Maternal chapter7

Chapter 7
Nutrition During Lactation:
Conditions and Interventions
Nutrition Through the Life Cycle
Judith E. Brown
• Two key considerations related to
conditions and interventions during
breastfeeding are:
1) The vast majority of women do not
experience significant problems during
2) Most problems could have been prevented
with proper prenatal breastfeeding education &
a positive breastfeeding initiation period
Common Breastfeeding
Sore, flat or inverted nipples
Letdown failure
Hyperactive letdown
Plugged duct
Mastitis (Infection)
Low milk supply
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
Condition: Flat or Inverted
• 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
Condition: Letdown Failure
When milk does not eject from the breast
Very uncommon
Oxytocin nasal spray may be prescribed
Relaxation techniques may help reduce
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
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
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
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
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
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
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
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
Resources on Drugs,
Medications. and contaminants in
human milk
Maternal Medications
• Drugs are divided into 7 categories
– Cytotoxic drugs- interferes with infant's cellular
– Drugs of abuse-adverse effects
– Radioactive compounds-temporary cessation of
– Drugs in which effect is unknown
– Drugs associated with significant effect
– Meds compatible with breastfeeding
– Agents with no effect on breastfeeding
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
• Progestin only OC & implants are safe &
Herbal Remedies
• Scientific information about herb use during
lactation is sparse
• Medicinal herbs should be viewed as drugs
• Many herbs are contraindicated during
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
• Table 7.6 lists “Herbal teas considered safe
during lactation”
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
– Goat’s Rue and Milk Thistle/Blessed Thistlepotential use as galactogues
Alcohol and Other Drugs
Nicotine (smoking cigarettes)
Other drugs of abuse
Environmental exposures
• Alcohol consumed quickly passes to breast milk
• Level of alcohol in breast milk is same as in
maternal plasma
• Peak plasma levels occur at 30-60 min. after
consumption if consumed w/o food and 60-90
min. if consumed with food
• Contrary to popular belief, alcohol decreases
oxytocin and let-down
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
Alcohol and Breastfeeding
Other Drugs and Lactation
• Nicotine (smoking cigarettes)
– Regardless of feeding choice, the health risks
for infants posed by a smoking mother are
Otitis media
Exacerbation of asthma
Respiratory infections
Gastrointestinal dysregulation
– Levels are 1.5 to 3 times higher in breast milk
than mother’s blood
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
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
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
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
Neonatal Jaundice and
• 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
Risk Factors for
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
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
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
• Pathological
• Begins within 1st day
after birth rises rapidly
& lasts longer
• Bilirubin >8 mg/dL in
1st day
• Medical intervention
with phototherapy
• Cause: various
Bilirubin Encepahlopathy
or Kernicterus
• Bilirubin is toxic to cells & may cause brain
– 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
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
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
Information for Parents
• Inform parents that most breastfed infants
will become jaundiced
• Only a small fraction of these infants will
develop extreme hyperbilirubinemia and
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:
Stress management
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
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
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
Near-Term Breastfeeding
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
Medical Contraindications to
• Few medical problems in the mother or
baby are absolute contraindications to
• Table 7.14 lists the medical problems and
contraindications for breastfeeding
• The theoretical risk must be measured
against the projected benefits of
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
Human Milk Collection and
“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
Human Milk Collection and
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
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