Anticipatory Guidance

Breastfeeding

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American Academy of Pediatrics Stance on Breastfeeding

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https://en.wikipedia.org/wiki/Breastfeeding

Epidemiology

CDC Healthy People 2020 data on US breastfeeding rates currently, and future goals: 

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Physiology

Increase in glandular components of breast tissue during pregnancy due to progesterone. Drop of progesterone and increase in prolactin, cortisol, and insulin lead to the onset of milk production. Lactation is maintained through removal of milk and suckling of the nipple.  Prolactin and oxytocin are induced by the nipple stimulation leading to synthesis of milk by lactocytes and milk ejection through contraction of myoepithelial cells, respectively.

5 Breastfeeding positions - click here

Benefits

  • Maternal
    • Weight loss
    • Icnreased uterine toxicity
    • Decreased post partum blood loss
    • Decreased risk of ovarian and breast cancer
    • Decreased post partum depression
    • Decreased osteoperosis 
    • Decreased DM2
    • Bonding
  • Infant
    • Decreased incidence of SIDS
    • Decreased risk of infections (otitis, URI, oral, UTI)
    • Increased IQ score (4 points)
    • Decreased risk of chronic diseases (IDM, DM2, Atherosclerosis, Asthma, Allergies)
    • Improved vision
    • Improved GI function 
    • Decreased obesity
    • Decreased NEC

Milk Composition

  • Protein: 70% whey, 30% casein
  • Fat: docosahexanoic acid and arachidonic acid thought to accumulate in retina and cortex
  • Carbohydrates: mostly lactose
  • Minerals: Calcium, Phosphorus, Iron
  • Protective factors: Immunoglobulins IgA, IgM, IgG, phagocytes, lymphocytes, cytokines
  • LACKING:  Adequate Vitamin D
    • Supplement: 400IU of Vitamin D daily for breastfed infants

Common breastfeeding problems

  • Inadequate feeding
    • Signs: Decreased infant urine output (<6 a day after first week), stool output (<3 per day), excess infant weight loss  (>10% of birth weight) 
    • Management: If inadequate milk production, dopamine antagonists (metoclopramide, domperidone) can augment production
  • Delay or failure to produce milk
    • Causes: Cesarean delivery, primagravid, premature infant, Sheehan’s syndrome (failure to lactate and loss of pubic hair, infarction of pituitary due to post partum hemorrhage)
  • Nipple soreness
    • Causes: Poor latch, torticollis, tight lingual frenulum, cleft lip/palate, oral thrush
    • Can be normal for 30s-1min after suckling begins for the first week of breastfeeding
  • Engorgement
    • Signs: breast pain, tenderness, fullness, firmness, difficulty latching
    • Management:
      • Ensure proper latch and feeding, manual expression or pumping prior to feed
      • Warm compress before feeding, cold compress after
      • Ibuprofen or acetaminophen for pain
  • Mastitis
    • Signs:  Fever over 38.5, myalgias, breast pain, erythema, firmness, lymphadenopathy
    • Management: Culture of breast milk (commonly MRSA +), cold compress, improved breast feeding technique, ibuprofen
      • Severe infection: IV Vancomycin
      • Non-severe infection:
        • Suspected MRSA: TMP-SMX or Clindamycin 
        • No MRSA: Dicloxacillin or cephalexin without risk for MRSA

Case

A mother of a 3 month old baby calls to tell you that she has been diagnosed with sinusitis and her physician has put her on Augmentin and Benadryl. She would like to know if she may continue to nurse her baby?

In many cases, drugs that are prescribed to nursing mothers have not been tested for their presence in breast milk. The questions to be asked are is the drug really necessary, is this the safest drug for the mother's condition or are there alternatives, could the drug present a risk to the infant, and by altering the timing of the drug administration, can you minimize the exposure?

Drugs contraindicated during Breastfeeding 

  1. Chemotherapeutic agents
  2. Drugs of abuse-e.g. marijuana, heroin, PCP/Amphetamines, nicotine 
  3. Radioactive compounds- require interruption of nursing and must consult nuclear medicine specialist to determine how long radioactivity is present in milk. 
  4. Antianxiety, Antidepressants, and Antipsychotic medications effects are not known but are of concern.
  5. Contraindicated- Lithium, Tetracycline, Cyclosporine, Ergotamines, Bromocroptine(suppresses lactation)

Maternal illnesses and nursing  

  1. Candida infection of the breast- Topical antifungals like Nystatin and Lotrimin should be used and the breast should  be wiped off before feeds. Check the infant for thrush and if present, treat with mycostatin.  Breastfeeding may continue
  2. Mastitis and Breast Abscess- mother usually develops flu-like symptoms and infection often caused by Staphylococcus. May come from plugged duct and nursing may help treat the infection and aleviate the obstruction. Should use antibiotic, heat, and acetaminophen. Should not stop nursing.
  3. Toxemia- generally drugs used to treat toxemia are contraindicated for nursing mothers and milk should be discarded until the medications are stopped
  4. Urinary Tract Infections- May use penicillins, cephalasporins, gentamicin, and ampicillin. Avoid sulfa drugs in the first month.   Tetracyclines and chloramphenicol are contraindicated. 
  5. Cytomegalovirus- although the breastmilk may contain viruses, it also contains antibodies that are protective against CMV. Therefore, breastfeeding should not be stopped in CMV infected mothers. Should avoid nursing if infant is preterm.
  6. Tuberculosis- Mothers with positive skin test and negative chest radiographs may continue nursing while taking INH. If the mother has active TB, there should be no contact between the mother and the infant until the mother is being successfully treated. The mother may pump and discard milk and return to nursing later.
  7. Hepatitis A- mother may nurse if she feels well. If she develops Hepatitis A 2 weeks prior to delivery or within one week of infants birth, infant should receive immunoglobulin
  8. Hepatitis B- Infant should receive HBIG and HBV vaccine after birth and mother may nurse.  Although Hep B has been isolated from human milk, the predominant mode of transmission is vertical at the time of delivery.
  9. Hepatitis C- Nursing is not contraindicated
  10. Varicella- if both infant and mother have varicella at birth, they should both be isolated and nursing may continue. If only the mother has lesions, the baby should be isolated and mother may pump and milk given to the infant. It is a good source of antibodies. Acyclovir treatment of nursing mother is not a contraindication to breastfeeding.
  11. Herpes- The infant should avoid contact with herpes lesions and if there are no vesicles on the breast, the mother may breastfeed. Other lesions should be covered while nursing.  Mother should observe careful hand washing technique.
  12. Syphilis- only contraindication is if there are syphilitic lesions on the breast. After the mother is treated and the sores are healed, nursing may resume
  13. HIV- HIV positive mothers should not breastfeed because the virus is transmitted through the milk to the infant. In areas where substitutes for breast milk are not available, nursing should be done by HIV + mothers i.e. 3rd world countries because of the risk of diarrheal illnesses in attempts to prepare formula with unclean water supplies.
  14. Breast Cancer- There is no increased risk of breast cancer in mothers whom breastfeed. If a mother is receiving radiation or chemotherapy, she should not nurse.

References  

  1. Freed, G and Clark, S. Breastfeeding and Maternal Illness. Contemporary Pediatrics April 1996
  2. Powers NG and Slusser W. Breastfeeding Update 2: Clinical Lactation Management. Pediatrics in Review. 1997; 18:147-161.
  3. Slusser W and Powers NG. Breastfeeding Update 1: Immunology, Nutrition and Advocacy. Pediatrics in Review. 1997; 18:111-119.
  4. 2000 Redbook
  5. Committee on Drugs The Transfer of Drugs and other Chemicals into Human Milk. Pediatrics September 2001
  6. Cahill John, and Wagner Carol. Challenges in Breastfeeding: Maternal considerations.  Contemporary Pediatrics May 2002
  7. Cahill John and Wagner Carol. Challenges in Breastfeeding:: Neonatal considerations.  Contemporary Pediatrics.  May 2002.
  8. American Academy of Pediatrics. Prevention of Rickets and Vitamin D Deficiency. Pediatrics Vol 111 April 2003
  9. American Academy of Pediatrics Breastfeeding and the Use of Human Milk.  Pediatrics February 2005
  10. Hale T. Drug Therapy and Breastfeeding: antibiotics Analgesics and Other Medications. NeoReviews. May 2005
  11. Database for drugs and breasfeeding    http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT