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

2. Key Nutrition Concept #1
Human milk is the preferred food for all premature and sick newborns, with rare exceptions.

3. Key Nutrition Concept #2
Breastfeeding women need consistent, informed, and individual care in the hospital and at home after discharge.

4. 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 mother’s breastfeeding must be justified by the fact that the risk to her baby clearly outweighs the benefits of breastfeeding.

5. 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.

6. 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.

7. Key Nutrition Concept #6
6. Twins and other multiples can be successfully breastfed without formula supplementation.

8. 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

9. Common Breastfeeding Conditions
Sore, flat or inverted nipples
Letdown failure
Hyperactive letdown
Hyperlactation
Engorgement
Plugged duct
Mastitis (Infection)
Low milk supply

10. Condition: Sore nipples
May be prevented by proper positioning of baby on breast
The areola should be in the baby’s mouth with tongue extended against lower lip

11. 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

12. 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

13. 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

14. 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

15. 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

16. Condition: Engorgement
Breasts are overfilled with milk
Results when supply-and-demand process is not yet established and milk is abundant
Best prevention: nurse frequently—newborns may nurse every 1 to 2 hours

17. 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

18. 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

20. 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

21. 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
Infant’s ability to absorb, detoxify & excrete drug
Infant’s age, feeding pattern, total diet, & health

22. 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

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

24. 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

25. Minimizing Effect of Maternal Medications

26. 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

27. Herbal Remedies
Scientific information about herb use during lactation is sparse
Medicinal herbs should be viewed as drugs
Many herbs are contraindicated during lactation

28. 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”

29. Herbs Widely Used in the U.S. with Impact on Breastfeeding
Echinacea - not recommended
Ginseng root - not recommended
St. John’s wort - may reduce milk supply
Ephedra (ma huang) - not recommended
Fenugreek - infants may be allergic
Cabbage leaves - safe for topical use to reduce engorgement
Goat’s Rue and Milk Thistle/Blessed Thistle- potential use as galactogues

30. Alcohol and Other Drugs
Nicotine (smoking cigarettes)
Marijuana
Caffeine
Other drugs of abuse
Environmental exposures

31. 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 min. after consumption if consumed w/o food and min. if consumed with food
Contrary to popular belief, alcohol decreases oxytocin and let-down

32. 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

33. Alcohol and Breastfeeding

34. 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 mother’s blood

35. 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

36. 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 mother’s plasma
May accumulate in infants younger than 3 to 4 months—varies from infant to infant
May interfere with sleep or cause hyperactivity & fussiness of infant

37. 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

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

39. Neonatal Jaundice and Kernicterus
Jaundice—a 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

40. Risk Factors for Severe Hyperbilirubinemia

41. Bilirubin Metabolism
Bilirubin—a pigment produced as heme from red blood cells (RBC) break down
Usually processed by the liver and excreted in the baby’s stool
Newborn’s 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

42. 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

43. Physiologic versus Pathologic Newborn Jaundice
Physiological
Begins after the 1st day of birth rising steadily with peak ~ day 6-7
Bilirubin <12 mg/dL
Condition resolves within a few days
Cause: normal heme breakdown
Pathological
Begins within 1st day after birth rises rapidly & lasts longer
Bilirubin >8 mg/dL in 1st day
Medical intervention with phototherapy
Cause: various pathological conditions

44. 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

45. Breast-Milk Jaundice Syndrome
Onset later than physiological jaundice—typically 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

46. 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

47. 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

48. 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

49. 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

50. Food Intolerance
No scientific evidence shows gassy foods in mother’s diet produce gas in infant
Low-allergen maternal diet associated with reduction in distressed behavior (colic)
Allergenic foods eliminated were cow’s milk, eggs, peanuts, tree nuts, wheat, soy, & fish

51. 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

53. Near-Term Breastfeeding Cascade
Illustration 7.1 Near-term infant breastfeeding cascade.

54. 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 mother’s 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

55. 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

56. 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...”

57. 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

58. Human Milk Collection and Storage

59. 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

60. 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