Introduction to Breastfeeding

1. Introduction to Breastfeeding Based on a powerpoint by Anita Bordoloi, MD given February 14, 2012

2. ACOG statement

3. AAP Policy The American Academy of Pediatrics (AAP) recommends that babies be exclusively breastfed for the first 6 months of life.

4. United States Preventative Services Task Force (USPSTF) The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding.Grade: B Recommendation.

5. Physiology of Breastfeeding

6. Breast Anatomy

7. Breast milk • Species-specific • Bio-active • Composed of: • Immunoglobulins (especially IgA) • Growth modulators • Protein • Carbohydrates • Minerals • Vitamins • Fats

8. Lactation • Cyclical process of milk synthesis and secretion • Activated by prolactin, oxytocin, TSH, and human placental lactogen(hPL) • Prolactin: milk production • Oxytocin: milk secretion • Inhibited by progesterone and estrogen

9. Prolactin • Initiates milk production • Elicited by suckling • Produced by anterior pituitary gland • Stimulates mammary glandular ductal growth and epithelial cell proliferation

10. Oxytocin • Milk ejection or letdown • Suckling activates touch receptors that stimulate dorsal root ganglia via intercostal nerves (4, 5, 6) to release oxytocin in a pulsatile fashion • Secreted by posterior pituitary gland • Causes contraction of myoepithelial cells that line the ducts of the breast

12. Hypothalamus

13. Breastfeeding and Contraception

14. Can breastfeeding act as contraception? • Moderate contraceptive effect • Dependent on suckling intensity and frequency • Equivalent to OCP (98%) only in amenorrheic women who exclusively breastfeed at regular intervals for first 6 months • With menstruation or after 6 months, chance of ovulation increases • Supplemental feeding increases chance of ovulation

15. Other contraceptives and effect on breastfeeding • Intrauterine contraception • Does not affect milk volume or composition • Progestin-only contraceptives • Historically preferred method of hormonal contraception • Does notaffect milk volume or composition • Estrogen-progestin contraceptives • Traditionally thought to suppress milk production • Recent study shows no effect on breastfeeding duration or infant growth

16. Breastfeeding and Contraception • Double-blind RCT examining the effect of progestin-only compared with combined hormonal contraceptive pillson rates of breastfeeding continuation • Similar breastfeeding continuation rate at 8wks, contraceptive continuation, and infant growth parameters

17. Benefits of Breastfeeding

18. Benefits of Breastfeeding - Infant  Death  SIDS  Infectious disease  Diabetes  Obesity  Hypercholesterolemia  Asthma  Atopy Lymphoma/leukemia/ Hodgkin’s disease Cognitive development

19. Case-control study examining association between breastfeeding and postneonatal death, N=1204 • Ever breastfed, OR 0.79 • Longer breastfeeding associated with lower risk • Decreased incidence of infectious cause (OR 0.76), injury (OR 0.59), and SIDS (0.84)

20. Benefits of Breastfeeding - Maternal  Postpartum bleeding  Menstrual blood loss  Risk of Breast CA  Risk of Ovarian CA  Risk of osteoporosis and hip fractures (post-menopausal)  Type 2 DM  Postpartum depression  Postpartum weight loss

21. Benefits of Breastfeeding - Community  Annual healthcare costs in United States  Cost for public health programs, i.e. WIC  Parental employee absenteeism  Environmental burden

22. Contraindications to Breastfeeding

23. Contraindications • Maternal active, untreated TB • Maternal HTLV+ • Maternal HIV (developed countries) • Maternal HSV lesions on breast • Maternal exposure to radioactive materials • Mothers receiving anti-metabolites or chemotherapy • Maternal drug use • Classic galactosemia

24. NOT Contraindications • Maternal +HepBsAg • Maternal Hepatitis C • Maternal seropositive CMV carriers • Febrile mothers • Mothers exposed to low-level environmental chemical agents • Maternal tobacco use • Maternal alcohol use – wait 2 hours

25. Breastfeeding 101

26. Keys to Successful Breastfeeding • The sooner, the better • Relaxed and supportive environment • Father’s assistance and support

27. Keys to Successful Breastfeeding • Positioning the infant • Cradle hold (most common) • Football hold

28. Keys to Successful Breastfeeding • Presenting the breast • Hand positions: • C-hold or palmar grasp • Scissor grasp • Ensure nipple is not tipped upward

29. Keys to Successful Breastfeeding • Achieving latch-on • Suck-swallow pattern • Bring nipple towards infant’s mouth

30. Keys to Successful Breastfeeding • Timing • 8-12 times a day during the first 4-5 days • Unrestricted breastfeeding based on infant’s demand

31. Problems and Troubleshooting

32. Insufficient milk supply • Solutions: • Frequent breastfeeding every 1.5-2 hours during the first few days • Galactogogues(milk production enhancers): • Herbal: fenugreek, fennel seeds, milk thistle, goat’s rue • Medical: Reglan, Domperidone

33. Breast Engorgement • Solutions: • Frequent breastfeeding • Manual expression, breast massage • Cool compresses or ice (to relieve pain) • Frequent warm showers (to express milk) • Mild analgesics • Manual or electric pumping • +/- Cabbage leaves (to relieve pain)

34. Nipple pain • Sore nipples: due to improper latching • Encourage mother to place areola/nipple in infant’s mouth • Cracked nipples • Begin breastfeeding on less-affected side • Place a drop of milk on each nipple and allow to air-dry after breastfeeding • High-grade lanolin or nipple shields • Avoid coarse fabric, bras w/ seams

35. Mastitis • More common in engorged breasts • Presents with flu-like symptoms • Most common pathogens: S. aureus, streptococcus, E. coli • Treatment: ibuprofen, dicloxacillin, cephalexin, clindamycin • Continue to breastfeed while taking antibiotics • Frequent emptying

36. Breast Abscess • Rare – incidence of 0.1% • Requires incision and drainage, antibiotics • Pump affected side • Continue to breastfeed on unaffected side

37. References • Centers for Disease and Control, Breastfeeding Report Card – United States, 2010. http://www.cdc.gov/breastfeeding/data/reportcard.htm. Accessed March 13, 2011. • Chen A, Roga, WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics 2004; 113:5 e435-e439. • Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008 Oct 21;149(8):565-82. • Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects. Obstet Gynecol. 2007 Feb;109(2 Pt 1):479-80. • Dewey KG, Heinig MJ, Nommsen LA. Maternal weight-loss patterns during prolonged lactation. Am J Clin Nutr. 1993 Aug;58(2):162-6. • Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, Eidelman AI; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005 Feb;115(2):496-506. • Kaunitz A. Postpartum and postabortion contraception. Up to Date, Inc. http://www.uptodate.com/contents/postpartum-and-postabortion-contraception?source=search_result&search=contraception+postpartum&selectedTitle=1%7E150#. Accessed Feb 8, 2012. • Merewood A, Mehta SD, Chamberlain LB, Philipp BL, Bauchner H. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics. 2005 Sep;116(3):628-34. • Speroff L, Fritz MA (2005). The Breast. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 625-633. Philadelphia: Lippincott Williams and Wilkins. • Wagner, C. Counseling the Breastfeeding Mother. Pediatrics: Cardiac Disease and Critical Care Medicine, Dec 14, 2010 . • Wagner, C. Human Milk and Lactation. Pediatrics: Cardiac Disease and Critical Care Medicine, Dec 14, 2010 .