Chapter 7 Nutrition During Lactation: Conditions and Interventions

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Chapter 7Nutrition During Lactation Conditions
and Interventions
Nutrition Through the Life Cycle Judith E. Brown
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Key Nutrition Concept 1

• Human milk is the preferred food for all
  premature and sick newborns, with rare exceptions.

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Key Nutrition Concept 2

• Breastfeeding women need consistent, informed,
  and individual care in the hospital and at home
  after discharge.

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Key Nutrition Concept 3

• It is usually not necessary to discontinue
  breastfeeding to manage medical problems of the
  mother or infant any medical decision to limit a
  mothers breastfeeding must be justified by the
  fact that the risk to her baby clearly outweighs
  the benefits of breastfeeding.

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Key Nutrition Concept 4

• Feeding infants early in the postdelivery period
  whenever possible is important to successful
  breastfeeding. Early intervention to address
  questions or problems is equally important for
  maintaining breastfeeding.

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Key Nutrition Concept 5

• Most medications (including over-the-counter as
  well as prescription drugs), drugs of abuse,
  alcohol, nicotine, and herbal remedies taken by
  nursing mothers are excreted in breast milk.

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Key Nutrition Concept 6

• 6. Twins and other multiples can be successfully
  breastfed without formula supplementation.

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Introduction

• Two key considerations related to conditions and
  interventions during breastfeeding are
• 1) The vast majority of women do not experience
  significant problems during breastfeeding
• 2) Most problems could have been prevented with
  proper prenatal breastfeeding education a
  positive breastfeeding initiation period

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Common Breastfeeding Conditions

• Sore, flat or inverted nipples
• Letdown failure
• Hyperactive letdown
• Hyperlactation
• Engorgement
• Plugged duct
• Mastitis (Infection)
• Low milk supply

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Condition Sore nipples

• May be prevented by proper positioning of baby on
  breast
• The areola should be in the babys mouth with
  tongue extended against lower lip

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Condition Flat or Inverted Nipples

• This should not impact breastfeeding if the latch
  is correct.
• If difficult to latch
• Mother may roll her nipple between her fingers
• Or use a breast pump prior to feeding
• Helps to draw out the nipple

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Condition Letdown Failure

• When milk does not eject from the breast
• Very uncommon
• Oxytocin nasal spray may be prescribed
• Relaxation techniques may help reduce problem

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Condition Hyperactive Letdown

• Streams of milk come from breast
• If too active, may cause infant to choke while
  nursing
• Management
• Wait for the milk flow to slow down before
  putting the infant to the breast
• Mother may express milk until the flow slows then
  allow infant to nurse

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Condition Hyperlactation

• Occurs when milk volume produced exceeds intake
  of the baby
• Symptoms in mother
• Breasts not drained completely
• Chronic plugged ducts
• Leaking between feedings
• Pain with letdown or deep in breast
• Symptoms in baby
• Spitting up, poor weight gain
• Difficulty maintaining latch

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Condition Hyperlactation

• Occurs when milk volume produced exceeds intake
  of the baby
• Management
• Reduce production
• Nurse baby on one side only and express for
  comfort on the other
• Cabbage leaves may be used to decrease production

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Condition Engorgement

• Breasts are overfilled with milk
• Results when supply-and-demand process is not yet
  established and milk is abundant
• Best prevention nurse frequentlynewborns may
  nurse every 1 to 2 hours

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Condition Plugged Duct

• Caused by milk staying in the ducts
• Painful knot may form in breast
• Treated by massage and warm compress
• Prevented by complete emptying of breasts and
  changing position of infant while feeding

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Condition Mastitis (Infection)

• Mastitis is inflammation of the breast
• May be infective or non-infective
• Occurs in 3 to 20 of breastfeeding women
• Most common at 2-6 weeks postpartum
• May result from
• Sore and cracked nipples
• Blood borne source of bacterial infection
• Missing a feeding resulting in engorgement, then
  plugged duct may precipitate engorgement

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Condition Low Milk Supply

• Most common reason for cessation of breastfeeding
• May be real or may be perceived
• Causes
• Insufficient breastfeeding or pumping
• Ineffective emptying
• Stress
• Management
• Nurse or pump every 2-3 hours
• Drugs or herbs may be prescribed
• Galactogogue, Metoclopromide, Fenugreek

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Maternal Medications

• Most medications are excreted in breast milk
• Variables to consider related to medications
  during lactation
• Pharmacokinetic properties of the drug
• Time-averaged breast milk/plasma drug
  concentration ratio
• Drug exposure index
• Infants ability to absorb, detoxify excrete
  drug
• Infants age, feeding pattern, total diet,
  health

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Maternal Medications

• Milk/Plasma Drug Concentration Ratio (M/P Ratio)
  The ratio of the concentration of drug in milk to
  the concentration of drug in maternal plasma
• Exposure Index The average infant milk intake per
  kilogram body weight per day X (the milk plasma
  ratio divided by the rate of drug clearance) X 100

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Resources on Drugs, Medications. and contaminants
in human milk
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Maternal Medications

• Drugs are divided into 7 categories
• Cytotoxic drugs- interferes with infant's
  cellular metabolism
• Drugs of abuse-adverse effects
• Radioactive compounds-temporary cessation of
  breastfeeding
• Drugs in which effect is unknown
• Drugs associated with significant effect
• Meds compatible with breastfeeding
• Agents with no effect on breastfeeding

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Minimizing Effect of Maternal Medications
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Safety of Oral Contraceptive Use During Lactation

• Current evidence suggests combined oral
  contraceptives (OC) may reduce the volume of
  breast milk
• The ACOG WHO recommend against use of combined
  OC during first 6 weeks postpartum
• Progestin only OC implants are safe effective
  

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Herbal Remedies

• Scientific information about herb use during
  lactation is sparse
• Medicinal herbs should be viewed as drugs
• Many herbs are contraindicated during lactation

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Herbal Remedies

• Table 7.4 lists Herbs traditionally used to
  affect milk production
• Table 7.5 lists Medicinal herbs considered not
  appropriate for use during pregnancy or
  lactation
• Table 7.6 lists Herbal teas considered safe
  during lactation

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Herbs Widely Used in the U.S. with Impact on
Breastfeeding

• Echinacea - not recommended
• Ginseng root - not recommended
• St. Johns wort - may reduce milk supply
• Ephedra (ma huang) - not recommended
• Fenugreek - infants may be allergic
• Cabbage leaves - safe for topical use to reduce
  engorgement
• Goats Rue and Milk Thistle/Blessed Thistle-
  potential use as galactogues

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Alcohol and Other Drugs

• Alcohol
• Nicotine (smoking cigarettes)
• Marijuana
• Caffeine
• Other drugs of abuse
• Environmental exposures

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Alcohol

• Alcohol consumed quickly passes to breast milk
• Level of alcohol in breast milk is same as in
  maternal plasma
• Peak plasma levels occur at 30-60 min. after
  consumption if consumed w/o food and 60-90 min.
  if consumed with food
• Contrary to popular belief, alcohol decreases
  oxytocin and let-down

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Impact of Alcohol on Lactation

• Contrary to popular belief, alcohol decreases
  oxytocin let-down
• Affects odor of milk
• Decreases volume consumed by infant
• Interferes with sleep pattern of infant

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Alcohol and Breastfeeding
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Other Drugs and Lactation

• Nicotine (smoking cigarettes)
• Regardless of feeding choice, the health risks
  for infants posed by a smoking mother are many
• Otitis media
• Exacerbation of asthma
• Respiratory infections
• Gastrointestinal dysregulation
• Levels are 1.5 to 3 times higher in breast milk
  than mothers blood

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Other Drugs and Lactation

• Marijuana
• Is transferred and concentrates in breast milk
  and it metabolized by the nursing infant
• May change DNA/RNA the proteins needed for
  growth

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Other Drugs and Lactation

• Caffeine
• Moderate intake causes no problems for most
  breastfeeding infants and mothers.
• Level in breast milk is only 1 of that in
  mothers plasma
• May accumulate in infants younger than 3 to 4
  monthsvaries from infant to infant
• May interfere with sleep or cause hyperactivity
  fussiness of infant

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Other Drugs and Lactation

• Other drugs of abuse
• Amphetamines, cocaine, heroin, phencyclidine
  (angel dust, PCP) are classified by the AAP as
  drugs of abuse that are contraindicated during
  lactation

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Environmental Exposures

• The advantages of breastfeeding far outweigh
  the potential risks from environmental
  pollutants. Taking into account breastfeedings
  short- and long-term health benefits for infants
  and mothers, the WHO recommends breastfeeding in
  all but extreme circumstances.
• World Health Organization

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Neonatal Jaundice and Kernicterus

• Jaundicea yellow color of the skin seen in
  about 60 of full-term 80 of preterm infants
  (AKA hyperbilirubinemia)
• If not resolved, the elevated bilirubin can
  cause permanent neurological damage
• It is the most frequent cause for hospital
  readmission for newborns

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Risk Factors for Severe Hyperbilirubinemia
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Bilirubin Metabolism

• Bilirubina pigment produced as heme from red
  blood cells (RBC) break down
• Usually processed by the liver and excreted in
  the babys stool
• Newborns liver not fully mature so jaundice is
  common during first few days of life
• Color appears first in the face upper body
  then progresses downward toward the toes

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Bilirubin Metabolism

• In the fetal state, high levels of hemoglobin
  were needed to carry oxygen delivered by the
  placenta
• At birth, infants have very high levels of
  hemoglobin and hematocrits of 50 to 60
• As infant breathes on his own, high hemoglobin is
  not needed, so RBC begin to break down

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Physiologic versus Pathologic Newborn Jaundice

• Physiological
• Begins after the 1st day of birth rising steadily
  with peak day 6-7
• Bilirubin lt12 mg/dL
• Condition resolves within a few days
• Cause normal heme breakdown

• Pathological
• Begins within 1st day after birth rises rapidly
  lasts longer
• Bilirubin gt8 mg/dL in 1st day
• Medical intervention with phototherapy
• Cause various pathological conditions

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Bilirubin Encepahlopathy or Kernicterus

• Bilirubin is toxic to cells may cause brain
  damage
• Brain brain cells destroyed by bilirubin do not
  regenerate
• Mortality rate is 50
• May cause cerebral palsy, hearing loss,
  paralysis of upward gaze, and intellectual and
  other handicaps

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Breast-Milk Jaundice Syndrome

• Onset later than physiological jaundicetypically
  7th to 10th day
• 1/3 of breast-fed infants are jaundiced at 3
  weeks
• Cause is unknown
• Thought that more bilirubin is reabsorbed due to
  factors in breast milk that promote its
  absorption
• Typically resolves itself but in severe cases is
  treated like regular physiological jaundice

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Treating Jaundice

• The AAP guidelines recommend phototherapy using
  fluorescent lights
• Light is absorbed in bilirubin changing it to a
  water-soluble product that can be excreted via
  the kidneys
• AAP guidelines encourage continuation of
  breastfeeding

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Information for Parents

• Inform parents that most breastfed infants will
  become jaundiced
• Only a small fraction of these infants will
  develop extreme hyperbilirubinemia and kernicterus

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Breastfeeding Multiples

• Breastfeeding twins, triplets quadruplets is
  possible
• Main obstacle is the time fatigue of mother
• Frequent nursing increases milk supply
• Parents of multiples need support in
• Organization
• Feeding
• Individualization
• Stress management

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Infant Allergies

• Exclusive breastfeeding for 4 months protects
  against allergies, ectopic dermatitis wheezing
• Development of food allergies influenced by
  numerous factors
• Genetics, duration of breastfeeding, time of
  introduction of other foods, maternal smoking,
  air pollution, exposure to infectious disease,
  maternal diet and immune systems
• Consumption of omega-3 fatty acids by lactating
  mother may protect against Allergies

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Food Intolerance

• No scientific evidence shows gassy foods in
  mothers diet produce gas in infant
• Low-allergen maternal diet associated with
  reduction in distressed behavior (colic)
• Allergenic foods eliminated were cows milk,
  eggs, peanuts, tree nuts, wheat, soy, fish

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Late-Preterm Infants

• Infant born 34 to 37 weeks
• May have subtle immaturity making breastfeeding
  difficult
• Complications include
• Cardio-respiratory instability, poor temperature
  control, lower glycogen fat stores, immature
  immune system, weak suck-swallow coordination

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Near-Term Breastfeeding Cascade
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Human Milk and Preterm Infants

• Hospital and physicians should recommend human
  milk for premature and other high-risk infants
  either by direct breastfeeding and/or using the
  mothers own expressed milk. Maternal support and
  education on breastfeeding and milk expression
  should be provided from the earliest possible
  time. Mother-infant skin-to-skin contact and
  direct breastfeeding should be encouraged as
  early as feasible. Fortification of expressed
  human milk is indicated for many very low birth
  weight infants.
• AAP Statement

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Medical Contraindications to Breastfeeding

• Few medical problems in the mother or baby are
  absolute contraindications to breastfeeding
• Table 7.14 lists the medical problems and
  contraindications for breastfeeding
• The theoretical risk must be measured against the
  projected benefits of breastfeeding

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Breastfeeding and HIV Infection

• HIV infection may be transmitted to infant by
  breast milk
• Transmission rates 5 to 20 depending on duration
  of breastfeeding
• DHHS recommends HIV infected women should not
  breastfeed or provide their breast milk for the
  nutrition of their own or other infants...

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Human Milk Collection and Storage

• Human milk is the most appropriate food for
  infants and is also used as medical therapy for
  older children and adults with certain medical
  conditions. Human milk has a long history and
  proven track record both as nutrition and
  therapy.
• Human Milk Banking Association of North America

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Human Milk Collection and Storage
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Milk Banking

• Human milk banks
• Provide human milk to infants who cannot be
  breastfed by their mothers
• Some neonates ICUs had milk banks until the 1980s
  when HIV infections, resurgence of TB and other
  risks became prevalent

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Model Programs

• Breastfeeding Promotion in Physicians Office
  Practices (BPPOP)
• Innovative program designed to boost
  breastfeeding promotion and support
• The Rush Mothers Milk Club
• Evidence based program of breastfeeding
  interventions in NICU

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