Presentation on theme: "Chapter 7 Nutrition During Lactation: Conditions and Interventions"— Presentation transcript:
1 Chapter 7 Nutrition During Lactation: Conditions and Interventions Nutrition Through the Life CycleJudith 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 IntroductionTwo key considerations related to conditions and interventions during breastfeeding are:1) The vast majority of women do not experience significant problems during breastfeeding2) Most problems could have been prevented with proper prenatal breastfeeding education & a positive breastfeeding initiation period
9 Common Breastfeeding Conditions Sore, flat or inverted nipplesLetdown failureHyperactive letdownHyperlactationEngorgementPlugged ductMastitis (Infection)Low milk supply
10 Condition: Sore nipples May be prevented by proper positioning of baby on breastThe 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 fingersOr use a breast pump prior to feedingHelps to draw out the nipple
12 Condition: Letdown Failure When milk does not eject from the breastVery uncommonOxytocin nasal spray may be prescribedRelaxation techniques may help reduce problem
13 Condition: Hyperactive Letdown Streams of milk come from breastIf too active, may cause infant to choke while nursingManagement:Wait for the milk flow to slow down before putting the infant to the breastMother may express milk until the flow slows then allow infant to nurse
14 Condition: Hyperlactation Occurs when milk volume produced exceeds intake of the babySymptoms in mother:Breasts not drained completelyChronic plugged ductsLeaking between feedingsPain with letdown or deep in breastSymptoms in baby:Spitting up, poor weight gainDifficulty maintaining latch
15 Condition: Hyperlactation Occurs when milk volume produced exceeds intake of the babyManagement:Reduce productionNurse baby on one side only and express for comfort on the otherCabbage leaves may be used to decrease production
16 Condition: Engorgement Breasts are overfilled with milkResults when supply-and-demand process is not yet established and milk is abundantBest prevention: nurse frequently—newborns may nurse every 1 to 2 hours
17 Condition: Plugged Duct Caused by milk staying in the ductsPainful knot may form in breastTreated by massage and warm compressPrevented by complete emptying of breasts and changing position of infant while feeding
18 Condition: Mastitis (Infection) Mastitis is inflammation of the breastMay be infective or non-infectiveOccurs in 3 to 20% of breastfeeding womenMost common at 2-6 weeks postpartumMay result from:Sore and cracked nipplesBlood borne source of bacterial infectionMissing a feeding resulting in engorgement, then plugged duct may precipitate engorgement
20 Condition: Low Milk Supply Most common reason for cessation of breastfeedingMay be real or may be perceivedCauses:Insufficient breastfeeding or pumpingIneffective emptyingStressManagementNurse or pump every 2-3 hoursDrugs or herbs may be prescribedGalactogogue, Metoclopromide, Fenugreek
21 Maternal Medications Most medications are excreted in breast milk Variables to consider related to medications during lactation:Pharmacokinetic properties of the drugTime-averaged breast milk/plasma drug concentration ratioDrug exposure indexInfant’s ability to absorb, detoxify & excrete drugInfant’s age, feeding pattern, total diet, & health
22 Maternal MedicationsMilk/Plasma Drug Concentration Ratio (M/P Ratio) The ratio of the concentration of drug in milk to the concentration of drug in maternal plasmaExposure 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 metabolismDrugs of abuse-adverse effectsRadioactive compounds-temporary cessation of breastfeedingDrugs in which effect is unknownDrugs associated with significant effectMeds compatible with breastfeedingAgents with no effect on breastfeeding
26 Safety of Oral Contraceptive Use During Lactation Current evidence suggests combined oral contraceptives (OC) may reduce the volume of breast milkThe ACOG & WHO recommend against use of combined OC during first 6 weeks postpartumProgestin only OC & implants are safe & effective
27 Herbal RemediesScientific information about herb use during lactation is sparseMedicinal herbs should be viewed as drugsMany herbs are contraindicated during lactation
28 Herbal RemediesTable 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 recommendedGinseng root - not recommendedSt. John’s wort - may reduce milk supplyEphedra (ma huang) - not recommendedFenugreek - infants may be allergicCabbage leaves - safe for topical use to reduce engorgementGoat’s Rue and Milk Thistle/Blessed Thistle- potential use as galactogues
30 Alcohol and Other Drugs Nicotine (smoking cigarettes)MarijuanaCaffeineOther drugs of abuseEnvironmental exposures
31 Alcohol Alcohol consumed quickly passes to breast milk Level of alcohol in breast milk is same as in maternal plasmaPeak plasma levels occur at min. after consumption if consumed w/o food and min. if consumed with foodContrary to popular belief, alcohol decreases oxytocin and let-down
32 Impact of Alcohol on Lactation Contrary to popular belief, alcohol decreases oxytocin & let-downAffects odor of milkDecreases volume consumed by infantInterferes with sleep pattern of infant
34 Other Drugs and Lactation Nicotine (smoking cigarettes)Regardless of feeding choice, the health risks for infants posed by a smoking mother are manyOtitis mediaExacerbation of asthmaRespiratory infectionsGastrointestinal dysregulationLevels are 1.5 to 3 times higher in breast milk than mother’s blood
35 Other Drugs and Lactation MarijuanaIs transferred and concentrates in breast milk and it metabolized by the nursing infantMay change DNA/RNA & the proteins needed for growth
36 Other Drugs and Lactation CaffeineModerate intake causes no problems for most breastfeeding infants and mothers.Level in breast milk is only 1% of that in mother’s plasmaMay accumulate in infants younger than 3 to 4 months—varies from infant to infantMay interfere with sleep or cause hyperactivity & fussiness of infant
37 Other Drugs and Lactation Other drugs of abuseAmphetamines, 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 damageIt is the most frequent cause for hospital readmission for newborns
41 Bilirubin MetabolismBilirubin—a pigment produced as heme from red blood cells (RBC) break downUsually processed by the liver and excreted in the baby’s stoolNewborn’s liver not fully mature so jaundice is common during first few days of lifeColor appears first in the face & upper body then progresses downward toward the toes
42 Bilirubin MetabolismIn the fetal state, high levels of hemoglobin were needed to carry oxygen delivered by the placentaAt 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 PhysiologicalBegins after the 1st day of birth rising steadily with peak ~ day 6-7Bilirubin <12 mg/dLCondition resolves within a few daysCause: normal heme breakdownPathologicalBegins within 1st day after birth rises rapidly & lasts longerBilirubin >8 mg/dL in 1st dayMedical intervention with phototherapyCause: various pathological conditions
44 Bilirubin Encepahlopathy or Kernicterus Bilirubin is toxic to cells & may cause brain damageBrain & brain cells destroyed by bilirubin do not regenerateMortality 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 day1/3 of breast-fed infants are jaundiced at 3 weeksCause is unknownThought that more bilirubin is reabsorbed due to factors in breast milk that promote its absorptionTypically resolves itself but in severe cases is treated like regular physiological jaundice
46 Treating JaundiceThe AAP guidelines recommend phototherapy using fluorescent lightsLight is absorbed in bilirubin changing it to a water-soluble product that can be excreted via the kidneysAAP guidelines encourage continuation of breastfeeding
47 Information for Parents Inform parents that most breastfed infants will become jaundicedOnly a small fraction of these infants will develop extreme hyperbilirubinemia and kernicterus
48 Breastfeeding Multiples Breastfeeding twins, triplets & quadruplets is possibleMain obstacle is the time & fatigue of motherFrequent nursing increases milk supplyParents of multiples need support in:OrganizationFeedingIndividualizationStress management
49 Infant AllergiesExclusive breastfeeding for ≥4 months protects against allergies, ectopic dermatitis & wheezingDevelopment 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 systemsConsumption of omega-3 fatty acids by lactating mother may protect against Allergies
50 Food IntoleranceNo scientific evidence shows gassy foods in mother’s diet produce gas in infantLow-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 difficultComplications include:Cardio-respiratory instability, poor temperature control, lower glycogen & fat stores, immature immune system, weak suck-swallow coordination
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 breastfeedingTable 7.14 lists the medical problems and contraindications for breastfeedingThe 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 milkTransmission rates 5 to 20% depending on duration of breastfeedingDHHS 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
59 Milk Banking Human milk banks Provide human milk to infants who cannot be breastfed by their mothersSome neonates ICUs had milk banks until the 1980s when HIV infections, resurgence of TB and other risks became prevalent
60 Model ProgramsBreastfeeding Promotion in Physicians’ Office Practices (BPPOP)Innovative program designed to boost breastfeeding promotion and supportThe Rush Mothers’ Milk ClubEvidence based program of breastfeeding interventions in NICU
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