Steven Ajl, MD
Department of Pediatrics
SUNY Downstate Medical Center, Brooklyn
Josephine Scalici, MD
SUNY Downstate Medical Center, Brooklyn
Rachael VanCura, MD
SUNY Downstate Medical Center, Brooklyn
___________________________________
PRE-TEST QUESTIONS
Q1: T or F. The caloric content of breast milk is the same as formula and cow milk?
Q2: Best answer. All of the following are advantages of breastfeeding except:
A. involution of the uterus
B. decrease rate of certain childhood infections, including otitis media and gastroenteritis
C. higher IQ in those term infants who were breastfed as opposed to those who were formula fed.
D. Reducing health care costs
Q3: Best Answer. Which of the following reflects the accurate percentage of calories acquired from human milk?
A. Carbohydrates supply 41% of calories, protein supplies 51% and lipid supplies the remaining 8% of the calories.
B. Carbohydrates supply 51% of calories, protein supplies about 8% and lipid supplies the remaining 41% of the calories.
C. Carbohydrates supply 41% of calories, protein supplies about 8% and lipid supplies the remaining 51% of the calories.
D. Carbohydrates supply 8% of calories, protein supplies 41% and lipid supplies the remaining 51% of the calories.
Q4: T or F. Breast fed infants are less likely to become obese.
OBJECTIVES
At the conclusion of this section, residents will be able to:
1. Appreciate the difference in the content of breast milk as the infant matures.
2. Identify the different fat, carbohydrate, and protein content in breast milk vs. formulas.
3. Discuss the advantages, contraindications, and common misconceptions of breast feeding.
4. Recognize differences in normal growth between breast and bottle fed Infants.
5. Identify and intervene effectively when common problems arise for breastfeeding infants and mothers.
6. Overcome institutional and communal practices or restrictions that adversely affect individuals and communities seeking to breast feed.
FACILITATOR PREPARATION
For this section, the facilitator should begin by reviewing the section in Pediatric Nutrition Notes on breast-feeding. See also:
(1) Meek, JY. (2002) American Academy of Pediatrics, New Mother’s Guide to Breast feeding. New York: Bantam Book
(2) American Academy of Pediatrics Committee on Nutrition, (2003-2004) Pediatric Nutrition Handbook (5th ed., pp. 55-86) USA: American Academy of Pediatrics.
(3) Ajl, SJ. (1993) Infant Feeding Practices. In Karp, RJ. Malnourished Children in the United States. (pp. 47-58) New York: Springer Publishing.
(4) Greene GW, Smicklas-Wright H, Scholl TO, Karp RJ. Post partum weight change: how much of the weight gained in pregnancy will be lost after delivery? Obstet Gynecol 1988;71;701-7.
A particularly useful practical guide to breast feeding is The Breastfeeding Atlas [Wilson-Clay B, Hoover K. (2002) The Breastfeeding Atlas, 2nd Edition. LactNews Press. Austin, TX.]
INTRODUCTION
Human milk is the ideal method of feeding for the human infant. It is recommended by the AAP, ACOG, AAFP as well as the Institute of Medicine as the sole source of nutrition for the initial 4-6 months of life and should be continued through the first year of life. The current goal/ recommendation for Healthy People 2010 is a breastfeeding initiation rate of 75% and a continuation rate of 50% at 6 months of age and 25% at one year of age.
The nutritional content of breast milk is the most appropriate for the growing infant with perfect percentages of calories derived from carbohydrate, protein and fat. The mineral and vitamin content are ideal as well. Breast milk is ideally suited for the newborn and the concept of species specificity should be highlighted. Human milk is for humans. Formula, which is usually a modification of cow milk, will never be a perfect substitute for mother’s milk. Breast feeding also offers benefits to the nursing mother. It decreases her risk of pre-menopausal breast cancer, ovarian cancer, and then osteoporosis as she goes through menopause. Breast feeding is also felt to enhance mothers’ over-all sense of well being as she proceeds through the difficult and demanding first year of her child’s life.
The case studies and discussion that follow illustrate the importance of breast feeding. Moreover, they highlight the importance of providing the parent medical information in a context that respects their own needs as well as addresses the social and economic barriers to breast feeding.
CASE STUDY - PART I
Mrs. Rosen is a 30 year old female G1P0 at 32, weeks pregnant by first trimester ultrasound. She is here for her first visit with her soon-to-be pediatrician. She has heard very good things from friends, co-workers and neighbors about the care provided at this practice and wishes to visit the office and meet with the pediatrician.
She and her husband have been trying to conceive for many years and consider this pregnancy a blessing. They have been adherent with obstetric appointments and advice. They attend Lamaze classes together, and have read “What to Expect When You’re Expecting”. They have worked so hard to have this baby, that they don’t want to do anything wrong.
As a first time mom, she has many questions and concerns; particularly regarding breastfeeding. She explains that most of her friends did not breast feed, and they all have beautiful healthy children. And so she asks, “Does breastfeeding really make that much of a difference?”
Group Exercise #1:
Preceptors- Before continuing, ask the students/residents what their response would be to the above question. Brainstorm and make a list of as many favorable differences there exists between human and cows milk. As you proceed through the case you may add/remove some items, in the end having compiled all of the important aspects of breastfeeding into one table.. Pediatric Nutrition Notes provides a comprehensive list of breast feeding advantages.
BACKGROUND MATERIAL: The Content of Breast Milk
The initial breast milk produced is colostrum, which might be thought of as pre-milk. It is present at birth. It is higher in protein than are transitional milk and mature milk and lower in fat and carbohydrate. It has higher level of secretory IgA than mature milk and also has a high level of lactoferrin. It also has a higher level of sodium than mature milk. The caloric density of colostrum is 67 kcal/dl, which is less than that of mature milk, which is 75 kcal/dl.
Transitional milk is produced between colostrum and mature milk, which takes between one to two weeks post-partum to appear. During this period immunoglobulin levels and protein in the milk will decrease as lactose and fats increase.
The caloric content of breast milk ( about 20 cal per oz or 0.7 cal/ml) is the same as formula; however, the percentages of calories derived from carbohydrate, lipid and protein vary somewhat. The carbohydrate is lactose, which supplies about 41% of calories, protein supplies about 8% and lipid supplies the remaining 51% of the calories. There is minimal amount of cholesterol in formula and a significant amount in human milk with a diurnal variation in its amount. The saturated to polyunsaturated fat ratio varies between human milk and formula.
Recently the poly-unsaturated fatty acids, which are in retinal and phospholipid membranes, have been discovered to enhance central nervous system activity and to enhanced visual acuity and Docosohexanoic acid and Arachidonic acid have been added to some formula to have them approximate what is in human milk.
In discussing content we must look at each substrate individually. Although the carbohydrate moiety in both breast milk and formula is lactose, there is an important difference. In formula there are no oligosaccharides or carbohydrate polymers. These elements inhibit bacterial adherence to mucosal epithelial cells, at least experimentally. The oligosaccharide content of human milk is about 10 times that of cow milk.
The protein differences are in fact the most dramatic. Although the percentage of calories derived is fairly similar the concentration and type of proteins are vastly different. Whey and casein are the predominant proteins. The whey/casein ratio reflects the solubility of the proteins in an acid media. Caseins are proteins with low solubility, while whey, which predominates, remains in solution after acid precipitation. In human milk the ratio is approximately 70% whey to 30% casein while in the formulae it can vary from having formula with 100% casein to 100% whey and anywhere in between. The major human whey protein is alpha-lactalbumin. Other main proteins are lactoferrin, lysozyme and secretory immunoglobulin A, which are all involved in human defense mechanisms. All of these are present in significant amounts in human milk and are anti-infectious. The main protein in formulae, again a modification of cow milk, is beta-lactoglobulin, which does not confer any special benefits to the growing infant. The addition of Taurine to formula approximately 20 years ago ensured that a critical neurotransmitter would be present in formula. However it remains clear that the anti-infective aspect as well as the immunogenic aspect of human milk exceeds that of formula.
The mineral and trace elements, which are in formula, approximate that of human milk but are not the same. The mineral content of human milk is often much lower than that of formula. For example, the iron content of human milk is significantly less than in formulae and yet the breast fed baby virtually never becomes iron deficient as the iron in breast milk is more bioavailable. On the other hand the vitamin D content of human milk is low and supplementation of the breast fed baby with 400mg of Vitamin D daily is recommended. The Vitamin K content of milk is also quite low and a single intramuscular dose of Vitamin K is recommended at birth for all infants.
There are also non-nutritional benefits in breast milk that are important to highlight. Human host defenses are enhanced by a profile of anti-microbial factors in the White Blood Cell family. Macrophages, lymphocytes, neutrophils are all available in human milk and provide antimicrobial activity It is likely that the tactile stimulation of infants affect bonding for both mother and baby..
Q1: What are the Advantages of Breastfeeding?
A1: In the case with Mrs. Rosen, and with all parents, it is not only important to emphasize the differences in composition of human and cows milk, but also to emphasize how this will directly affect the well-being of her baby as the infant develops into a growing child and even into adulthood. The advantages to the baby and to the mother are tremendous and multiple.
TABLE 1. BREAST FEEDING — Why "breast is best" for human infants.
ANTI-INFECTION: The initial colostrum is high in Secretory IgA, which will prevent bacteria form adhering to the intestine of the newborn. Numerous studies show a clear benefit of human milk in continuing this protection. It is important for the medical provider to be knowledgeable about the benefits of breastfeeding in order to be an advocate for breast-feeding to parents. Researches have shown a significant decrease in otitis media and gastrointestinal infections in the nursing baby. The suggestion has been made that it is not something inherently in human milk, which might cause these infections to be diminished in the nursing baby.
Dr. Jack Paradise in Pittsburgh looked at infants with cleft palate who were unable to suckle at the breast. Historically infants with cleft palate have a 100% incidence of otitis media. In the subset of patients fed expressed breast milk vs. formula there was one third less incidence of otitis media. There is also evidence to suggest that there is a decreased incidence of diarrhea in the nursing baby and we now know that Mucin, a large glycoprotein in human milk inhibits rotavirus replication. In general there appears to be less respiratory infections in the nursing baby and there is evidence that in early childhood there is a decreased incidence of wheezing in breast fed infants as well.
OBESITY: Of heightened concern presently is the epidemic of obesity. From large prospective studies done on children up to about grade one it appears there is approximately a 30% less risk of obesity in infants exclusively breastfed for the first 3 months of life. Breast fed infants achieve non-nutritive suckling more easily than bottle fed ones.
“INTELLIGENCE” (IQ): The issue of intelligence has been a very difficult one to assess. Data is suggestive that at least in the preterm infant, exposure to human milk may enhance intelligence in the early years of life.
Necrotizing Enterocolitis (NEC): There also seems to be a favorable effect on the incidence of necrotizing enterocolitis in the pre-term baby who has solely received human milk.
Sudden Infant Death Syndrome (SIDS): There is a suggestion from the New Zealand Cot Study, which discussed risk factors for SIDS that in addition to prone sleeping position and exposure to cigarette smoke, not breastfeeding may increase risk for SIDS.
GROWTH:
Growth patterns differ from breast to bottle-fed babies. The World Health Organization (WHO) Working Group on Infant Growth assessed the growth patterns of infants fed as part of a study conducted between 1992 and 1994. The study developed a growth curve for breast-fed infants in six western nations. This curve is compared with the WHO-NCHS curve that is currently used in the United States what was thought to be failure to thrive at 6 months of age in infants solely fed on beast milk might be an artifact of the curves used to assess “normal” growth.
The Figure below shows the 3rd, 50th, and 97th percentiles for growth from the WHO curves for girls and boys, birth to 12 months of age, superimposed on the National Center for Health Statistics (U.S.) curve.
Figure 1.
TEACHING CAPTION: Note the substantial differences in growth of children assumed to be healthy. Are the U.S. “normal” children above WHO 97%ile overweight, or are the children in the WHO sample below the NCHS 5th percentile “failing to thrive?” The former is certain. The latter is possible.
[from: WHO Working Group on Infant Growth, Nutrition Unit, World Health Organization. An evaluation of infant growth. 1994.]
Babies who nurse seem to grow differently from formula fed babies. The growth curves which are presently in use in most pediatric settings were derived from the Fels Longitudinal Study and were developed by the National Center on Health Statistics and looked at data from the mid 1970s in Yellow Springs, Ohio where there were not a lot of nursing mothers and infants. As shown above, those charts are not appropriate for the breastfeeding infant.
The World Health Organization is presently developing charts, based on their studies, which more approximate the way in which breastfed babies grow. There is a period of rapid growth over the first several months of life followed by a slowing down period and then followed by a more rapid “catch up” phase. This means that initially a nursing baby will outpace a formula fed infant. This may be followed by a 6 to 9 month interval during which they grow slower than the formula fed child. The child returns back to the curve by 12-15 months of age.
Other claims for infant health: There are also suggestions that nursing may reduce the risk for the development of some Leukemias and Lymphomas. Currently under investigation is the role breastfeeding may play in diminishing the risk of developing Type I Insulin Dependant Diabetes Mellitus. There is also the suggestion that there is a reduced incidence of Cardiovascular Disease in the adult who was breastfed as an infant. One should not use this information to influence a mother who is determined to bottle feed. The data are not there.
Benefits to the mother: Weight reductions in the nursing mother and more rapid uterine involution have been documented. There is less osteoporosis during menopause and there is less premenapausal breast cancer and ovarian cancer as well. There is a contraceptive effect to breastfeeding, which may be more critical in the developing world where access to other forms of birth control is limited. The caveat to this contraceptive effect is that a continual pattern of breast feeding is necessary to diminish fertility, which is unlikely in western societies.
There are societal benefits as well, which include reducing health care costs and reducing employee absenteeism, which results form the increased rates of illness associated with the non-breast fed infant.
Q2: What is the role of the prenatal counselor with respect to breast feeding?
A2: If there is prenatal contact between the pediatric care provider and the prospective mother, she should be counseled about breastfeeding so that she is able to make an informed decision about how her baby will be nourished. The partner should be encouraged to be part of that decision as well. She should be asked about prior breast surgery. An abnormal appearing breast might compromise the ability to lactate. The nipple does not need to be “toughened up” in order for lactation to proceed. It can often damage the nipple. The nipple should be inspected to see if it is inverted. Most often, a nipple that appears to be inverted is merely a flat nipple. This can be ascertained by compressing the nipple between two fingers. A truly inverted nipple will retract during this maneuver whereas a flat nipple will evert. The prenatal period is also an opportune time to reinforce the fact that when the child is born there will be sufficient milk for the baby and supplementation with formula is unnecessary.
The prenatal and first newborn visit in hospital or birthing center should instruct on timing and technique. The current recommendation is for the infant to nurse at one breast for 15 to 20 minutes until that breast is empty. The infant can then be placed on the second breast. One must ensure a single breast emptying to promote let-down the next time.. Techniques are discussed below.
CASE STUDY - PART 2
Mr. and Mrs. Rosen return 2 weeks after the birth of their baby girl, Valerie. With an uncomplicated pregnancy, she had an NSVD at 39 weeks and 3 days. The delivery was uncomplicated and the baby’s Apgars were 9 and 9.
Valerie was 7 pounds 5 ounces and went to the regular nursery. She received erythromycin prophylactic eye ointment, Vitamin K, and her first dosage of the Hepatitis B vaccination series. She passed the neonatal hearing test and was sent home with mom 2 days after delivery.
In the hours following delivery, Mrs. Rosen noticed her breast swell and become tender throughout the day. When the baby was brought back into her room, hours later, it was very difficult for her to try feeding because her breasts hard and tender. Those symptoms resolved as breast feeding ensued and she was relieved. However, Mrs. Rosen expresses frustration with the progress of their breast-feeding. She admits that she was not prepared for it to be so painful and she feels that they “are doing it wrong”. She wants to do what is best for her child, but her nipples are very sore and she approaches every feed with hesitation as to the pain that will ensue.
Q3: What changes did Mrs. Rosen describe in her breasts post partum? How could she have alleviated these symptoms?
A3: What she noted was engorgement. There is a normal degree of engorgement after birth. There are several facets of engorgement. There is vascular engorgement, lymphatic engorgement, and milk let down. The engorgement may involve the entire breast or may be limited to the areola or breast tissue independently. The best treatment is prevention. There are some measures that can be taken to avoid the painful engorgement that often occurs with the delivery of the baby. These include allowing the baby to latch on just after delivery, analgesics and cool compresses. In settings other than just after delivery engorgement may be relieved by increased frequency of breastfeeding or the above mentioned methods. When the breasts are engorged it may be difficult for the infant to latch on. In this case gentle compressing and softening up of the areola will be helpful. This manipulation will soften the areola and allow the infant to latch on to the areola and successfully initiate breastfeeding. Cool cabbage leaves have also been used to relieve breast engorgement.
Q4: Is breastfeeding painful?
A4: Breastfeeding should NOT be painful. If it is, watch mom breast feed and suggest ways to diminish pain. Almost certainly the position of the infant is incorrect.
Q5: What is the proper technique for breastfeeding?
A5: In order to assure adequate lactation and minimize discomfort the cardinal rules are that the mother should be sitting in a relaxed position with the baby cradled in her arm. She should then bring the baby to her, as opposed to bringing her to the baby. Wait for the baby to open the mouth wide, and then bring the baby to the breast such that he/she latches high onto the areola not just the nipple. The baby’s nose should abut the areola. This will take practice and may take several attempts before a comfortable position is obtained for both mom and baby. Proper positioning on the areola is important not only to prevent discomfort but also because the lactiferous sinuses, where the milk collects, are located behind the areola. If the baby is only on the nipple the baby will not get sufficient milk and pain will ensue. The areola does not have pain fibers whereas the nipple does. Initially the mother may experience “let down”, the myoepithelial cells contracting and the milk flowing down the ducts and this might be experienced as a tingling sensation, but not actual pain.
Most of the milk will come out of the breast in the first 5 minutes. These are only approximate guidelines. The baby’s weight gain will give the provider the best idea of how breastfeeding is progressing. If the baby does not easily “come off “ the breast after 15-20 minutes and is still eager to nurse the mother should gently break the suction between the breast and the baby’s mouth with her finger and in that manner allow the baby to come off that breast and continue to nurse on the other breast. The baby should initiate lactation on the second feeding side at the next nursing interval. The parents can assess adequacy of nursing by keeping track of wet diapers and stool-laden diapers. As the first week progresses the number of wet and stool diapers should incrementally increase by about 1 per day, so that by the end of the first week the baby will have between 5-7 wet diapers a day and 4-6 stools a day.
Q6: What factors may lead to nipple soreness?
A6: If a woman complains of sore nipples her complaints need to be further elucidated. The origin of her discomfort needs to be identified and eliminated to ensure efficient and pain free breast feeding. It is often uncomfortable as the infant first begins to latch onto the breast and that discomfort should ease as breastfeeding ensues. If mom describes pain when the baby comes off the breast the provider should inquire how the infant comes off. The baby should be allowed to come off the breast by himself after nursing on that side. If the baby is pulled off the breast it will be painful. If the baby does not come off the breast on his own, instruct mom to gently insert a finger into the baby’s mouth to break the suction, which will allow the baby to come off the breast without experiencing pain. If the mother experiences pain while nursing, the position of the baby on the breast is often the culprit and the baby should be repositioned so that the baby latches on higher on the areola as described above. The nipples should also be inspected to look for redness or cracks which might be indicative of a yeast infection. One should also inspect the mouth of the infant looking for oral thrush. If a Candidal infection is diagnosed or suspected both the mother and the infant need to be treated. The initial treatment should be with Nystatin cream to mother’s nipples and oral Mycostatin to the baby’s mouth. If that is unsuccessful the secondary treatments include Diflucan for mother and baby as well as Gentian Violet applied to the baby’s mouth and to mother’s breast.
Q7: What is the role of post-partum management in breastfeeding and how important is it to initiate contact immediately after delivery?
A7: Ideally the mother should be offered to nurse the baby as soon as the baby is delivered. Soon after birth most babies become sedate and are often not very arousable (birth is a lot of work for baby too!). During the first couple of hours directly after birth they are very alert and interested in feeding. The baby who is offered the opportunity to nurse at this juncture will often allay the fears of the mother who may be concerned about her ability to breastfeed. While the mother and baby are in the hospital, rooming in should be encouraged, as breastfed babies do not adhere to schedules. The baby should be offered the breast at each feeding interval. Initially the baby should be allowed to nurse at one breast for up to 15-20 minutes and at the next feeding offered the second breast. During the early days the baby will most often not get to the second breast at each feeding. Approximate guidelines for discharge are that the baby should nurse for 15-20 minutes per breast alternating the breast that the baby starts with and feeding intervals should be every 2-4 hours. Until lactation is well established babies should not go more than 4 hours between nursing.
CASE STUDY- PART 3
After counseling Mrs. Rosen and reviewing breastfeeding techniques, she is reassured and relieved.
On examination, Valerie is sleeping comfortably in her mother’s arms. Her vital signs are stable and she is gaining weight. Her examination is within normal limits with the exception of jaundice.
Q8: In light of the previous history provided by Mrs. Rosen, what is the most likely reason for Valerie’s jaundice?
A8: The breast-fed infant may have a unique susceptibility to jaundice. There is a breast feeding jaundice associated jaundice syndrome characterized by early hyperbilirubinemia and inadequate breastfeeding. Inadequate caloric intake increases entero-hepatic circulation of bilirubin leading to hyperbilirubinemia. The treatment for this is to encourage more active and frequent nursing.
There is also a breast milk jaundice syndrome. The cause is obscure. Past implications of circulating pregnanediol inhibiting glucuronyl transferase activity in the infant liver are probably incorrect. The inhibiting factor has not been identified. It occurs between 5 and 7 days of life and is a diagnosis of exclusion. The provider must exclude pathologic causes of jaundice before attributing the hyperbilirubinemia to breast milk alone. In breast milk jaundice it is unusual to have elevated bilirubin levels in the range to cause kernicterus (>20), therefore it will not be necessary to cease nursing.
CASE STUDY - PART 4
Two months have passed and Mrs. Rosen has been breastfeeding without any complaints and Valerie has been gaining weight appropriately. You receive a phone call from Mrs. Rosen stating that she is feeling a bit under the weather. She has had a low-grade fever of 100.8, weakness, and right breast swelling and tenderness for 2 days. She has decreased the number of feeds on the right side out of fear that she would get Valerie sick.
Q9: What are the most likely causes and management of breast swelling and/or tenderness?
A9: If the mother’s breast is sore in a localized area one might be dealing with a plugged duct, which is a localized area of milk stasis. This can be remedied by deep compression into the area of stasis. If there is recurrent engorgement other causes need to be considered, such as the brassiere is too tight or the infant carrier may be impinging on the breast in a peculiar area or manner. A painful sore breast associated with fever and “flu like syndrome” is most often mastitis. Mastitis is cellulitis of the interlobar connective tissue and is usually caused by Staphylococcus and has several modalities of treatment. Increased fluid intake, rest, analgesics, increased feeding at the breast and an anti-staphylococcal antibiotic should be administered. Breastfeeding should be continued.
CASE STUDY - PART 5
After exhausting her maternity leave, Mrs. Rosen has to return to work. She works as a legal secretary for a major law firm in New York. Her husband is a mechanic and is part owner in a shop in Brooklyn. They cannot afford to live on one salary and have decided that it would be in the family’s best interest if she returns to work. Mr. Rosen’s parents live in the neighborhood and are more than happy to look after Valerie while they are working. Mrs. Rosen wished to breastfeed exclusively for at least 6 months, but now feels as if she will be unable to do so while she is at work.
Q10: Can the working mother breastfeed? What resources are available?
A10: Unfortunately, in most places in the United States, working and breastfeeding have become antithetical. Women are typically unaware of the options they have to facilitate breastfeeding and being a working mom. Once nursing is established they can offer their baby either expressed breast milk or formula in a bottle as a substitute for nursing when they are not available without fear of “nipple confusion”.
There are many hand pumps and electric pumps that are available to the nursing mother. Breastfeeding is usually well established after 3-6 weeks with individual variation. Feeding expressed breast milk with a bottle should be discouraged until the baby mother dyad is successfully nursing. After this time baby should be able to go back and forth from bottle and breast feedings without difficulty. Intermittent bottle-feeding of expressed breast milk will not interfere with successful lactation. If the breast milk is pumped it may be stored in the refrigerator for 48 hours or in the freezer for several months. Gentle thawing under warm water is the best way to prepare the milk for the infant. Micro-waving the milk is not recommended, because the milk is heated unevenly and there have been uvular burns in babies fed micro-waved milk. Glass bottles are not recommended because the Lymphocytes will adhere to the glass.
CASE STUDY - PART 6
You are making a post-partum visit for Mrs. Stehle, a new mom who is interested in breast feeding her son Paul. Mom wants to know if it is OK to breast feed as she is taking an anticonvulsant for her seizure disorder.
Q11: What are the contraindications to breastfeeding?
A11: There are very few actual contraindications to nursing. A woman who is simply too ill to nurse because of post partum illness should not be made to nurse. If the illness is predicted to be short term the baby may be cup fed until the mother can resume or initiate lactation.
In the case of an HIV infected mother in the developed world, where there is access to a breast milk substitute, she should be told of the risk for transmission of the virus through breast milk. Breastfeeding should be strongly discouraged.. In the developing world however, the risks of other infection through contaminated water or malnutrition due to inadequate breast milk substitute usually outweigh the risk of HIV transmission, and those mothers should not be discouraged from breastfeeding. If the infant is diagnosed with galactosemia, lactose would be contraindicated and breastfeeding would be forbidden. This is also the case for infants with inborn errors of metabolism such as phenylketonuria or “maple syrup urine” (absent debranching enzyme) disease. Specific amino acid depleted formulae are available for these infants. If th mother has an active case of tuberculosis, she would not nursing.
There are specific medications, which are contraindicated during lactation, and the AAP releases a statement on Drugs and Breastfeeding approximately every 4 years. This is an excellent resource for the clinician to look up a drug. A common example is Lithium, which is actively secreted in breast milk.
There are also several textbooks, which have more specific data on drugs in pregnancy and lactation. [see Briggs, et al: Drugs in Lactation. Williams and Wilkins] Women who have had breast augmentation or reduction surgeries may not be able to breastfeed particularly if the ducts were severed or if there was nerve damage to the area. These complications are seen much less with augmentation surgeries.
Most maternal illness will not interfere with her ability to nurse her baby. The treatment however may interfere, for example the type of medication(s) chosen. Most medications are classified as to their safety in breast feeding. See table for classification. Be sure to work closely with obstetrician, gynecologist or other health providers to inform them of efficacy of treatments.
TABLE 2: Drug safety in lactation (derived from safety index for pregnancy)
TEACHING CAPTION: Instructions vary for each class of drug and specific individual drugs. Consult a table of choices to pick the least noxious. Medications listed as A and B can be given freely with assurance to mother. “C” medications may be used, but it is always better to move to a “B” “D” medications are not used when bottle-feeding is safe, as in the United State,” and “X” medications are contraindicated everywhere.
Q12: What are common misconceptions about breastfeeding?
A12: The rates of breastfeeding in this country are not as high as the goals which have been set and there is both a racial and class disparity in these rates. The current goal is a 90% initiation rate of breastfeeding and a 70% breastfeeding rate maintained at 6 months of age. The current initiation rate is about 70% in a more affluent well-educated, older, non-WIC (Women, infant and children program- a supplemental food program prenatally for the pregnant women and postnatally for the nursing mother and the child up to 5 years of age) receiving population with continuation rate of 25-30% at 6 months of age. In the less affluent, less educated, younger, WIC receiving population the initiation rate is about 25-30 % with the continuation rate at 6 months between 5-10%.
In general, there is a lack of awareness on the provider’s part as well as the consumer about the benefits of breastfeeding. This is coupled which a lack of encouragement on the providers part to new families about breastfeeding. New mothers may have physical concerns such as thinking that their breasts and or nipples may be too big or too small or will remain too large after breastfeeding has ceased. Those are misconceptions.
There is a misconception that breastfeeding is a painful enterprise, which often has been obtained from a close family member, friend or acquaintance who attempted to nurse and had a less than positive experience. This person often did not receive appropriate support and guidance and ceased to nurse because of the pain and frustration that unsupported mothers often face. Another common fear is inability to produce adequate milk for their baby. This fear may be reinforced at one nursing episode while still in the hospital wherein the infant cried after nursing or this information might have been gleaned from another well meaning friend or relative who stopped nursing because they were sure that they did not make enough milk either. In truth, very few if any women actually cannot make enough milk for their infants, especially if they have appropriate guidance and support. There are misconceptions about medications and their compatibility with nursing and as previously stated there are sources for checking, many medications are compatible with nursing or there are comparable substitutions which can be made to accommodate nursing. When going the “nursing route” mom should also be counseled on the use of alcohol and tobacco products. It is clear that small amounts of alcohol, possibly several glasses of wine or beer a week are compatible with nursing and may just make the baby a bit sleepier than usual after their intake.
Initiatives to promote breastfeeding
The clinician should be well versed in the common issues, which will be present for the nursing dyad and should present themselves as being comfortable and available to answer those queries. There should be an earlier post discharge visit to the clinician for the nursing family in order to deal with the inevitable early nursing concerns. The clinician should maintain a breastfeeding friendly attitude, so that when issues arise the family will be comfortable addressing them with the provider. In a setting where there cannot be an early visit to the primary care provider, a Breastfeeding Clinic should be considered. The baby and family can make an early visit and maintain contact with a breastfeeding friendly support person who will be able to monitor the baby as well as be a resource for the family and other clinicians. The hospital should consider implementing the Baby Friendly Hospital Initiative (BFHI), which is an intensive campaign promoted by UNICEF and the World Health Organization to promote breastfeeding in hospitals.
Here are questions to open discussion related to your home institution
Question: What institutional practices affect the likelihood that a mother will breast feed?
For the presenter: think of bottle sets in nursery, lack of dignity for breast feeding mom, attitudes towards the breast as sex object.
Question: What personal difficulties do mother’s face in the community?
For the presenter: Think of work, lack of network of breast feeding mothers and Time…Time….Time. Mothers need ample support so that will have the time and energy to breast feed.
ANNOTATED ANSWERS
A1. False. Human milk, cow milk, and formulae all have 0.7 calories per cc (20 calories per ounce). The formerly encouraged use of adjusted cow milk for infants prior to the development of modern formulas does also. Cow milk, even with added sugar and water to child the 0.7 cal/cc still has cow proteins and far too high a solute load for human infants.
A2. C. The clear advantage for breast fed babies is for preterm and low birth weight infants. With these infants, human milk has been shown to be superior with respect to early childhood development. Needless to say, these advantages require continued developmental support to be sustained. “IQ” and developmental advantages have not been shown when comparing breast with bottle for term infants. There is better maternal recovery, less infections, and lower health care costs with breast as compared to bottle-feeding.
A3. C. The distinct character of human milk is its remarkably low protein content. The Biologic Value of that protein is one as it is human protein. There is substantial fat (about 50% of calories). This provides a reminder, or perhaps better said a warning, that reducing the fat content of the infant diet is dangerous.
A4. True. This is not an absolute outcome. Breast fed infants can become obese and well-instructed formulae feeding mothers have lean children. Feeding factors in infancy are only a part of a large and complex system.
