Week 11: Problems with Breastfeeding and Lactation

Week 11: Problems with breastfeeding and lactation

Breastfeeding and Lactation disorders

Objectives:

To be able to

·  discuss the physiology and pathophysiology of normal and abnormal lactation;

·  know the effect of maternal and infant factors on the let-down and milk production reflexes;

·  be able to recognize and effectively deal with problems of lactation;

·  know and discuss the conditions associated with “insufficient milk”, breast engorgement and mastitis and inadequate let-down reflexes

Illustrative Case Report:

Mrs Z has just delivered her first baby at term, birth weight 3.5 Kg. There were no problems in the antenatal period. Apart from an episiotomy, labour and delivery went well. Mild jaundice was seen on day 3, for which the attending paediatrician prescribed phototherapy for 24 hours.

While in the hospital, Mrs Z breastfed her baby. He seemed to take the breast well and there were no problems. He had already started to gain weight when she was discharged home to her 3-roomed flat in Sunnyside on day 5.

One week later, the City Health Department’s Nurse came on a home visit. At this stage, Mrs Z appeared to be tired and down-hearted. Her baby was crying a lot, did not sleep well, and was not gaining weight well. Even though mother seemed to have so much milk that the breasts were engorged and quite sore, baby was not satisfied. He would start well, but soon stop, apparently because he was not getting enough. He would then cry and be reluctant to take the breast again. As a consequence, he would still be hungry and not sleep well.

Mrs Z’s neighbour has suggested that her breastmilk is not agreeing with baby and that she should start a bottle. Mrs Z is desperate because she had actually so wanted to feed this baby on her breast, and has therefore made an appointment to see her doctor.

Introduction

Even though lactation is a perfectly normal physiological process, successful breastfeeding has to be learnt by both the mother and the baby. It may therefore be expected that first-time breastfeeding mothers may have more difficulties than those with prior experience.

Task

Review the physiology of normal lactation with particular emphasis on the milk production reflex mediated by prolactin and the milk ejection reflex (let-down reflex) mediated by oxytocin. Concentrate on the factors which may hinder or interfere with the above reflexes. What other factors influence production of milk? List the factors which might have interfered with breastfeeding reflexes in the case report above.

Prior to the development of

·  baby feeding bottles,

·  hygienic methods of preparation and storage of milk, and

·  safe formula feeds,

all neonates were absolutely dependent on their mother’s milk for survival. In fact, by the end of the 19th century, virtually 100% non-breastfed babies were still doomed to die because of infection.

The rapid introduction of bottle feeding has been associated with huge increases in infant malnutrition during the 20th century. Previously, breastfed infants were largely protected from malnutrition until the weaning stage; once bottle-feeding was being “modelled” in societies by the affluent members of that society, diluted contaminated formula feeding was a potent source of illness and death through malnutrition and diarrhoeal disease.

Today, we are witnessing the reverse trend amongst women who have a choice on how they want to feed their babies. The breastfeeding decision is being taken by the more affluent, educated, stable women of society because they have come to realise that breastmilk is the right food designed by nature for human infants for the following reasons:

·  Better protein compatibility: All non-human milk formulae are based on animal milk or vegetable protein with the consequent risk of earlier development of sensitisation and allergy;

·  Non-protein nitrogen components including growth factors and nucleotides have direct influence on gastrointestinal mucosal growth and differentiation as well as on certain immune parameters

·  Better balance of essential and protective fatty acids

·  Presence of live immunocompetent cells primed for colonisation and protection of the gut in the vulnerable developing phase

·  Better performance indicators right up to probable effect on intelligence

·  Breastfed babies are less vulnerable to child abuse, sudden infant death, emotional and physical neglect

·  Breastfed babies have less risk of infection even in well-resourced communities.

What about HIV ? Can breastfeeding be risky?

A number of drugs and viruses have been shown to cross into the breast milk and can therefore affect the baby.

·  Cytotoxic drugs

·  Psychotropic drugs

·  Laxatives

·  Salicylates

·  Some antibiotics eg Chloramphenicol, Tetracycline

·  HIV, CMV, Hep B, Hep C

The mother may be so debilitated by disease that the extra energy needed for her breastmilk production will place an intolerable burden on her own health

Contraindications to breastfeeding

Maternal:

·  Psychosis

·  Carcinoma of the breast

·  Cytotoxic drug therapy for malignant disease

·  Antithyroid drugs and Radio-iodine

Infant

·  Inherited disorder involving galactose or lactose

Eg Galactosaemia

Risk factors for breastfeeding

Maternal

·  Maternal debilitating disease

·  Maternal virus infection

Eg HIV infection

Infant

·  Abnormal mouth and swallowing mechanism

Eg Cleft lip/palate

Exclusive breastfeeding

This refers to the practice of giving nothing else but breastmilk by mouth. This means nothing, not even added water and no pacifiers/dummies.

Shown to be completely sufficient for all the babies’ nutritional needs for at least 4 months in healthy thriving babies. Shown to supply the water needs of babies even in hot environments because of the fact that breastmilk is a low osmolality feed.

The big advantage is the fact that exclusive breastfeeding protects the developing gut from exposure to any injurious influence including infective and antigenic contamination, osmotic or other stresses. There is some suggestive evidence that exclusive breastfeeding may even be protective against HIV infection provided it is really exclusive.

Risks of not breastfeeding

Depend on the socio-economic situation of the family.

In impoverished families without access to safe water and adequate sanitation, failure to breastfeed may result in catastrophic increases in gut infections, malnutrition, morbidity and deaths. This may completely negate any positive effect of potentially preventing HIV infection.

Task

Assume the following statistics apply at an antenatal clinic in a peri-urban informal settlement: Antenatal clinic HIV prevalence 25%. HIV Mother-to-child transmission rate with breastfeeding 30%. Transmission rate 15% without breastfeeding.

Example (a)

If all mothers at the above antenatal clinic decided to stop breastfeeding because of their fear of the risk of transmission of HIV, calculate the number of babies who would be placed at risk.

All mothers of unknown HIV status : 25% positive, therefore 75% negative

Of 25% positive mothers, transmission rate 30% with breastfeeding, ie 30% of 25 = 8 affected babies, 70% of 25 = 17 unaffected babies

Of 75% negative mothers, transmission rate 0, ie 75 unaffected babies

Therefore, of mothers attending antenatal clinic, 8% babies will be HIV infected if breastfeeding is uniformly chosen, 92% unaffected.

If all mothers decide to stop breastfeeding, only 15% of exposed babies will be infected. In the example, this reduces the number of babies eventually infected from 8% to 4% of the total group of mothers. Therefore, 96% of babies would be deprived of breastfeeding even though they are not at risk of contracting HIV at this stage.

Example (b)

If the clinic mentioned above offers HIV testing, and all HIV positive mothers are counselled to stop breastfeeding, what proportion of their babies would be at nutritional risk?

At the clinic, 25% are HIV positive. With breastfeeding, the transmission rate is 30%, ie 70% children of HIV positive mothers are unaffected. Without breastfeeding, transmission rate is now 15%, ie 85% of babies of HIV positive mothers are uninfected and placed at nutritional risk from not breastfeeding. If malnutrition or infection-related death rates of non-breastfed babies of HIV positive mothers exceed 15%, such mothers should not be advised to stop breastfeeding without guaranteeing safe alternative feeding

Lactation disorders

Mrs Z has encountered problems in feeding her baby on the breast, even though it seemed as if lactation had been successfully established in the maternity hospital. A week later, the baby is crying a lot, is not sleeping and gaining weight well. Mother’s breasts are engorged and painful. Could it be that breastmilk is not agreeing with him? Reference Coovadia 5th ed pp 175 - 185

Successful lactation is not only instinctual behaviour; it has to be learnt by both mother and baby. It is further dependent on regular frequent emptying of both breasts and on a mutually satisfying relationship and interaction between mother and child. Many first mothers will need up to 2 – 3 weeks before lactation and regular breastfeeding is fully established.

Successful initiation

First feed serves to stimulate the milk-producing reflex and the secretion of oxytocin. The earlier the baby is put to the breast after birth while still wide awake in the first half hour or so, and before it falls asleep, the stronger it suckles. Such mothers are usually able to breastfeed for longer periods.

Difficulties arise when baby is too small, immature, asphyxiated, physically abnormal (cleft palate), hypotonic, sick or sedated and cannot latch onto the breast well, or where there are maternal factors such as anaesthesia, sedation, illness, pain, severe anxiety in a mother who is very young, alone or emotionally disturbed.

Exclusive demand feeding

In the first few days, not much colostrum and milk is secreted. Baby therefore needs frequent opportunities to suckle and stimulate prolactin secretion to allow milk to “come in”. In view of the newborn infant’s sleeping pattern of 16 – 18 hours per day, this is best done “on demand” when baby is optimally awake and hungry. “Clocking systems” of offering the breast at set times will often mismatch the physiological responses.

Babies who are offered bottles of water or milk formula will frequently be sleepy not yet hungry and therefore not feed adequately when put to the breast. Supplementing baby feeds in the onset phase of lactation will result in earlier cessation of lactation.

If babies are expected to conform to set times for feeding, they may miss the best awake time for suckling and be excessively unhappy/crying, or have gone back to sleep.

If mother has no help and has to return to household chores or work obligations before lactation has been truly established, conflicting schedules for mother and baby may mean that baby’s feeding loses out against domestic obligations.

Normal milk production and let-down reflexes

Prolactin mediated milk production is dependent on suckling and regular emptying of the breast.

After milk production has begun within a few days after birth, the breast has to be emptied regularly in order to maintain milk production. Infrequent emptying or breast engorgement limits milk production.

Oxytocin secretion for the let-down reflex is mediated via suckling and stimulation of the areola skin but also via higher centres such as thinking about feeding the baby. The onset of this reflex is delayed for a few days after birth.

Breastfeeding reflexes, especially the let-down reflex, are inhibited through unfavourable effects on the higher centres: Anxiety, tiredness, emotional tenseness, sickness and pain. All these may operate in a first time mother discharged home who perhaps has inadequate support, help, rest and who is frightened and uncertain.

Drugs may affect milk production negatively: oestrogens as in contraceptive pills, sedatives in high doses( as well as possibly affecting the baby through breast milk) or positively, such as metoclopramide for milk secretion, oxytocin for the let down reflex.

A primiparous mother may thus have problems of insufficient or delayed milk production (inadequate prolactin effect) or breast engorgement (let-down not established yet or inhibited, infrequent emptying). This may lead to the possibility of mastitis with painful lumpiness in the breast not emptying completely with feeds. Risk of bacterial infection and abscess formation. Associated fever and constitutional symptoms.

Engorged breasts and ineffectual suckling leads to cracked nipples, with severe pain when baby suckles.

Baby-related feeding problems

Baby feeding problems relate to problems of positioning during feeds, swallowing of air and difficulty with “burping”, as well as issues of disordered gut motility related to the onset of feeding (regurgitation, slow or rapid transit) and possibly influences related to drugs or chemical constituents passing through breast milk (caffeine, cocoa). In addition, baby’s digestive tract may show maturation-related problems such as insufficient lactase with fermentative symptoms (bloating, cramps, loose stools)

Describe practical management to establish and maintain successful breast feeding (primiparous mother)

Anticipation

During pregnancy : Establish positive attitude of support from mother and family. Husband/care-taker support important

Reassure about incorrect perceptions regarding feeding : eg breast size, quality of milk, advantages of breast feeding

Optimal management of labour

Putting baby to the breast early while baby and mother are both still wide awake and on a “high” after birth. Adequate help available to help position baby correctly (best done by an experienced older woman)

Early days while under supervision in hospital or at home

Frequent exclusive demand feeds. Adequate help at feed times for positioning, reassurance.

Adequate rest and analgesia for mother if necessary

On discharge

Guarantee rest and help and knowledgeable support with demand feeding. No supplements.

Reassurance. Encourage joyful anticipation. Maintain positive attitude, both mother and baby will learn. Do not allow mother to become anxious about quantity of milk taken. This can vary from feed to feed.

Engorged breasts: warm compresses before feed, cold compresses after feed. Occasionally sublingual oxytocin helps with let-down reflex. Frequent suckling to empty the breasts. Support breasts to reduce pain.

Mastitis: adequate hydration, analgesia. Cold packs to reduce pain and swelling. Frequent emptying of breast. Only if abscess is present should breast not be offered. Antibiotic therapy for fever and abscess.

Cracked nipples: prevent by attention to the way the baby places nipple and part of areola into mouth, so that it does not suckle on nipple. Avoid too frequent washing with soap; it removes protective fatty layers. Allow to air-dry, breast milk onto nipple. Otherwise zinc-containing or lanolin ointments, wipe off before feed. Analgesia and continue feeding.