09.01.23 CM_Lactation_Cullen_Notes.pdf

Sept. 1, 2023 Lactation Page 1 of 10 Lactation Instructor: Danielle Cullen, MD ([email protected]) Block 5: Urology/Endocrine/Reproduction Thread: Clinical Medicine Conflict of interest: none Further Reading: WellStart International: www.wellstart.org Learning Objectives 1. Recall br...

Sept. 1, 2023 Lactation Page 1 of 10 Lactation Instructor: Danielle Cullen, MD ([email protected]) Block 5: Urology/Endocrine/Reproduction Thread: Clinical Medicine Conflict of interest: none Further Reading: WellStart International: www.wellstart.org Learning Objectives 1. Recall breast anatomy 2. Describe the physiology of lactation & milk composition 3. Recognize the benefits of breastfeeding for both parent and baby 4. Summarize the recommendations for breastfeeding & epidemiology of breast feeding 5. Recognize the elements of successful breastfeeding (ex. latch) 6. Recognize the goals of the “Baby Friendly” initiative 7. Identify common breastfeeding problems 8. Discuss contraindications, medication use, contraception & imaging studies while breastfeeding 9. Discuss milk expression and storage (hand expression, pumps) guidelines 10. Recognize barriers to breastfeeding in real life Study Questions 1. Describe the breastmilk composition and how it changes over time. 2. Describe the elements of successful breastfeeding. Sept. 1, 2023 Lactation Page 2 of 10 A. Breast Anatomy 1. Sensory innervation by 3rd-6th intercostal nerves 2. Early pregnancy changes: tender, full, more prominent venous pattern 3. Late pregnancy changes: areola may increase in size and darken 4. Montgomery tubercles are small nodules on the areola that secrete lubricating substance 5. Each nipple contains 5-9 milk ducts 6. Each duct extends into a mammary lobule where milk is produced in the alveoli 7. Alveoli is where milk is produced in response to prolactin 8. Alveoli are surrounded by myopeithelial cells which contract in response to oxytocin and push milk out of alveoli, down ducts, and out of nipple B. Physiology of Lactation 1. Early, frequent and complete breast emptying is what promotes an adequate milk supply; feeding frequency and duration dictates milk supply 2. Estrogen and progesterone are high during pregnancy and drop once the placenta is delivered 3. After delivery, prolactin remains elevated, but now with estrogen and progesterone low, this is the signal to the breast to begin lactogenesis 4. Breast suckling triggers release of prolactin from anterior pituitary and oxytocin from posterior pituitary 5. Prolactin is responsible for milk production; oxytocin is responsible for milk ejection C. Human milk composition 1. Colostrum a. Starts forming at 12 weeks gestation and more is made during labor and delivery; persists for 2-4 days after delivery b. Typically 40-50 cc made on PPD#1 c. More protein, less fat, and less lactose than mature milk d. Rich in beta carotene which is what gives it the yellow color e. High in immunoglobulins, providing passive immunization f. Provides lactos, which prevents hypoglycemia and facilitates passage of meconium (acts as a natural laxative) Sept. 1, 2023 Lactation Page 3 of 10 2. Transitional milk a. Present around PPD#7-10 3. Mature milk a. Produced around PPD#14; can produce 20-30 oz daily b. Components are water, lipids, carbohydrates, protein, minerals c. Sufficient iron in breastmilk for infants; iron absorption better from breastmilk than cow’s milk d. Infants who are breastfed need vitamin D supplementation (400 IU/day) e. All infants need vitamin K injection after birth to help with coagulation due to poor absorption D. Breastfeeding Benefits 1. Parental a. Increased post-partum weight loss b. Amenorrhea, decreased rate of unintended pregnancy c. Reduced response to stress, lower rates of post-partum depression d. Uterine involution, decreased post-partum blood loss e. Cancer reduction (breast/ovarian/endometrial) f. Reduction in risk of hypertension, hyperlipidemia, diabetes, cardiovascular disease 2. Infant a. Reduced risk of diabetes and childhood obesity b. Higher IQ c. Reduction in rate of respiratory, gastrointestinal, urinary tract and ear infections d. Reduced risk of food allergies and eczema e. Less likely to require orthodontia f. Reduced risk of inflammatory bowel disease E. Breastfeeding Recommendations 1. WHO, AAP and ACOG: continued breastfeeding up to age 2 and beyond Sept. 1, 2023 Lactation Page 4 of 10 F. Breastfeeding Epidemiology 1. 83% of babies in the U.S are ever breastfed, but only 36% are still breastfed at 12 months 2. Most breastfeeding patients wean before they have met their breastfeeding goal G. Elements of Successful Breastfeeding/Chestfeeding 1. Latch: wide open mouth, lips phalanged outward, tongue pressed down, nose/chin against breast, entire areola in mouth 2. Positioning: cradle, cross cradle, football, side lying 3. Skin to skin: promotes recognition of early feeding cues 4. Feeding frequency: 8-12 feedings/24 hour period H. Baby Friendly 1. A hospital designation which promotes an environment to help people have success with breastfeeding; ten steps a. Have a written breastfeeding policy that is routinely communicated to all health care staff b. Train all health care staff in skills necessary to implement this policy c. Inform all pregnant people about the benefits and management of breastfeeding d. Help patients initiate breastfeeding within an hour of birth e. Show patients how to breastfeed and how to maintain lactation even if they should be separated from their infants f. Given newborn infants no food or drink other than breast milk, unless medically indicated g. Practice rooming in, and allow parents and infants to remain together 24 hours a day h. Encourage breastfeeding on demand i. Give no artificial nipples or pacifiers to breastfeeding infants j. Foster the establishment of breastfeeding support groups and refer parents to them upon discharge from the hospital or clinic Sept. 1, 2023 Lactation Page 5 of 10 I. Common Breastfeeding Problems 1. Nipple pain: due to poor latch, infections, ankyloglossia, not breaking suction at end of feed 2. Inverted nipples: no nipple preparation needed; may need to pump, use nipple shield 3. Prior breast surgery: augmentation or reduction may impact milk supply 4. Engorgement a. Due to infrequent or ineffective milk removal b. Breasts tender, warm, enlarged, firm and skin is shiny c. Resolves with milk removal -->nursing, pumping/hand expression if breasts too engorged for infant to latch; warm compresses/shower help 5. Obstructed duct a. Painful, firm mass on breast that may be tender; caused by tight clothing, ineffective breast emptying; b. Treatment is changing positions, feeding from affected breast first, lecithin 6. Mastitis a. Inflammation of the breast characterized by erythema, warmth, tenderness and flu-like symptoms b. Bacterial infection usually caused by Staph Aureus (sometimes MRSA) due to skin break in nipple c. Treated with Dicloxacillin (Clindamycin if MRSA) and continued breastfeeding d. Can progress to abscess; diagnosed by ultrasound and treated with I&D 7. Candida a. Presentation: severe nipple pain shooting through to back; pink, shiny nipple b. Diagnosis: usually clinical; KOH prep or breastmilk culture if needed c. Treatment for mom: topical azoles; gentian violet; oral diflucan d. Treatment for infant: oral nystatin 8. Jaundice a. Most infants have elevated unconjugated bilirubin level in first few weeks of life b. Due to: i. Increased bilirubin production due to shorter life span of Sept. 1, 2023 Lactation Page 6 of 10 erythrocytes (bilirubin is a breakdown product of erythrocytes) ii. Increased intestinal absorption of bilirubin iii. Decreased hepatic metabolism/clearance of bilirubin c. Normal physiology: unconjugated bilirubin binds albumin and is transported to the liver where it is conjugated by glucuronyl transferase into direct bilirubin and excreted in bile-->excreted into duodenum d. Much of the conjugated bilirubin then hydrolyzed back into unconjugated bilirubin by beta glucoronidase enzyme in the intestine-->reabsorbed and flows back to liver via portal circulation e. Limited ability of newborn liver to conjugate bilirubin leads to excess of unconjugated bilirubin; worsened by exaggerated hemolysis for Rh or ABO incompatibility or decreased hepatic ability to metabolize due to prematurity or enzyme defects f. Jaundice visible on skin when bilirubin > 5 mg/dl (normal adult < 1.5 mg/dl); starts on the face and moves downward; when on legs/trunk, levels are 15-20 mg/dl g. Breastmilk jaundice: protective mechanism; unconjugated bilirubin is a protective antioxidant; this is a prolongation of physiologic newborn jaundice h. Kernicterus: neurologic damage due to excessive levels of bilirubin-->when excessive, can enter brain and destroy neurons in basal ganglia and cerebellum; can lead to permanent brain damage; starts with lethargy/poor feeding and progresses to seizures, hearing loss, motor deficits i. Infants monitored with serum and transcutaneous bilirubin levels; >15 mg/dl usually leads to lethargy and poor feeding j. Treatment: improved breastfeeding, donor milk, pumped milk, formula, phototherapy, exchange transfusion k. Phototherapy works by several mechanisms: i. Photo-oxidation of bilirubin to a colorless substance excreted in urine ii. Converts bilirubin to lumirubin by isomerization - lumirubin is more soluble and excreted without conjugation into bile and urine Sept. 1, 2023 Lactation Page 7 of 10 J. Milk Supply 1. Low milk supply a. Most common cause is ineffective breast emptying and infrequent feedings b. Introduction of formula decreases nipple stimulation which then decreases milk supply c. 8 or more feedings in 24 hours is the goal; continuing night feeding when prolactin is highest can be helpful d. Reassurance of growth spurts and cluster feeding to avoid inappropriate formula supplementation e. Supplement with pumped/hand expressed milk if low supply f. Triple feeding 2. Measuring milk supply a. All babies lose weight after delivery and usually re-gain it by DOL#14 b. More than 10% weight loss typically triggers recommendation for supplementation c. Infant weight gain of 30 grams (roughly 1 oz) daily is normal in newborn period d. Infant “getting enough” milk if content after feeding, having 3-4 stools/day and 6+ urine-stained diapers by DOL#3 and if audible swallowing e. Milk production likely sufficient if breasts engorged prior to a feeding and soft afterward K. Contraindications to breastfeeding 1. Infant with galactosemia 2. HIV 3. Human T cell lymphotropic virus type I/II 4. Active untreated tuberculosis 5. HSV on nipple 6. Cytotoxic chemotherapeutic use (ex. methotrexate) 7. Illicit drug use Sept. 1, 2023 Lactation Page 8 of 10 L. Radiology while lactating 1. After anesthesia for surgical procedures, people can breastfeed as soon as they’re stable, awake and alert enough to hold their infant 2. Breastfeeding can be continued without interruption after use of iodinated contrast or gadolinium 3. No risk to lactation from ionizing radiation or ultrasound 4. LactMed resource to look up safety of medications while breastfeeding 5. Nuclear medicine imaging: radionucleide compounds are excreted into breastmilk in varying concentrations/for varying amounts of time M. Medications while lactating 1. Most medications are safe during lactation; when in doubt, look it up (LactMed is peer-reviewed database) 2. Time medications for after breastfeeding, avoid long-acting meds, observe infant for adverse effects 3. Rule of thumb: if safe for infant to take, safe for lactating parent to take 4. Avoid: pseudoephedrine, codeine, tramadol N. Lactation and contraception 1. Exclusive breastfeeding in first 6 months, if amenorrheic, inhibits ovulation and pregnancy is very unlikely 2. Concerns about progestin-containing contraceptives decreasing milk supply have not been substantiated 3. Breastfeeding during pregnancy is safe, as long as no other contraindication to oxytocin release in pregnancy O. Milk Expression/Storage 1. Hand expression: requires no special equipment and is as effective as pumping 2. Breast pumps: manual and electric 3. Milk storage rule of 6’s: 6 months in freezer, 6 days in refrigerator, 6 hours at room temperature 4. Don’t microwave stored breastmilk -->heat by immersion and swirl until homogenous 5. Once an infant starts drinking milk from a bottle, must finish that bottle in one Sept. 1, 2023 Lactation Page 9 of 10 sitting or discard remaining unconsumed milk P. Lactation in the real world 1. ACA requires employers to provide reasonable (not necessarily paid) break time and a private space other than a bathroom to express breastmilk until infant is 12 months old 2. All pregnant people can obtain a breast pump free of charge through their health insurance Sept. 1, 2023 Lactation Page 10 of 10 Study Question Answers 1. Describe the breastmilk composition and how it changes over time. a. Early breastmilk is called colostrum and persists for the first 2-4 days after delivery. This milk has high protein content, and lower fat and lactose content than mature milk. It is high in beta carotene and immunoglobulins. After colostrum, the milk becomes transitional. This is present until around 7-14 days postpartum and is high in protein. This milk is the slow transition between colostrum and mature milk, and patients will notice a feeling of breast fullness during this time. Mature milk typically is present around 14 days postpartum and is often in volumes of about 20-30 oz per day. It includes water, lipids, carbohydrates, protein and minerals. There is enough iron for the baby in this mature milk, but Vit D levels are low so infants who are fed human milk will require supplementation. It is also low in Vit K. The milk supply is largely related to the supply/demand relationship between parent and infant. 2. Describe the elements of successful breastfeeding. a. Successful breastfeeding requires appropriate latch and frequency of feeding. The infant should have their mouth wide open and should have the entire areola in their mouth. The lips should be phalanged outward. It is most effective when a comfortable position is found for the dyad (parent and infant) allowing for best latch and head position. There are multiple different positions that baby can be held in for successful latch. The frequency of feeding is very important to establish and maintain an adequate milk supply. When the breasts frequently get full, your body will decrease milk production. If the breasts are frequently empty, the body will increase milk production. Baby should latch every 2-3 hours in the weeks after birth, and if that is not possible, a breast pump can be used every 2-3 hours to establish supply.