1. family and parenting
2. motherhood
3. pregnancy

CMP19
BREASTFEEDING: MAINSTAYS AND MYTHS
APRIL 28, 2014
PAMELA D. BERENS, MD
MCCORMICK PLACE LAKESIDE CENTER
CHICAGO, ILLINOIS
Faculty Disclosures
In accordance with ACOG policy, all
planning committee members and faculty
have declared any financial interests or
other relationships with industry relative to
topics they will discuss.
This disclosure allows you to better
evaluate the scientific objectivity of the
information presented.
ACCME
Accreditation
AMA PRA CATEGORY 1 CREDIT(S)™
The American College of Obstetricians and Gynecologists designates
this live activity for a maximum of 27 AMA PRA Category Credit(s)TM
Physicians should only claim those credits commensurate with the
extent of their participation in the activity.
College Cognate Credit(s)
The American College of Obstetricians and Gynecologists designates
this live activity for a maximum of 27 College Cognate Credit(s) toward
the Program for Continuing Professional Development for the Annual
Clinical Meeting. The College has a reciprocity agreement with the
AMA that allows AMA PRA Category 1 CreditsTM to be equivalent to
College Cognate Credits.
Please refer to the Annual Clinical Meeting Final Program for an
additional breakdown of credits.
Introduction of Speakers
Pamela D. Berens, MD
– University of Texas
– Houston, Texas
Faculty Disclosures
Pamela D. Berens, MD – This speaker has
relevant financial relationships with the
following commercial interests: Speaker:
Texas Department of Health and Human
Services; Royalties: Pharmasoft publishing,
UpToDat; NICHQ: Texas Breastfeeding
Learning Collaborative Physician Advisor
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Breastfeeding: Myths &
Mainstays
Pamela D. Berens, MD, IBCLC, FACOG, FABM
Professor Obstetrics & Gynecology
Disclosures
• 1) COI:
– Speaker for Texas Department of Health and Human
Services
– Royalties: Pharmasoft publishing, UpToDate
– NICHQ: Texas Breastfeeding Learning Collaborative
Physician Advisor
Objectives
At the end of this presentation, participants should
be able to:
•
•
•
Encourage strategies for finding evidence-based
information for breastfeeding support for obstetric
providers and education to counteract common myths.
Provide evidence and practical considerations for
breastfeeding supportive prenatal care and childbirth
practices, overcoming commonly perceived and
encountered obstacles.
Provide education and resources for postpartum
breastfeeding difficulties and advice that obstetricians may
commonly encounter.
U.S. Breastfeeding Rates
Breastfeeding Among U.S. Children Born 2000–2010,CDC National
Immunization Survey
Myth #1
• Breastfeeding, bottle feeding and formula
feeding are basically equivalent….
• “Are you planning on breast or bottle
feeding?”
ACOG
• Committee Opinion Aug 2013 # 570
• “ The College calls on its Fellows…to
support women in choosing to
breastfeed……facilitate continuation of
breastfeeding in the workplace and public
facilities, and advocate for changes to the
public environment that support
breastfeeding locally and nationally.”
Mainstay: Breastfeeding
benefits both mother & infant
Infant benefits:
Risk Reduction
Gastroenteritis
Atopic Dermatitis
Asthma (* BF 3mos+)
Risk Reduction
Lower Respiratory
Infections
Otitis Media
0%
20%
40%
60%
Source: AHRQ 2007
80%
Mainstay: Breastfeeding
benefits both mother & infant
Infant benefits:
Risk Reduction
Sudden Infant Death
Syndrome
Childhood Leukemia
(ALL, AML)* 15‐19%
Type II Diabetes
Risk Reduction
Type I Diabetes * (19‐
27% but suboptimal)
Obesity
0% 10% 20% 30% 40% 50%
Source: AHRQ 2007
Mainstay: Breastfeeding
benefits both mother & infant
Maternal benefits:
Risk Reduction
Ovarian Cancer
Breast Cancer * (Per
yr of BF)
Risk Reduction
Type II Diabetes * (4‐
12%)
0% 5% 10% 15% 20% 25%
Source: AHRQ 2007
Mainstay: Breastfeeding
benefits both mother & infant
• Maternal benefits:
– Breastfeeding uses an additional 600+
kcal/d. More about breastfeeding & weight
loss later…
– Postpartum depression appears reduced in
mothers who breastfeed vs. those who do
not
Mainstay: Breast and bottle are
NOT mechanically the same
Infant grasps most of
the areola in his mouth
• Tongue “milks” milk to
the back of the mouth
prior to swallowing.
• Failure to develop
good milk transfer is
the major cause of
lactational failure and
breast pain
Good latch: The baby’s tongue moves milk from
areola to nipple. Tongue acts to stop bottle flow.
•
Mainstay: Breastfeeding &
bottle feeding may be different
Breastfeeding & Self-Regulation
Mother’s were asked how often infant emptied
bottle/cup > 7 mos
Exclusive BF @ Breast
Expressed BM in bottle
How Often Emptied
Combination BF and bottle
feeding (some formula)
All Formula / Bottle
0%
20%
40%
60%
80%
Mainstay #1
• Breastfeeding is the preferred method of infant
feeding and is beneficial for both mom and baby
• Almost all women can breastfeed (but NOT all)
• Use open ended/positively framed questions:
“Are you planning on breastfeeding?”, “ What
have you heard about breastfeeding?”
• If her response is “No, I’m planning on bottle
feeding” – explore reason and provide
education.
Myth #2
• Prenatal education doesn’t matter and just
don’t have time
Antepartum Education
(1st Trimester)
Early Pregnancy visit:
 Discuss decision (partner/family present)
 Review benefits/reinforce + decision/encourage
exclusivity
 ? Not breastfeeding - explore reasons for
decision/attitudes
 Prior breastfeeding experience?
 Breast growth?
 Almost every mother can breastfeed.
 Discuss implications of PMHx/medications
Antepartum Education
(2nd Trimester 24-28 wks)
Subsequent pregnancy visits:
• No need for nipple preparation/Rituals may be
harmful
• Readdress decision not to breastfeed
• Encourage attendance at prenatal breastfeeding
classes
• Discuss: baby-led feeding, supply–demand, latch &
positioning. Review BF goals, importance of
exclusivity x 6 mos and continued feeding with
addition of complementary foods after 6 mos
• Consider scripting for staff to assist
Antepartum Education
(3rd Trimester 34-36 wks)
Subsequent pregnancy visits:
• Educate about anticipated events for
hospital: Labor pain relief, skin to skin for
1st hour, DCC, delayed wt, rooming-in (no
low risk nursery), no supplement w/o
med. indication & if indicated ask why
• Communicate risk factors to infant’s care
provider (they may not examine breasts)
Antepartum Education
Who needs to know?
• Patient and their family/support (of course)
• Physicians – 3 hr physician education
(BFHI)
• Clinic staff
– Offer education for office staff: CEUs for nurses,
basic education for MA’s
– Have visible supportive literature/posters
(DSHS/WIC – not from formula companies)
– NO formula advertising/coupons, etc.!!!
Antepartum Education
Why does it matter?
• Decision frequently made prior to pregnancy
• Nearly all expectant mothers have made
decision by 3rd trimester.
Antepartum Education
Why does it matter?
• 1997 study (JHL) found that 23% of expecting
mothers received counseling from OB
• 1998 study (JHL) ass’d antenatal advice with intent
to BF (61% vs. 35%)
• 2007 Cochrane review found that professional
support was effective in prolonging any
breastfeeding.
• 2008 Retrospective cohort: attendance at prenatal
class found higher BF rates @ 6 mos
• 2011 BMJ review found breastfeeding promotion
interventions increased exclusive and any BF @ 4-6
wks & 6 mos
Antepartum Education
Why does it matter?
•
•
•
•
12/13 Demirci J, Bogan D, Holland C et al.
Breastfeeding discussion @ initial OB visit
172 recorded encounters
BF discussion @ 29% of visits for mean 39
sec.
• CNM more likely to initiate discussion than
OB residents.
Mainstay #2
• Prenatal education does matter and routine
practice can be structured to allow improved
breastfeeding education.
• Consider use of physician extenders/
scripting, recommend prenatal BF classes,
consider LC office support
Myth #3
• Labor & Delivery Practices don’t matter for
breastfeeding success.
10 Steps
1) Written Policy routinely communicated to all
staff.
2) Train all staff in skills necessary to implement
policy.
3) Inform all pregnant women about benefits
and management of BF.
4) Initiate BF within 1st hour of birth.
5) Show mothers how to BF - even if separated
from infant.
10 Steps
6)
Give newborn NO other food/drink
unless medically indicated.
7) Rooming – In (23 of 24 hrs)
8) BF on demand.
9) No artificial teats or pacifiers.
10) Foster BF support groups & refer
mothers on discharge.
Labor & Delivery:
Induction of labor
• Indication for Induction?
– PIH, pre-eclampsia, CVD, DM, IUGR,
PROM, post-dates, prior stillbirth
– Infant may be premature, “near term” or
otherwise ill & require separation and
treatments
– Potential confounding influences:
medications, anesthesia, separation,
undermining maternal confidence
So What about Cesarean
Delivery?
Labor & Delivery:
Cesarean Delivery
Labor & Delivery:
Cesarean Delivery
• 88 SVD, 97 Cesarean
• Volume of breastmilk transferred to infant (BMT)
• Significantly less BMT with cesarean on days 25 (p<.05)
• No difference on day 6
• Birth weight was regained by day 6 in 40% of
infants delivered vaginally verses 20% by
cesarean
• Cesarean group also statistically less likely to
breastfeed in the hour after birth
Evans 2002
Labor & Delivery:
Cesarean Delivery
• 280 pairs, 1st 2 weeks after birth
• Infant Breastfeeding Assessment Tool (IBFAT)
• Suboptimal Infant Breastfeeding Behavior (SIBB)
defined as a score ≤ 10
• Cesarean: increased risk of SIBB on dol 0 &
increased risk for delayed lactation > 72 hours
• Excessive infant weight loss ( ≥ 10% by 72-96 hrs)
• SIBB on day 0, 2.6 x increased risk
• Delayed onset of lactation, 7.1 x increased risk
Dewey 2002
Labor & Delivery:
Cesarean Delivery
• Practical considerations:
• Avoid contact with incision during nursing
– Use of pillows over incision
– Football position, side lying
• Time oral narcotics to avoid peak drug
levels while nursing to minimize infant
sedation
• Adequate help at home
Labor & Delivery:
Hospital Practices
• 2005-2007 Infant Feeding Practices Study
II
• 6 Baby Friendly Practices:
– BF< 1 hr (62.6%)
– No supplement (60.3%)
– Rooming In (57.8%)
– On Demand Feeding (57%)
– No Pacifiers (46.9%)
– Information on BF support (72.8%)
Labor & Delivery:
Hospital Practices
• 2005-2007 Infant Feeding Practices Study II
– Met exclusively BF goals:
• 0-1 : 23.4%
• All 6: 46.9%
• 2.7 x odds of achieving exclusive BF
intent with all 6
Labor & Delivery:
Hospital Practices
• 2005-2007 Infant Feeding Practices Study
II
• Intending to BF prior to delivery
– 85% desired to BF exclusively 3 mos or more
– 32.4% met goal
– + correlation: married, multiparous, BF < 1hr
– - correlation: obese, smokers, supplement,
paci’s
• After adjusting: #1 Supplement (OR 2.3)
Labor & Delivery:
Hospital Practices
• Cochrane review 5/12
• 34 RCT, 2177 dyads
• + SSC and BF @ 1 and 4 mos (rr 1.27)
– 13 trials
• + SSC and BF duration (mean duration
42.5d)
– 7 trials
• Improved blood glucose @ 75 - 90 min
– 2 trials
Moore et al
Labor & Delivery:
Hospital Practices
• Benefits of skin-to-skin contact
– Thermoregulation
– Cardiorespiratory Stability
– Blood glucose
– Infant crying
– Breastfeeding
– Bonding/attachment
Labor & Delivery:
Hospital Practices
• Breastfeed in delivery room, skin to skin,
transitioning in room ideal
• Room in, demand feeding, look for early
feeding cues
• Avoid supplementation unless a medical
indication exists
• Avoid early introduction of paci’s (x for
procedures) and bottle nipples
Labor & Delivery:
Hospital Practices
• Strongest risk factors for early
termination by 6 weeks post-partum:
– Delayed breastfeeding initiation
– Supplementation
DiGirolamo, 2001
Labor & Delivery:
Hospital Practices
• WHO/Healthy People 2020 MICH 23
– Reduce % newborns receiving formula
supplementation 1st 2 DOL to 14.2%
– Currently 24.2% newborns receive this
Percent of U.S. Breastfed infants who are supplemented with
infant formula, by birth year, National Immunization Survey,
).
United States (percent +/- half 95% Confidence Interval
2003
2004
2005
2006
2007
Provisional
Before 2 d
22.3
23.5
24.9
24.2
25.4 +/- 1.4
Before 3
mos
38.1
37.4
38.1
36.7
37.2 +/- 1.8
Before 6
mos
47.4
44.5
45.9
44.7
43.8 +/-2.0
Mainstay #3
• Skin to skin at delivery, early initiation of
breastfeeding and not using supplementation
without a medical indication can be helpful in
improving breastfeeding success
• What happens in the hospital matters to helping
mother’s meet their intended breastfeeding
goals.
Myth #4
• Postpartum breastfeeding support is the
pediatrician's purview.
Perspectives on Breastfeeding
After Delivery….
• New mother has had regular contact
during antenatal care…..
• Need support during initial transition to
pediatric care to avoid complications
(breastfed infants recommended to
have f/u within 72 hrs after d/c)
Perspectives on Breastfeeding
After Delivery….
• Post-Partum Blues/Depression
• Post-Partum Weight Loss
• Potential breastfeeding complications:
• Acute: nipple trauma, engorgement,
mastitis, breast abscess
• Chronic: Insufficient milk supply,
oversupply, persistent breast pain
• Impact of Contraceptive Options on
Breastfeeding & Milk supply
Perspectives on Breastfeeding
After Delivery….
Weight Loss
• Postpartum weight retention (PPWR)
significant contributor to obesity for women
• 1/5 retain 5kg+
• Increasing parity ass‘d with increased BMI
Gunderson et al 1999; Weng et al 2004
Post-Partum Milk Volume (ml)
Months PP
0-2
3-5
6-8
9-11
Exclusive
Industrialized
710
787
803
900
Exclusive
Developing
714
784
776
1223
Butte et al 2005
Energy Cost of Milk
Production (kcalg-1)
Months PP
0-2
3-5
6-8
9-11
Exclusive
Industrialized
595
657
671
752
Exclusive
Developing
597
654
650
12-23
Energy cost based on milk production rates, milk
energy density of 2.8 kJg-1 and energetic efficiency
of milk synthesis of 0.80
Butte et al 2005
Perspectives on Breastfeeding
After Delivery….
Weight Loss
• Danish National Birth Cohort: Prospective
1996
• f/u @ 6 mos (36, 030) & 18 mos (26, 846)
• GWG ass’d with PPWR @ 6 & 18 mos
• Breastfeeding ass’d with lower PPWR in all
pre-preg BMI gps
• If all women exclusively BF x 6 mos, PPWR
could be eliminated by that time
Perspectives on Breastfeeding
After Delivery….
Mastitis
• Predisposing factors: Nipple Trauma,
plugged Ducts/Milk Stasis/Untreated
engorgement, abrupt change in feeding frequency
• Symptoms: Sudden onset of breast pain,
ertyhema, myalgia, flu like symptoms, fever
• Usually unilateral, within first 6 weeks post-partum
• Reported incidence between 9-20% lactating
women
Perspectives on Breastfeeding
After Delivery….
Mastitis
• Remove predisposing factors!!
• Antibiotics – Penicillinase-resistant
penicillin or cephalosporin 10-14d
• Continued & frequent breastfeeding
• Affected breast well drained
• Consider milk culture:
– Recent hospitalization, prematurity, exclusive
pumping, your community, etc
Perspectives on Breastfeeding
After Delivery….
Mastitis
• If unable to nurse - pump or manual expression
• Milk not harmful to term healthy infant
• Weaning during infection harmful to mom
(increased risk of abscess)
• Staphlococcus aureus, strep, E. Coli (know your
community and sensitivities)
• If afebrile/inappropriate response - entertain
diagnosis of malignancy
Perspectives on Breastfeeding
After Delivery….
Breast Abscess
• Risk Factors: Delayed or inadequate
treatment of mastitis, primiparity, older
moms
• 3% of those with mastitis, 0.4% of all
nursing moms (Amir)
• Fever, myalgia, pain + fluctuant mass
Perspectives on Breastfeeding
After Delivery….
Breast Abscess
• Old therapy: surgical drainage & antibiotics:
Not typical 1st line therapy (reverse for
conservative failure or unusual case)
• Contemporary reports of successful
management with antibiotics & repeated
ultrasound guided aspirations reported
(Dixon, Christensen, Ulitzsch, etc)
• Feeding from contralateral breast continued
• Feeding from affected breast depends
Perspectives on Breastfeeding
After Delivery….
Breast Abscess
• U/S guided drainage
• 89 with puerperal abscesses (& 62 nonpuerperal)
• 97% success with single aspiration in postpartum population
• 0.8 – 1.2 mm needle if <3cm & 5.7 Fr cath if >
3cm
• Oral dicloxacillin 1 gm TID
• Cath removed in mean 4 d (2-6)
Perspectives on Breastfeeding
After Delivery….
Contraception
• Discuss risk/benefits of options
• Can it be delayed until post-partum visit
when breastfeeding is well established?
• Not all options are equal
Perspectives on Breastfeeding
After Delivery….
Contraception
• LAM – used reliably effectiveness
approaches 98% 1st 6 months
• Provide easy access for back-up
contraception if supplement begins
or menses resume
Perspectives on Breastfeeding
After Delivery….
Contraception
• Progesterone Only Contraception
– Less (if any) effect on milk supply when
started after 6 wks postpartum
– Side effect of irregular bleeding
appears less problematic in lactation
– “Mini” pill (Micronor), Depo-provera,
Implanon, Mirena IUD
• Barrier Methods
• Discuss Vaginal Atrophy
Perspectives on Breastfeeding
After Delivery….
Contraception
• IUD:
– Non-hormonal or progesterone only
– Poss. Risk of perforation
• Combined Oral Contraceptive Pills
– ? Decreased milk supply - most data from
1/50 pills
– Lowest estrogen dosage probably best...
– Begin after supply well established
– Counsel to monitor supply
Perspectives on Breastfeeding
After Delivery….
Visits
• Urgent BF concerns worked into clinic
i.e., acute mastitis for Abx & Milk Cx
• Others scheduled for BF specific clinic
time (chronic pain, oversupply, IMS,
etc.)
• Lactation/Education room in office
Mainstay #4
Obstetricians play a continued key role
after delivery in helping patients meet
their breastfeeding goals
Perspectives on Breastfeeding
After Delivery….
Medication Resources
• Hard Copy: Medications in Mothers’
Milk, Hale (2012), Drugs in Pregnancy
and Lactation, Briggs, Freeman &
Yaffee (2011), American Academy of
Pediatrics, Committee on Drugs
• Websites: LactMed database, National
Library of Medicine, Toxnet.nlm.nih.gov
• Apps: LactMed (free) , Infant risk
Other Breastfeeding Educational
Materials
• HCP’s Guide to Breastfeeding
Resources (Free App for download), 5
stars
• http://texastenstep.org/starachievertexastenstep/Star_Achiever_Ten_Step
_Modules