mother feeling confident attaching the infant to the breast and knowing that he or she is feeding well? Although it takes time to feel confident with all aspects of infant care, increasing confidence is often a sign that the mother is adapting to motherhood and breastfeeding.

Take note if the mother:

  • is having difficulties attaching the infant to the breast;
  • lacks confidence with her mothering skills and her milk supply; or
  • appears depressed.

Infant examination

Weight gain

Most infants will lose some weight (usually <7 percent of their body weight) in the first two to three days postpartum but begin to gain again with the onset of copious milk production around day three. Weight loss of >10 percent is suggestive of insufficient breast milk intake8. It is expected that infants will regain their birth weight by day 10 to 148 and continue to gain more than 150 g/week (or 500g/month) in the first three months9. It is important the scales used are accurate and have sufficient precision to be able to monitor weights correctly. Variations in weight can occur with elimination and feeding patterns (e.g. weighing before or after a large bowel motion, or before or after a breastfeed may make a significant difference to estimated weight gain), as well as different scales.

Take note if the infant:

  • loses more than 7 percent of body weight (especially if the loss is >10 percent); or has not regained birth weight by two weeks;
  • regularly gains less than 125gms per week.

Jaundice

Jaundice is a common condition in the first week. Breastfed infants are more likely to become jaundiced and remain jaundiced for longer if their energy intake is low. (See Case B for further information about breastfeeding and jaundice.)

Take note if jaundice continues to progress after hospital discharge.

General examination

Assess the infant's state of hydration, muscle tone, subcutaneous fat and general demeanour.

Take note if the infant:

  • appears dehydrated;
  • has little subcutaneous fat; or
  • is apathetic and listless.

An abnormality in any one of the indicators listed above must be assessed in the context of any previous assessments and with the remaining indicators. Sometimes the best indicators of underfeeding are a change in some of the indicators mentioned – for example, a reduction in the wetness or number of wet nappies, fewer bowel motions or excessive sleepiness.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
  2. # Butte NF et al. (1985) Feeding patterns of exclusively breast-fed infants during the first four months of life
  3. # Hill PD et al. (2005) Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants
  4. # Shrago LC et al. (2006) The Neonatal Bowel Output Study: indicators of adequate breast milk intake in neonates
  5. # Nommsen-Rivers LA et al. (2008) Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy
  6. # Weaver LT et al. (1988) The bowel habit of milk-fed infants
  7. # Ziemer MM et al. (1993) Skin changes and pain in the nipple during the 1st week of lactation
  8. # Powers NG (2001) How to assess slow growth in the breastfed infant. Birth to 3 months.
  9. # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers

4.2 Milk production

Key Points

Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?

Topic 4.1: Initial assessment
To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.

Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.

Topic 4.2: Milk production
Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.

Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.

What initiates and controls milk production?

Hormones necessary for the development of the breasts during pregnancy and the subsequent secretion of colostrum and milk include (but are not limited to) placental lactogen, oestrogen, progesterone, prolactin, glucocorticoids, thyroxin and growth hormone.

During the first half of the pregnancy, mammogenesis occurs with growth and proliferation of the TDLUs, resulting in an increase in breast size for most women. Continued growth occurs during the second half of pregnancy, along with the differentiation of alveolar cells into lactocytes and the production of small quantities of secretion (colostrum) (lactogenesis I)(1,2). High oestrogen levels during the pregnancy stimulate the release of prolactin. However, progesterone inhibits the effect of prolactin on the lactocytes and thus production of milk. Nevertheless, colostrum production is related to prolactin levels. Junctions between the lactocytes are not tightly closed during pregnancy, enabling lactose secreted into the alveoli to enter the maternal bloodstream and be excreted by the kidney. Urinary lactose levels indicate lactogenesis I has occurred and have been used to calculate the amount of colostrum produced each day (30mls)3. As the breasts are capable of producing milk from the middle of pregnancy, delivery of the foetus/infant from that time will result in an increase in milk production – often an unexpected and unwanted development if the pregnancy ends in miscarriage or the infant is not viable.

In the presence of high levels of prolactin and with a primed mammary epithelium lactogenesis II, the onset of copious milk production begins with the delivery of the placenta and the subsequent drop in progesterone levels4. The tight junctions between lactocytes close, preventing the passage of molecules from the maternal circulation to alveolar spaces and resulting in an increase in lactose and a decrease in sodium and chloride levels in the milk secreted. As lactogenesis II progresses, the fat levels increase, as does the concentration of citrate, potassium, casein, calcium and phosphate1. Concentrations of Secretory IgA and lactoferrin also rise during the first 48 hours, but then fall – mainly due to an increase in milk volume rather than a decrease in the total amount secreted. Copious milk production begins around 36 hours postpartum with the volume increasing up to ten times over the next 36 hours. Lactose synthesis largely determines the volume of milk produced as its osmotic activity draws water into the lactocytes and thus to milk2. Women experience this increase in milk volume as "milk coming in"5.

Although lactogenesis II is primarily hormonally driven, regardless of milk removal, there is some evidence that early, frequent feeding increases subsequent breast milk volumes and it is hypothesised that for some women milk removal is necessary for closure of the tight junctions4. Regardless, by day three milk removal is essential for continued milk production.

Prolactin is produced by the anterior pituitary gland under the control of the hypothalamus. In response to tactile stimulation of the nipple (usually the infant breastfeeding), levels rise, peaking after 25 to 40 minutes and returning to resting levels by 180 minutes6. Both resting levels and suckling-evoked peaks are highest in the first month or so after birth, and then gradually fall so that by six months postpartum the resting levels are only slightly higher than those of non-lactating women7, although milk volumes appear unaltered. Therefore, while prolactin is essential for the initiation of lactation, it is not the main determinant of ongoing milk production.

Oxytocin, an octapeptide produced by the posterior pituitary, is released in a pulsatile fashion in response to the infant suckling at the breast. Oxytocin causes contraction of myoepithelial cells surrounding the mammary ducts, resulting in shortening and widening of the ductal structures and expulsion of milk through the nipple. This reflex, called the milk-ejection or let-down reflex, is essential for the removal of milk already stored in the breast. It can be conditioned so that seeing the infant, or hearing the infant cry in preparation for a breastfeed, results in a rise in oxytocin levels8 and in a milk-ejection. Conversely, the milk-ejection reflex can be inhibited by stimuli such as pain and other stressful events (6,9). Mothers often recognise milk ejection by a tingling sensation in the breast soon after the infant begins to feed, milk dripping from the "other" breast, or a change in the infant's sucking pattern.

Risk factors for a delay in Lactogenesis II

Click on the bullet points below for more detail:

  • Diabetes
    • Women with IDDM have a delay in the onset of copious milk production of approximately 28 hours, although their milk volumes by day seven are within the normal range. As insulin is necessary for lactogenesis and glucose is an important substrate for milk production, it is uncertain whether women with poorly controlled diabetes are more at risk (10,11). There does not appear to be a similar delay in women with gestational diabetes11.
  • Primiparity
    • Primiparous women, especially those with large infants, notice an increase in breast fullness later than multiparous women12. In addition, multiparous women produce higher milk volumes on day seven (13,14).
  • Caesarean section
    • After adjusting for timing of the first feed and other confounders, the amount of milk an infant delivered by caesarean section receives during the first six days of life is less than that received by infants delivered vaginally15. Other studies have also noted a delay in the onset of milk production for women who have undergone caesarean section12, especially if the caesarean section was unplanned16.
  • Stress and pain in labour
    • Difficult and protracted labours, especially with a long second stage, have also been associated with a delay in lactogenesis II16.
  • Obesity
    • The onset of lactation for women with a body mass index in the obese range is delayed (12,16,17). Additionally, overweight and obese women are less likely to be breastfeeding at six months than normal weight women18.
  • Preterm delivery
    • Women who deliver prematurely tend to produce less milk than women whose infants are born at term19. This effect is often thought to be due to the differences in both the frequency and mechanism of milk removal. However, 82 percent of women who delivered prematurely had at least one of four markers for lactogenesis II outside the normal range on day five (compared with no abnormal markers for women who delivered at term)20. These women also had reduced milk production.

After the initiation of lactation, the most important determinant of ongoing milk production (lactogenesis III or galactopoiesis) is milk removal. Short-term milk synthesis rates are related to the degree of fullness of the breast so that milk is made at a much faster rate when the breasts are drained, compared with when they are full21. A milk protein that inhibits milk production has been found in animal studies, and it is thought that a similar autocrine mechanism is also present in humans. Thus the daily amount of milk a mother makes will be determined by the frequency with which her infant feeds, and the degree of breast emptying at each feed (i.e. the infant's appetite).

There is great variation between mothers in the amount of milk each breast is able to store (e.g. 74 to 382 mls)22. The infants of women with small storage capacities will tend to remove all or most of the available milk at each feed and feed more frequently1, while infants of mothers with large storage capacities may only remove a proportion of the milk available even though they may consume more milk per feed. On average, infants do not remove all available milk at each feed22. The differences in storage capacities between mothers helps explain the differences in feeding patterns between mother–infant couples – including the number and timing of feeds, and whether the infant feeds from one or two breasts at each feed. Therefore, watching for feeding cues and following the infant's lead regarding the pattern of feeding is the most appropriate way to ensure adequate milk production and infant growth.

Notes

  1. # Kent JC (2007) How breastfeeding works
  2. # Czank C et al. (2007) Hormonal control of the lactation cycle
  3. # Cox DB et al. (1999) Breast growth and the urinary excretion of lactose during human pregnancy and early lactation: endocrine relationships
  4. # Neville M et al. (2001) Physiology and Endocrine Changes Underlying Human Lactogenesis II
  5. # Neville M et al. (2001) Lactogenesis: The transition from pregnancy to lactation
  6. # Hartmann PE et al. (1995) Endocrine and autocrine strategies for the control of lactation in women and sows
  7. # Cox DB et al. (1996) Blood and milk prolactin and the rate of milk synthesis in women
  8. # McNeilly A et al. (1983) Release of oxytocin and prolactin in response to suckling
  9. # Ueda T et al. (1994) Influence of psychological stress on suckling-induced pulsatile oxytocin release
  10. # Arthur PG et al. (1989) Milk lactose, citrate, and glucose as markers of lactogenesis in normal and diabetic women
  11. # Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity
  12. # Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss
  13. # Hill PD et al. (2005) Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants
  14. # Ingram J et al. (2001) Breastfeeding: it is worth trying with a second baby
  15. # Evans K et al. (2003) Effect of casearean section on breast milk transfer to the normal term newborn over the first week of life
  16. # Chapman D et al. (1999) Identification of risk factors for delayed onset of lactation
  17. # Rasmussen KM et al. (2001) Obesity may impair lactogenesis II
  18. # Oddy WH et al. (2006) The association of maternal overweight and obesity with breastfeeding duration
  19. # Hill PD et al. (2005) Comparison of milk output between mothers of preterm and term infants: the first 6 weeks after birth
  20. # Cregan MD et al. (2002) Initiation of lactation in women after preterm delivery
  21. # Daly SE et al. (1993) The short-term synthesis and infant-regulated removal of milk in lactating women
  22. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day

4.3 Causes of inadequate infant growth

Key Points - Case Study D

Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?

Topic 4.1: Initial assessment
To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.

Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.

Topic 4.2: Milk production
Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.

What may cause inadequate growth in breastfed infants such as Emily?

Topic 4.3: Causes of inadequate infant growth
The main reasons for inadequate growth in a breastfed infant are: reduced milk intake due to suboptimal feeding patterns or routines; low milk supply; difficulty transferring milk; and increased energy expenditure in the infant.

What may cause inadequate growth in breastfed infants such as Emily?

Reduced milk intake due to feeding patterns or routines

Frequency
As mentioned earlier, most infants require at least eight breastfeeds a day in the early months of life (i.e. at least every three hours). However, breastfeeds are not usually spaced evenly throughout the day. At times the infant may want to feed every 30–60 minutes (cluster feeds) while they may go for a longer stretch during the night. Feeding frequency is positively correlated with milk volume in the early weeks1. Additionally, because of the differences in maternal storage capacities and infant feeding cues, stipulating a specific number of breastfeeds at equal intervals throughout the day limits the volume of milk the infant receives and reduces breast stimulation and drainage necessary for further milk production. Night-time feeds are also important for ongoing breastfeeding, especially in the early weeks and months.
Length of feeds
In the first few weeks postpartum, most infants will take between 20 and 40 minutes to feed; however, the length of effective sucking will vary between infants and between feeds by the same infant. However, limiting the time at the breast, or removing the infant from the breast after a specified time, may not allow the infant to receive as much milk as he or she needs, especially if the milk-ejection reflex is slow. Conversely, infants who spend a long time at the breast (>50 minutes routinely) may not be feeding effectively for some or all of that time, and the breastfeeds may need to be assessed by a trained observer.
One breast or two

Fat concentration of breast milk is correlated with the degree of breast fullness – with the fat concentration increasing as the breast is drained. Concern has been expressed that infants feeding from both breasts at each feed when their mothers' milk supply is large would receive a low-fat, high-volume feed resulting in symptoms of lactose intolerance and large, or rarely low weight gain2. Conversely, mothers may initially be encouraged to feed from only one breast at each feed while their breasts are very full or engorged, or to ensure their infant receives the higher fat milk when the breast is drained. This advice can be interpreted as only ever feeding from one breast at each feed. For many infants, this routine will not provide sufficient milk volume for adequate growth.

The ideal situation is to allow the infant to feed from one breast for as long as he or she is feeding effectively, and then offer the second breast. Most infants (57%) will take one breast at some feeds and two breasts at others, while some infants will only ever use one breast at each feed (30%) and others will always use two breasts (13%)3. Most infants with signs and symptoms of lactose overload respond well when allowed to determine whether they feed from one breast or two at a feed. Lactose-free formula is not necessary nor appropriate management.

Use of breast/breast milk substitutes

Dummy or pacifier use has been associated with reduced breastfeeding duration (4,5). Dummies are thought to reduce the desire of the infant to feed at the breast, especially if used to quieten the infant rather than feeding him or her, or alter the infant's sucking pattern. However, it is difficult to determine whether dummies initiate breastfeeding problems or are used because of them.

Complementary feeds also reduce the infant's desire to feed at the breast. If the complement is infant formula, the infant's weight may not be affected, but milk supply will invariable decrease unless measures are instituted to increase milk production.

Feeding routines that reduce breast drainage not only affect infant growth, but also adversely affect ongoing milk supply.

Low milk supply

Hormonal reasons
  • Retained products of conception. A rapid decrease in progesterone levels is essential for the initiation of lactation. When progesterone levels fail to fall to pre-pregnancy levels due to retained products of conception, milk production is often slow to begin and does not reach normal levels. Removal of the retained products usually results in a rapid increase in milk volume (6,7).
  • Sheehan's syndrome and postpartum haemorrhage. Sheehan's syndrome, due to ischaemic necrosis of the pituitary gland following hypotension related to severe postpartum haemorrhage, may present initially with failure to lactate. Some authors report women experiencing a delay in the initiation of lactation, or low milk supply following episodes of postpartum hypotension (usually due to postpartum haemorrhage), although the remainder of the pituitary function is intact (8,9). Another study showed a relationship between postpartum anaemia and apparent insufficient milk, leading to early weaning10. Although the study did not report the reasons for anaemia, excessive peripartum blood loss may have contributed.
  • Thyroid disorders. As thyroxine is also required for ongoing milk production, women with hypothyroidism are at risk of having a low milk supply. Adequate treatment with thyroxine allows breastfeeding to commence and continue normally11. Postpartum thyroiditis often presents initially with hyperthyroidism, with many women becoming hypothyroid with time12.
  • Other hormonal disorders. There is some evidence that women with polycystic ovaries (13,14) and theca-lutean cysts (15,16) are more likely to have difficulty establishing their milk supply or produce a low milk volume. In rare instances, an isolated prolactin deficiency leads to alactogenesis (17,18,19).
Smoking
Women who smoke are less likely to initiate lactation and breastfeed for a shorter length of time. However, it is uncertain whether this effect is due to a lack of maternal motivation or a direct effect of nicotine or other substance on milk production (20,21,22).
Obesity
As described previously, women who are overweight or obese have difficulty establishing breastfeeding are less likely to continue to breastfeed.
Medications
Some medications such as the oral contraceptive pill23, pseudoephedrine24 and herbal preparations such as sage tea11 are known to inhibit milk production.
Anatomical problems
Some women lack sufficient mammary tissue to produce enough milk for their infant25. These women are more likely to have asymmetric underdeveloped breasts that are more widely spaced than normal (>4 cms). In extreme cases, the breasts sit on a small base with severe breast constriction and large nipple-areola complexes (tubular breasts)26. Lack of breast development during pregnancy and lack of postpartum breast fullness are often noted (26,27).
Breast surgery
Disturbance of ductal structures, reduction in the amount of glandular tissue and the severing of the afferent arm of the milk-ejection reflex (usually the lateral cutaneous branch of the 4th intercostal nerve) as a consequence of breast surgery can all impact on the mother's capacity to produce milk27. Breast reduction surgery nearly always results in reduced milk volume. Periareolar incisions, although cosmetically desirable, are more likely to interfere with the major lactiferous ducts and the milk-ejection reflex and have been associated with a reduction in nipple sensitivity (11,27).

Difficulty transferring milk

Poor positioning and attachment
Breast drainage is facilitated by optimal positioning and attachment of the infant at the breast. Case E describes the assessment of effective positioning and attachment.
Efficacy of the milk-ejection reflex
Contraction of the myoepithelial cells around the lactiferous ducts (the milk-ejection reflex), either stimulated by the infant or by expressing, is essential for the removal of milk from the breasts. Stress, pain or other factors may inhibit this reflex and must be considered when an infant is not gaining weight. While most mothers will be aware of this reflex working, it is often less noticeable for women with a low milk supply. Watching for changes in the infant's sucking pattern (from suck-suck-suck-swallow to suck-swallow, suck-swallow) may be a more reliable sign that milk is flowing.
Sucking problems
Some infants, even though they are positioned and attached to the breast well, have a poor or ineffective suck. Contributing factors include hyper or hypotonia, thumb-sucking in-utero, prematurity or illness. However, other infants may have tonic bites or are not able to coordinate tongue movements or maintain sufficient negative pressure to extract milk. These infants tend to slip off the breast easily and may "click" during the feed every time suction is broken. Their mothers often have damaged nipples.
Tongue-tie (ankyloglossia)
Further information about tongue-tie and its effect on breastfeeding is found in Case E.

Increased energy expenditure

Other medical conditions
Congenital heart disease, urinary tract infections and other medical conditions may initially present with low weight gain and failure to thrive. As well as having an increased energy expenditure, the infant may not be robust enough to adequately stimulate the breast, resulting in a secondary low supply problem.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Hill PD et al. (2005) Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants
  2. # Woolridge MW et al. (1988) Colic, "overfeeding", and symptoms of lactose malabsorption in the breast-fed baby: a possible artifact of feed management?
  3. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
  4. # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
  5. # Kramer MS et al. (2001) Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial
  6. # Anderson AM (2001) Disruption of lactogenesis by retained placental fragments
  7. # Neifert MR et al. (1981) Failure of lactogenesis associated with placental retention
  8. # Willis C et al. (1995) Infant insufficient milk syndrome associated with maternal postpartum hemorrhage
  9. # Livingstone V (2006) Failure to thrive while breastfeeding
  10. # Henly SJ et al. (1995) Anemia and insufficient milk in first-time mothers
  11. # Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession
  12. # de Swiet M (1995) Medical disorders in obstetric practice
  13. # Vanky E et al. (2008) Breastfeeding in polycystic ovary syndrome
  14. # Marasco L et al. (2000, May) Polycystic ovary syndrome: a connection to insufficient milk supply?
  15. # Betzold CM et al. (2004) Delayed lactogenesis II: a comparison of four cases
  16. # Hoover KL et al. (2002) Delayed lactogenesis II secondary to gestational ovarian theca lutein cysts in two normal singleton pregnancies
  17. # Saito T et al. (2007) A case of prolactin deficiency with familial puerperal alactogenesis accompanying impaired ACTH secretion
  18. # Douchi T et al. (2001) A woman with isolated prolactin deficiency
  19. # Kauppila A (1997) Isolated prolactin deficiency
  20. # Donath SM et al. (2004) The relationship between maternal smoking and breastfeeding duration after adjustment for maternal infant feeding intention
  21. # Giglia R et al. (2006) Maternal cigarette smoking and breastfeeding duration.
  22. # McAfee G ( 2007) Drugs of abuse and breastfeeding.
  23. # Hale TW (2007) Medications that alter milk production
  24. # Aljazaf K (2003) Pseudoephidrine: effects on milk production in women and estimation of infant exposure via breastmilk
  25. # Neifert MR et al. (1985) Lactation failure due to insufficient glandular development of the breast
  26. # Huggins K et al. (2000) Markers of Lactation Insufficiency: A study of 34 mothers
  27. # Neifert MR et al. (1990) The influence of breast surgery, breast appearance, and pregnancy-induced breast changes on lactation sufficiency as measured by infant weight gain

4.4 Increasing milk supply

Key Points - Case Study D

Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?

Topic 4.1: Initial assessment
To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.

Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.

Topic 4.2: Milk production
Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.

What may cause inadequate growth in breastfed infants such as Emily?

Topic 4.3: Causes of inadequate infant growth
The main reasons for inadequate growth in a breastfed infant are: reduced milk intake due to suboptimal feeding patterns or routines; low milk supply; difficulty transferring milk; and increased energy expenditure in the infant.

How could Sally increase her milk supply?

Topic 4.4: Increasing milk supply
To increase a mother's milk supply correct any underlying problems, if possible, and increase breast drainage. Encourage adequate rest and a balanced diet. Some women require galactagogues. Some infants who are malnourished at presentation, or do not respond to effective, frequent feeding, may need supplementation with donor breast milk or infant formula.

How could Sally increase her milk supply?

First, ensure there are no medical problems or other underlying factors that could be affecting Sally's milk supply or Emily's growth. Appropriate management of these factors is necessary in addition to the following suggestions to increase milk production.

Increase breast drainage

Click on the bullet points below for more detail:

  • Positioning and attachment
    • Ensure that the infant is positioned and attached well to the breast to maximise breast drainage (see Case E).
  • Feeds — frequency and length
    • Recommend that the infant be fed at least eight times a day. This may mean waking the infant to feed every two and a half to three hours during the day if he/she is sleeping for long periods of time. Feeding at least once during the night is also important. Switch feeds by swapping to the second breast once the infant ceases feeding effectively from the first and then swapping back to the first and then the second again until the infant is satisfied1.
  • Expressing
    • Because the rate of milk synthesis is higher with well-drained breasts, fully draining the breasts by expressing by hand or pump can increase overall milk production. This is especially important if the infant does not drain the breasts as a result of an ineffective suck, or due to tiring at the breast. Expressing immediately after a feed may yield very little milk if the infant is feeding effectively. Waiting an hour or so after a feed and then expressing may be more effective in increasing milk supply. The expressed milk can be fed to the infant by cup, spoon, dropper or bottle if the infant continues to be hungry after he or she has been fed.
  • Breast compression
    • By firmly compressing the breast when the baby stops sucking well, the milk flow increases and the infant begins to suck effectively again. Click on this link for PDFfurther information about breast compression[link: http://www.beyondbirth.ca/BeyondBirthDownloads/Breast%20compression-January%202005.pdf].
  • Inappropriate use of dummies and complements
    • As described previously, using dummies or providing the infant with other fluids or solids (under six months of age) may reduce the infant's desire to breastfeed and thus reduce breast drainage. Reducing the use of a dummy and complements increases the opportunities for the infant to breastfeed, thus increasing his or her milk input and increasing breast drainage.

Food and rest

While poor maternal diet and fatigue do not necessarily result in low milk supply, some women find improving their diet and resting when possible increases their milk production2. There is no evidence that increasing a mother's fluid intake will increase her milk supply, especially in women who are adequately hydrated (3,4).

Galactagogues

Herbal remedies such as fenugreek, goat's rue, blessed thistle and marshmallow have been used as galactagogues, although there is little evidence-based research to suggest that they have a significant effect on milk supply5. The two most commonly prescribed galactagogues are metoclopramide and domperidone, which increase prolactin levels by their antidopaminergic action. Both have been shown to increase prolactin levels and increase milk production in lactating women when prolactin levels are low, at doses of 10 mg three times a day (metoclopramide) and 10–20 mg three to four times a day (domperidone). Women appear to suffer few side-effects at these doses, although domperidone appears to cause fewer side-effects than metoclopramide. Milk transfer of the drugs to the infant is minimal. Tapering of the dose once the desired effect on milk supply has been achieved is recommended to minimise any reduction in supply (6,7).

Supplementation

Most infants will stabilise any weight loss and begin to gain weight using these suggestions without the need for additional supplementation. However, supplements of donor milk or infant formula may be required if the infant appears malnourished at presentation or does not respond to effective, frequent breastfeeding. A suggested minimum amount of supplement is 50ml/kg/day given in divided volumes after breastfeeds when the infant appears hungry1. As the mother's milk supply increases, the amount of supplement can be decreased. A supplemental nursing system can provide the supplement to the infant while he or she is feeding at the breast. This form of supplementation encourages further breast stimulation, and is often time efficient for the mother.


© B.Ingle IBCLC


Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Powers NG (2001) How to assess slow growth in the breastfed infant. Birth to 3 months.
  2. # Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession
  3. # Dusdieker LB et al. (1990) Prolonged maternal fluid supplementation in breast-feeding.
  4. # Morse JM et al. (1992) The effect of maternal fluid intake on breast milk supply: a pilot study
  5. # Humphrey S (2007) Herbal therapeutics during lactation
  6. # Hale TW (2007) Medications that alter milk production
  7. # Montgomery A et al. (2004) Clinical Protocol #9: Use of galactogogues in initiating or augmenting maternal milk supply

5.0 Case Study E (Anna)

Key Points - Case Study E

Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?

Topic 5.1: Sore nipples
Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.

What other conditions may contribute to nipple damage occurring in the first week postpartum?

Topic 5.2: Factors causing nipple damage
Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.

After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?

Topic 5.3: General treatment for sore nipples
The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.

Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?

Topic 5.4: Further causes of nipple pain
Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.

Anna's cracked nipples have some yellow exudate and appear inflamed. She is given a prescription for mupirocin; however, the next day she notices a firm, tender area in the upper inner aspect of her left breast that is gradually becoming more painful. She is beginning to feel unwell and has developed a fever. What is your diagnosis?

Topic 5.5: Mastitis – diagnosis
Mastitis is an inflammation in the breast, and in lactating women may cause breast pain, erythema, tenderness, heat and a lump as well as fever, rigors, myalgia and malaise. Predisposing factors include sore or cracked nipples, poor breast drainage, a past history of mastitis and maternal factors such as illness, stress or a depressed immune system.

What would be the appropriate treatment to give her now?

Topic 5.6: Mastitis – treatment and complications
Good breast drainage is an essential component of the treatment of mastitis. Antibiotics may be required, especially if the mother has moderate to severe local or systemic symptoms, that she has cracked nipples, or the symptoms have been present for more than 12 hours without improving. Recurrent infection, Candida and a breast abscess are complications of mastitis.

5.1 Sore nipples

Key Points - Case Study E

Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?

Topic 5.1: Sore nipples
Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.

Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?

Nipple tenderness, related to changes in the hormonal milieu1, is common in the first seven to 10 days postpartum, often peaking between days three and five (2,3). Antenatal nipple preparation4 or restricting the number or length of breastfeeds in the immediate postpartum period5 has not been shown to reduce the incidence of nipple tenderness or damage. Nipple cracks, grazes or significant pain indicate the occurrence of nipple trauma, usually associated with sub-optimal positioning and attachment of the infant at the breast6.

Poorly positioned and latched baby

Poorly positioned and latched baby.
© WHO

What is good attachment?

When an infant attaches well to the breast, his tongue is down and forward over the lower gum, his mouth is open wide so that the breast fills the oral cavity and the tip of the nipple reaches towards the junction of the hard and soft palate. In this position, there is little friction or trauma to the nipple. The nipple lying along the tongue and at the back of the hard palate is thought to elicit the sucking reflex. It is important to note that the infant breastfeeds not nipple feeds.

Well positioned and latched baby

Well positioned and latched baby.
© D.Fisher, IBCLC

To facilitate optimal attachment to the breast, the infant has to receive appropriate sensory input and positional stability to enable his or her innate reflexes to function7.

  • The mother holds the slightly flexed infant firmly and close to her body, ventral surface to ventral surface.
  • Support across the shoulders and lower neck provides the stability for appropriate head and neck movement.
  • The head, neck and body are aligned.
  • The infant is at breast level with the nipple opposite the infant's nose.
  • The mother often holds and shapes the breast in the plane of the infant's mouth, although her fingers should not be close enough to the nipple to interfere with attachment8.
  • As the infant opens his/her mouth wide, either instinctively or in response to contact with the breast/nipple, the mother brings the infant closer to the breast – chin first so that he/she takes more breast from the underside side of the breast than the upper side (asymmetric latch)8.

What to look for when assessing positioning and attachment

  • Mother is comfortable and has minimal pain or discomfort.
  • The infant faces the mother’s body and is held firmly.
  • The head, neck and body are aligned.
  • The chin is pressed into the breast, the nose is clear and the neck slightly extended.
  • Upper and lower lips are flanged and wide.
  • More areola is evident above the upper lip than below the lower lip.
  • The tip of the tongue is over the lower lip and may be seen. However, the infant is usually too close to the breast for this to be routinely observed.
  • After the first few minutes, the infant takes deep rhythmic sucks with wide excursion of the mandible. The cheeks do not cave in and there is no clicking noise, although audible swallowing is evident.
  • The nipple should not appear pinched or deformed after a feed.

Pause a moment

Visual assessment of positioning and attachment is only one aspect. If the mother is experiencing pain, something is wrong.9.

Notes

  1. # Robinson JE et al. (1977) Changes in breast sensitivity at puberty, during the menstrual cycle, and at parturition
  2. # Hewat RJ et al. (1987) A comparison of the effectiveness of two methods of nipple care
  3. # Ziemer MM et al. (1993) Skin changes and pain in the nipple during the 1st week of lactation
  4. # Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review
  5. # de Carvalho M et al. (1984) Does the duration and frequency of early breastfeeding affect nipple pain?
  6. # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers
  7. # Glover R (July 14-18 2004) Lessons from Innate Feeding Abilities Transforms Breastfeed Outcomes
  8. # Neifert MR (2004) Breastmilk transfer: Positioning, latch-on, and screening for problems in milk transfer
  9. # Renfrew MJ (1989) Positioning the baby at the breast: More than a visual skill

5.2 Factors causing nipple damage

Key Points - Case Study E

Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?

Topic 5.1: Sore nipples
Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.

What other conditions may contribute to nipple damage occurring in the first week postpartum?

Topic 5.2: Factors causing nipple damage
Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.

What other conditions may contribute to nipple damage occurring in the first week postpartum?

Nipple damage

Nipple damage caused by poor latch.
© S.Cox IBCLC

Engorgement

As the breasts become full with the onset of copious milk production (usually day three or four), they tend to loose their elasticity, the nipples become flatter and some infants have difficulty attaching properly to the breast. This is a common time for nipple damage to occur. Relieving breast fullness before commencing a feed by expressing a small amount of milk usually allows the infant to attach well and prevents or relieves further nipple trauma (see Case C).

Anatomical variations of mother

There are many variations in the size and shape of mothers' nipples and breasts, with most not interfering with breastfeeding. As long as the infant can draw sufficient breast into his/her mouth to form a teat so that the nipple area is near the junction of the hard and soft palate, breastfeeding can proceed normally. When the infant attaches but is unable to draw the nipple/breast far enough into his/her mouth, the nipple may become sore and cracked/traumatised.

Concern is often expressed regarding the ability to breastfeed, with flat or inverted nipples that were described in Case A. No specific treatment has been shown to "improve" nipple protractility antenatally (1,2), although flat nipples often become more elastic and flexible during pregnancy.

Infants find it easiest to attach to breasts with flat or inverted nipples when their reflexes are at their peak and the breasts are soft, usually within the first hour of birth. Being very careful about correct positioning and attachment from the first feed is important. Firm nipple substitutes such as bottle teats and dummies are a different shape and texture to the breast, and their use before the infant has had an opportunity to attach and breastfeed independently often leads to ongoing attachment difficulties. Devices, including breast pumps, the Avent Niplette™3 and modified disposable syringes4, can help draw out the nipple prior to a breastfeed. Some women also use these devices antenatally. Nipple shields may also provide protection to the nipple and a firm surface for the infant to attach to if he/she cannot attach unaided5.

A Modified Syringe

A Modified Syringe.
© Health e-Learning

Using a nipple shield

Using a nipple shield.
© Breastfeeding Atlas


Anatomical variations of the infant

Tongue-tie (ankyloglossia) and a high arched palate (genetic) or other palatal abnormalities from intubation (particularly in premature infants) can cause sore and traumatised nipples.

Ankyloglossia

Ankyloglossia.
© B.Ingle, IBCLC

Between 3.2 and 4.6 percent of infants are born with a tongue-tie (6,7). Tongue movement, such as the ability to protrude the tongue over the lower gum, cup a finger or the breast8 or to generate a normally shaped peristaltic wave may be limited when the sub-lingual frenulum extends further towards the tip of the tongue than normal. The degree to which breastfeeding is affected will depend on the movement restriction, the shape of the infant's mouth and the elasticity and shape of the mother's breast and nipple. In some situations (but not all), ankyloglossia results in ongoing severe nipple trauma that is not improved with corrections to positioning and attachment, and poor breast drainage9. Frenotomy (division of the tongue-tie) provides almost instantaneous pain relief, no further nipple trauma and improved attachment of the infant (7,8). The Hazelbaker Assessment Tool for Lingual Frenulum Function is an objective method of assessing the impact of a tongue tie on breastfeeding effectiveness and can be useful in deciding whether a frenotomy is necessary10.

Neurological issues with the infant

Neurological problems resulting in uncoordinated tongue movements, tonic bites or other abnormalities that preclude good attachment may present initially with sore/cracked nipples. Infants with these conditions require appropriate assessment and specialised assistance outside the scope of this resource11.

Inappropriate use of lactation aids

If the base of a nipple shield or the flange of a breast pump is too small for the nipple, pressure and friction can occur during use, exacerbating any nipple trauma already present. Different sized shields and pump flanges are available if needed. Pump pressure set too high can also prolong nipple pain.

High intra-oral pressure

Recent research indicates that the infants of some mothers who suffer from ongoing sore nipples without apparent cause generate much higher intraoral pressures than other infants12. Other researchers have identified different sucking behaviours amongst infants that may have an effect on their mothers' nipples13. Further research in this area will help elucidate further causes and treatments for nipple pain and trauma.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Alexander JM et al. (1992) Randomised controlled trial of breast shells and Hoffman's exercises for inverted and non-protractile nipples.
  2. # McCandlish R et al. (1995) MAIN Trial Collaborative Group. Antenatal treatments for flat or inverted nipples: the MAIN Trial results
  3. # McGeorge DD (1994) The "Niplette": an instrument for the non-surgical correction of inverted nipples
  4. # Arsenault G (1997) Using a disposable syringe to treat inverted nipples
  5. # Wilson-Clay B (1996) Clinical use of silicone nipple shields
  6. # Messner AH et al. (2000) Ankyloglossia: incidence and associated feeding difficulties
  7. # Ballard JL et al. (2002) Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad
  8. # Srinivasan A et al. (2006) Ankyloglossia in breastfeeding infants: The effect of frenotomy on maternal nipple pain and latch
  9. # Lalalea ML et al. (2003) Ankyloglossia: does it matter?
  10. # Amir LH et al. (2006) Reliability of the hazelbaker assessment tool for lingual frenulum function
  11. # Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession
  12. # McClellan H et al. (2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums
  13. # Mizuno K et al. (2004) Sucking behavior at breast during the early newborn period affects later breast-feeding rate and duration of breast-feeding

5.3 General treatment for sore nipples

Key Points - Case Study E

Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?

Topic 5.1: Sore nipples
Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.

What other conditions may contribute to nipple damage occurring in the first week postpartum?

Topic 5.2: Factors causing nipple damage
Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.

After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?

Topic 5.3: General treatment for sore nipples
The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.

After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?

Assess positioning and attachment

  • Provide appropriate assistance to ensure optimal attachment at all feeds.

Advice about breastfeeds

  • Commence feeds when the infant initiates feeding cues (beginning to root, hands to mouth), rather than waiting until he is very hungry and crying.
  • Start feeds on the least sore side. The baby can be swapped to the other side once milk is flowing freely.
  • If both sides are very painful, express (preferably by hand) until the milk is flowing freely, and then attach the infant.
  • Gently remove the infant from the breast by releasing the suction when he has stopped sucking effectively.
  • Suggest using different feeding positions.

Advice about nipple treatment

  • Warm water compresses provide some pain relief between feeds1.
  • Breast milk left to dry on the nipple may also be beneficial and is simple and readily available1.
  • There is no evidence that any particular topical treatment is effective in preventing or relieving nipple pain or cracks1.

Lactation aids

Breast shells or nipple airers lift clothing from the nipple and allow air to circulate2, providing pain relief for some women.

Rest nipples

If Anna finds it too painful to continue to breastfeed, she can express her milk (hand expression creates less nipple trauma) for 24 to 48 hours and feed this milk to Joshua with a cup, spoon or bottle. Once the nipples begin to heal, breastfeeds can gradually be reintroduced.

These measures should be used for all women with sore/cracked nipple, regardless of the cause, in conjunction with other treatments if necessary.

Notes

  1. # Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review
  2. # Brodribb W (2004) Breastfeeding Management

5.4 Further causes of nipple pain

Key Points - Case Study E

Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?

Topic 5.1: Sore nipples
Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.

What other conditions may contribute to nipple damage occurring in the first week postpartum?

Topic 5.2: Factors causing nipple damage
Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.

After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?

Topic 5.3: General treatment for sore nipples
The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.

Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?

Topic 5.4: Further causes of nipple pain
Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.

Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?

Infection

Click on the points below for more detail:

  • Staphylococcal infection
    • Colonisation of the nipple with Staphylococcus aureus appears to be a common occurrence in women with sore, cracked or fissured nipples. Symptoms include persistent sore nipples or non-healing cracks or fissures after resolution of any obvious cause. A yellow exudate in cracks or fissures may be evident. Women with proven Staphylococcus aureus colonisation have a much higher risk of mastitis than other breastfeeding women1.
    • Treatment (in addition to the measures discussed previously):
      • Clean affected nipples with warm salty water, especially if cracks and/or exudate are evident2.
      • Treat with ointment such as mupirocin (Bactroban) or oral antibiotics such as dicloxacillin or cephalexin. One study showed a reduction in the incidence of mastitis in women with infected nipples who were treated with oral rather than topical antibiotics1.
  • Thrush
    • Symptoms attributed to candida (usually Candida albicans) infection of the nipple and/or breast include persistent nipple pain (burning or stinging that last throughout and after a feed), very tender nipples, and breast pain (stabbing, shooting, like hot cords) that often radiates through the breast to the back. There may be no obvious abnormality seen on clinical examination or the skin of the nipple/areola may be red, shiny or flaky. Nipple fissures and cracks may fail to heal3. The infant may have oral thrush or candida nappy rash and the mother may have a history of vaginal thrush.
      • Treatment (both mother and infant need to be treated):
        • Infant – miconazole oral gel qid4, or nystatin oral drops, one drop in each cheek qid for a week and then daily until one week after symptoms resolve.
        • Mother – wash nipples with a solution of a cup of water and one tablespoon of white vinegar (5,6).
        • Mother – Miconozole oral gel or cream or Nystatin cream applied to nipples four to six times a day after feeds.
        • Mother – If symptoms are severe or long-standing, The Royal Women's Hospital (Melbourne) Clinical Practice Guidelines4 recommend Nystatin tablets or capsules 500,000 units two tds for a course of 50 tables. If pain has not resolved in a week continue Nystatin and add Fluconazole 150mg on alternate days for three doses.
      Nipple candidiasis

      Nipple candidiasis.
      © B.Ingle, IBCLC


  • Herpes
    • Blisters occurring on the nipple or areola associated with significant pain may be due to Herpes simplex infection. Because of the risk to young infants if they contract Herpes infection, breastfeeding from the affected breast should be withheld until the blisters have healed, or another diagnosis is confirmed7. If the infant is older, or the infant transmits the infection to the mother, the risk of continued breastfeeding is less of an issue.
  • Investigations for infected nipples
    • Swabbing sore nipples and those with cracks, fissures or vesicles often enables a more definitive diagnosis and appropriate treatment of Staphyloccus or Herpes infection. Candida, however, is difficult to grow and a negative result does not preclude the diagnosis. Culture media with added iron has a higher positive culture rate8.

Vasospasm

Women with nipple vasospasm present with nipple and breast pain, often throbbing, sharp or burning, that begins towards the end of the feed, after the feed or independent of the feed. Vasospasm is similar to Raynaud's phenomenon and is associated with bi- or tri-colour change of the nipple. Blanching of the face of the nipple when pain occurs is usually the most obvious clinical sign. Vasospasm does not cause nipple tenderness at other times. Vasospasm is more common in women with a history of Raynaud's phenomenon; in colder weather; in association with other nipple conditions such as trauma or infection; or with medications (theophylline, diflucan) and other drugs (nicotine and caffeine)9.

  • Treatment:
    • Give an explanation of the pain, and reduce stress if possible10.
    • Apply warmth to nipples and breast.
    • Correct any underlying causes.
    • Reduce smoking/caffeine.
    • Ca++ 2000mg/day and Mg 1000mg/day.
    • Nifedipine 30mg/day (9,11).
Vasospasm - white

Vasospasm - blanched nipple.
© Goldfarb Breastfeeding Clinic

Vasospasm - red

Vasospasm - perfused nipple.
© Goldfarb Breastfeeding Clinic


Other dermatological conditions

Click on the points below for more detail:
  • Eczema
    • Symptoms and signs of eczema of the nipple and areola (endogenous atopic eczema, irritant contact dermatitis and allergic contact dermatitis) may include an itchy, painful erythematous rash that may be associated with dry, flaky skin, or crusting vesicular eruptions12. The rash may be more prominent where the infant's mouth would rest during a breastfeed. It occurs more commonly on the areola and tends to spare the area around the junction of the nipple and areola. Women may have a history of eczema on other parts of the body or it may be in response to contact with allergens such as nipple creams, soaps, detergents, or with food particles in the infant's mouth following the introduction of solids.
      • Avoid aggravating factors such as nipple creams, detergents or soaps.
      • Use topical corticosteroids (ointments in preference) sparingly after breastfeeds. Potent corticosteroids may be used for a short period (no longer than seven days) if necessary12.
  • Paget's disease of the nipple
    • Paget's disease of the nipple is a form of ductal carcinoma-in-situ where cancer cells track under the epidermis and causes skin changes13. It begins as a red velvety rash on the face of the nipple but over time spreads outwards becoming ulcerated and crusting. Although non-painful to start with, itching and burning are not uncommon. Breast lumps are often not palpable. Urgent referral and biopsy is required.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Livingstone V et al. (1999) The treatment of staphylococcus aureus infected sore nipples: a randomized comparative study
  2. # Wilson-Clay B et al. (2002) The Breastfeeding Atlas
  3. # Amir LH et al. (2002) Candidiasis and breastfeeding Lactation Consultant Series 2
  4. # Royal Women's Hospital (Melbourne) (2006) Thrush in lactation
  5. # Heinig M et al. (1999) Mammary candidosis in lactating women
  6. # Hoover K (2001) The link between infants' oral thrush and nipple and breast pain in lactating women
  7. # Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession
  8. # Morrill JF et al. (2005) Risk factors for mammary candidosis among lactating women
  9. # Anderson JE et al. (April 2004) Raynaud's phenomenon of the nipple: a treatable cause of painful breastfeeding
  10. # Morino C et al. (2007) Raynaud's Phenomenon of the nipples: An elusive diagnosis
  11. # Lawlor-Smith L et al. (1997) Raynaud's phenomenon of the nipple: A treatable cause of breastfeeding failure
  12. # Barankin B et al. (2004) Nipple and areolar eczema in the breastfeeding woman
  13. # Bassett L et al. (1997) Diagnosis of diseases of the breast

5.5 Mastitis – diagnosis

Key Points - Case Study E

Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?

Topic 5.1: Sore nipples
Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.

What other conditions may contribute to nipple damage occurring in the first week postpartum?

Topic 5.2: Factors causing nipple damage
Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.

After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?

Topic 5.3: General treatment for sore nipples
The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.

Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?

Topic 5.4: Further causes of nipple pain
Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.

Anna's cracked nipples have some yellow exudate and appear inflamed. She is given a prescription for mupirocin; however, the next day she notices a firm, tender area in the upper inner aspect of her left breast that is gradually becoming more painful. She is beginning to feel unwell and has developed a fever. What is your diagnosis?

Topic 5.5: Mastitis – diagnosis
Mastitis is an inflammation in the breast, and in lactating women may cause breast pain, erythema, tenderness, heat and a lump as well as fever, rigors, myalgia and malaise. Predisposing factors include sore or cracked nipples, poor breast drainage, a past history of mastitis and maternal factors such as illness, stress or a depressed immune system.

Anna's cracked nipples have some yellow exudate and appear inflamed. She is given a prescription for mupirocin; however, the next day she notices a firm, tender area in the upper inner aspect of her left breast that is gradually becoming more painful. She is beginning to feel unwell and has developed a fever. What is your diagnosis?

Mastitis


© S.Cox IBCLC

The incidence of mastitis in breastfeeding women is approximately 20 percent, with most episodes occurring within the first three months (1,2,3,4). Mastitis is simply an inflammation in the breast and in the lactating breast manifests by a combination of the following symptoms:

  • Local breast symptoms include:
    • pain (can be quite severe and distressing);
    • erythema;
    • tenderness;
    • lump;
    • heat/warmth.
  • Systemic symptoms include:
    • ever;
    • rigors;
    • myalgia; and
    • malaise.

While usually unilateral, bilateral mastitis also occurs, especially in the first two weeks postpartum1. The severity of the symptoms and signs of mastitis varies considerably and it is not unusual to have a discrepancy between the severity of the local and systemic symptoms. More severe local symptoms at presentation tend to persist for longer1. Many women find mastitis quite debilitating, and some require hospitalisation. Some also report systemic symptoms before noticing any breast problems – mastitis should always be a differential diagnosis for a breastfeeding woman who presents with flu-like symptoms.

Mastitis is not always due to bacterial infection. Milk stasis can also lead to the release of cytokines into surrounding breast tissue causing an inflammatory response with local and systemic symptoms indistinguishable from those caused by a bacterial infection (5,6). While measuring the quantity of leukocytes and bacteria in the milk has been used by researchers to distinguish between infective and non-infective (inflammatory mastitis)7, it is of limited clinical use. Similarly, in the majority of circumstances, culturing breast milk provides only limited information for the clinician. First, it is difficult to obtain an adequate and uncontaminated specimen. Second, many specimens either do not grow anything, or grow bacteria regarded as normal skin flora. Additionally, it is often inappropriate to wait for microbiological results to commence treatment.

Staphylococcus aureus is the most common pathogenic bacteria associated with mastitis (6,7,8). Streptococci, especially B-haemolyitic streptococci (implicated in bilateral disease) and Escherichia coli, have also been known to cause mastitis9. MRSA has been cultured from breast milk and breast abscesses and should always be considered if mastitis is not responding to antibiotics as anticipated10. Additionally, bacteria regarded as normal skin flora have been grown from the milk of women with mastitis, occasionally in high concentrations. It is uncertain whether these bacteria are contaminants or have a pathological role in some instances6.

Investigations
For most women, investigations prior to commencing treatment are unwarranted. However, culture of a mid-stream specimen of milk from the affected breast is indicated if there is no response to antibiotic treatment within 48 hours, mastitis recurs despite apparently adequate treatment or there are other unusual features. If the mother is extremely ill, blood cultures and other investigations may also be necessary9.
Differential diagnosis
  • Engorgement.
  • Blocked duct.
  • Breast abscess – see below.
  • Inflammatory carcinoma.
  • Galactocoele.

Diagnosing Mastitis

Click on graphic for a larger image. Table E.1.

What may predispose Anna to developing mastitis?

Click on the points below for more detail:

  • Sore/cracked nipples
    • Women with sore nipples only or with nipple cracks are more likely to develop mastitis, perhaps due to the retrograde spread of bacteria from the damaged nipple epithelium into the breast tissue. Nipple soreness with feeding, even when nipples look "normal", usually indicates some nipple trauma. Additionally, as discussed previously, nipple cracks may become colonised, with Staphylococcus aureus providing a ready source of infection. Anna's cracked nipple is an important predisposing factor for her developing mastitis (2,3,11,12,13).
  • Milk stasis (poor breast drainage)
    Inadequate breast drainage
    Suboptimal positioning and attachment of the infant at the breast, hurried or timed feeds, over-supply of milk, changes in feeding routines (i.e. infant sleeping through the night) or the replacement of breastfeeds with complementary feeds may all result in sections of one or both breasts not being adequately drained. While breasts are not fully ‘emptied’ at every feed, each breast should be drained once per day. In Anna's case, her sore nipples suggest positioning and attachment difficulties. In addition, as breastfeeding with a cracked nipple is very painful, she may be hesitant attaching the infant to the breast and reluctant to allow the infant to stay attached for long enough to fully drain the breast (11,14).
    Engorgement
    Although engorgement usually occurs in the first week postpartum, women may develop engorged breasts if there is a long interval between feeds (11,15).
    Blocked ducts
    A description of the signs and symptoms of blocked ducts is in Table E.1. When milk is not removed from a section of the breast, for whatever reason, the risk of non-infective and then infective mastitis increases (12,14).
    Mechanical obstruction
    Mechanical obstruction of breast drainage. Pressure on the breast from clothing, seatbelts, breast pumps, nipple shields and nipple airers have been implicated in milk stasis and mastitis (11,13).
  • Sources of staph infection
    • Nasal carriage of Staphylococcus aureus in infants increases the risk of mastitis in their mothers11. It is also suggested that other sources of Staph infections such as contaminated nipple creams or other family members may also be implicated.
  • Past history of mastitis
    • Women who have had a previous episode of mastitis in a past or present lactation have an increased risk of developing mastitis again (12,13,14).
  • Maternal factors (illness, depressed immune system)
    • Stress, fatigue, anaemia, and low IgA, C3 and lactoferrin levels are also considered predisposing factors for mastitis (14,15).

Notes

  1. # Fetherston C (1997) Characteristics of lactation mastitis in a Western Australian cohort
  2. # Amir LH et al. (2007) A descriptive study of mastitis in Australian breastfeeding women: incidence and determinants
  3. # Vogel A et al. (1999) Mastitis in the first year postpartum
  4. # Kinlay JR et al. (1998) Incidence of mastitis in breastfeeding women during the six months after delivery: a prospective cohort study
  5. # Fetherston C (2001) Mastitis in lactating women: physiology or pathology?
  6. # Osterman KL et al. (2000) Lactation mastitis: bacterial cultivation of breast milk, symptoms, treatment, and outcome
  7. # Thomsen AC et al. (1984) Course and treatment of milk stasis, noninfectious inflammation of the breast, and infectious mastitis in nursing women
  8. # Amir LH et al. (1999) An audit of mastitis in the emergency department
  9. # World Health Organization WHO (2000) Mastitis: Causes and management
  10. # Reddy P et al. (2007) Postpartum mastitis and community-acquired methicillin-resistant Staphylococcus aureus
  11. # Amir LH et al. (2006) A case-control study of mastitis: nasal carriage of Staphylococcus aureus
  12. # Kinlay JR et al. (2001) Risk factors for mastitis in breastfeeding women: results of a prospective cohort study
  13. # Foxman B et al. (2002) Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States
  14. # Fetherston C (1998) Risk factors for lactation mastitis
  15. # Wambach KA (2003) Lactation mastitis: a descriptive study of the experience

5.6 Mastitis – treatment and complications

Key Points - Case Study E

Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?

Topic 5.1: Sore nipples
Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.

What other conditions may contribute to nipple damage occurring in the first week postpartum?

Topic 5.2: Factors causing nipple damage
Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.

After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?

Topic 5.3: General treatment for sore nipples
The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.

Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?

Topic 5.4: Further causes of nipple pain
Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.

Anna's cracked nipples have some yellow exudate and appear inflamed. She is given a prescription for mupirocin; however, the next day she notices a firm, tender area in the upper inner aspect of her left breast that is gradually becoming more painful. She is beginning to feel unwell and has developed a fever. What is your diagnosis?

Topic 5.5: Mastitis – diagnosis
Mastitis is an inflammation in the breast, and in lactating women may cause breast pain, erythema, tenderness, heat and a lump as well as fever, rigors, myalgia and malaise. Predisposing factors include sore or cracked nipples, poor breast drainage, a past history of mastitis and maternal factors such as illness, stress or a depressed immune system.

What would be the appropriate treatment to give her now?

Topic 5.6: Mastitis – treatment and complications
Good breast drainage is an essential component of the treatment of mastitis. Antibiotics may be required, especially if the mother has moderate to severe local or systemic symptoms, that she has cracked nipples, or the symptoms have been present for more than 12 hours without improving. Recurrent infection, Candida and a breast abscess are complications of mastitis.

What would be the appropriate treatment to give her now?

Effective milk removal/breast drainage

As milk stasis is an important precursor for mastitis, good breast drainage is an essential component of treatment.

Clinical Note

This is not a time to wean.

  • The infant should be encouraged to feed frequently (at least eight times a day) from the affected breast. Occasionally expressing by hand or pump is also required to drain the breast well.
  • Frequent breast expression by hand or pump is required if the infant refuses the breast (milk often has higher sodium and chloride levels and lower lactose levels) or the mother finds it too painful to breastfeed.
  • Correcting any positioning and attachment problems is integral to good breast drainage.

Analgesia

Paracetamol or anti-inflammatory medications such as Ibuprofen reduce local and systemic symptoms.

Antibiotics

Non-infective mastitis will resolve with good breast drainage and supportive measures. It is not possible to distinguish between non-infective and infective mastitis by symptoms and signs alone, therefore prescribing antibiotics initially is appropriate when:

  • local symptoms are moderate to severe;
  • systemic symptoms are moderate to severe;
  • the woman has cracked nipples;
  • symptoms have been present for more than 12 hours and are not improving.

The most appropriate antibiotics are:

  • penicillinase-resistant penicillins such as dicloxacillin and flucloxicillin 500mg qid; or cephalexin 500mg qid;
  • Clindamycin 450mg qid can be used if there is concern about severe penicillin allergy or there are indications of an unusual or severe infection1.

Most authorities suggest a 10–14 day course of antibiotics, although there are no trials of a shorter course (2,3). Women with mild symptoms can be watched expectantly for 12 to 24 hours and treated with antibiotics if there is no improvement in symptoms.

Supportive measures

  • Bed rest.
  • Gentle breast massage.
  • Correcting underlying problems such as anaemia or constricting clothing.
  • Adequate fluid and nutrition.
  • Hot packs prior to a feed and cold packs following a feed may give symptomatic relief3.

The infant

Very few infants are affected adversely if their mother develops mastitis. There is no need to stop the infant feeding on the affected side, or to discard any milk expressed from that side, although as mentioned previously some infants will refuse the breast. The infant does not need to be treated at the same time as the mother. The antibiotics and anti-inflammatory medications mentioned are compatible with breastfeeding, although some infants may develop self-limiting diarrhoea due to maternal treatment3.

What complications may arise from mastitis?

Recurrent mastitis

Approximately 17–27 percent of women with mastitis have recurrent episodes. It is often thought to be due to inadequate or inappropriate treatment for the original episode of mastitis, or the persistence of predisposing causes such as chronic over-supply or ongoing nipple problems. Mid-stream milk leukocyte counts, culture and sensitivity and nasal swabs of mother and infant may provide useful information for ongoing management. Further antibiotic treatment for at least 10 days is indicated. Long-term low-dose antibiotic therapy may be appropriate for some women.

Candida infection

Described previously may be secondary to antibiotic use.

Occasionally, a woman with mastitis develops a breast abscess. What would predispose Anna to a breast abscess?

  • Poor breast drainage during an episode of mastitis. These may be ongoing problems that predisposed to the development of mastitis in the first place (e.g. difficulties with positioning and attachment) or as a consequence of mastitis (e.g. weaning, infant refusing to breastfeed on the affected side, but the breast not being drained by expression).
  • Antibiotic treatment that is inappropriate or for a short duration.
  • A delay in seeking treatment for mastitis.
  • Occasionally, abscesses develop rapidly despite appropriate treatment. Approximately 3 percent of women who are treated for mastitis develop a breast abscess4.

What symptoms or signs would make you suspect a breast abscess?

  • A localised red, tender, indurated area that has not responded to antibiotic therapy.
  • Symptoms may range from palpable lump and few local or systemic symptoms to an extremely ill woman with a red, erythematous breast and a localised area of increased induration.
  • Fluctuant mass in a breastfeeding woman, particularly if she had recently been treated for mastitis.

How would you investigate a suspected breast abscess, and what would be the most appropriate treatment?

Ultrasound

Ultrasound is the investigation of choice. It will distinguish between ongoing inflammation and the development of a fluid collection.

Abscess drainage

Fine needle aspiration biopsy (preferably under ultrasound control)
This provides material for culture and sensitivity and in many cases provides definitive treatment. Depending on the size and shape of the abscess, recurrent aspiration may be required (5,6).
Incision and drainage
This is the most appropriate treatment in some cases, particularly if the abscess is large and is multiloculated (5,6).

Antibiotics

Antibiotics should be commenced immediately but may need to be changed based on culture results when available. They should be continued until the abscess has resolved.

Breast emptying

  • Breastfeeding can continue on both breasts, providing the infant continues to attach to the breast properly (depends on position of abscess, incision and drain if necessary) (2,7).
  • Expressing (hand or pump) may be necessary if the infant is unable or refuses to breastfeed.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Therapeutic Guidelines Ltd (2003) Therapeutic guidelines: Antibiotics
  2. # World Health Organization WHO (2000) Mastitis: Causes and management
  3. # Amir LH (2008) Clinical Protocol # 4: Mastitis
  4. # Amir LH et al. (2004) Incidence of breast abscess in lactating women: report from an Australian cohort
  5. # Dener C et al. (2003) Breast abscesses in lactating women
  6. # Eryilmaz R et al. (2005) Management of lactational breast abscesses
  7. # Marchant DJ (2002) Inflammation of the breast

6.0 In conclusion

Thank you for completing Breastfeeding Foundations for Doctors. Please take time to complete the post-test quiz so that you can see the improvement in your knowledge base, and also see any areas that need further revision. Of course, the course does not cover all the breastfeeding problems that you will encounter during your medical career. However, you will be able to apply the general principles and management options contained in the course to consider the most appropriate response to other issues that arise. I hope this course will give you confidence to effectively assist pregnant and breastfeeding women in the future.