PEDIATRICS
Volume 61, Issue 39
October 21, 2015
BREASTFEEDING, PART 2
From Pediatric Update 2015, presented by Georgia Regents University Medical College
of Georgia, and the Division of Professional and Community Education
Supporting Breastfeeding in the Outpatient Setting
Kathryn S. McLeod, MD, IBCLC, Associate Professor of
Pediatrics, Georgia Regents University Medical College of
Georgia, Augusta
LATCH score: latch — 0 = too sleepy; 1 = repeated attempts,
hold nipple in mouth, stimulated to suck; 2 = grabs breast, lips
flanged, rhythmic sucking; audible swallowing — 0 = none;
1 = a few with stimulation; 2 = spontaneous and intermittent
(<24 hr old), spontaneous and frequent (>24 hr old); type of
nipple — 0 = inverted (does not preclude breastfeeding; continuous feeding can break adhesions under skin that prevent
nipple from protruding); 1 = flat; 2 = everted (often induced
by compression); comfort — 0 = engorged, cracked, bleeding, blisters or bruises, discomfort; 1 = filling, reddened, small
blisters or bruises, mild to moderate discomfort; 2 = soft, nontender; hold — 0 = full assistance (nurse must place baby on
breast); 1 = minimal assistance; 2 = no assistance
Challenges to successful breastfeeding for clinicians: lack of
knowledge and training; parental lack of knowledge; discomfort examining and discussing breast (clinician lacking confidence may consider assigning someone else in office); lack of
time; discomfort treating mother and baby
Reasons for discontinuing breastfeeding: mother’s lack of
confidence; sore nipples; family disapproval; real or perceived
lack of support; work problems; perception of inadequate
milk supply; public opinion; American Association of Pediatrics — exclusive breastfeeding should be continued for 6 mo;
baby may breastfeed for 12 mo or longer if desired; breastfeeding not required to stop at 12 mo of age; Special Supplemental
Nutrition Program for Women, Infants, and Children — provides resources for mothers who breastfeed, including lactation
peer counselors
Evaluation: evaluate weight gain or loss; weight loss of 7% to
10% requires further observation and assessment; presence of
meconium stools concerning; evaluate frequency and duration of feeding (should occur more frequently than every 4-5
hr); observe for jaundice (amount of erythromycin jaundice
increased in preterm babies); infants born at 35 to 37 wk gestation less able than term babies to fit mouth around breast, suck,
and swallow; observe, or assign someone to observe, feeding;
monitor for wide open corners of mouth while baby feeds; vitamin D — 15 min of morning or late afternoon sunlight per day
recommended for infant; monitor maternal stores of vitamin
D, especially in dark-skinned women; mother should continue
Educational Objectives
The goal of this program is to optimize the support of breastfeeding in the outpatient setting. After hearing and assimilating
this program, the clinician will be better able to:
1. Counsel patients on appropriate breastfeeding
techniques.
2. Manage a breastfeeding patient with postpartum
depression.
3. Evaluate a breastfeeding patient with breast and
nipple pain.
4. Choose the appropriate medication for
breastfeeding patients.
with prenatal vitamins and may also take supplements including calcium 1000 mg and vitamin D 1000 to 4000 IU (probably
easier than having baby take supplements)
Techniques: mother can compress breast or express by hand if
baby slows down on feed; breastfeeding not necessarily pain
free, depending on mother’s perception of pain; discomfort
most likely in first 5 to 10 sec of feeding, but should diminish;
if no relief, take baby off, then relatch; compression or flattening of areola and placement in baby’s mouth can decrease discomfort; cross-cradle hold involves holding baby in one hand
and using opposite hand to compress breast, which deepens
latch (mother should remove hand and perform deep compression once baby latched to breast); baby usually opens mouth
unless at 35 to 37 wk gestational age or has history of negative stimuli (eg, intubation); touching nipple to mouth or nose
can cause reflexive opening of mouth; breastfeeding infants
should be positioned with abdomen facing mother’s abdomen;
position used for bottle feeding (abdomen facing upward) not
recommended (causes pulling and pain for mother); pressing
on chin causes mouth to open wide; effective transfer of milk
indicated by audible swallowing, appropriate output of urine
and stool, and weight gain of 20 to 30 g/day after day 4 (consider supplementing if necessary)
Emotional state: mothers may experience some decline in mood
in first 1 to 2 wk, however, decline in mood must be distinguished from postpartum depression; if low mood persists, ask
questions about sleep and thoughts about hurting baby; most
mothers state that lack of sleep most difficult part of caring
for baby; clinician can suggest sleeping when baby sleeps, and
limiting visitors; acknowledge or validate feelings of anxiety,
frustration, and so on; consider use of Edinburgh Postnatal
Depression Scale, with referral as needed; breastfeeding protects against postpartum depression
Treatment of postpartum depression: Academy of Breastfeeding Medicine — ≈25 freely accessible protocols in breastfeeding;
protocol 18 concerns use of antidepressants; selective serotonin
reuptake inhibitors in use longer than serotonin-norepinephrine
reuptake inhibitors (SNRIs); SNRIs have fewer side effects;
concentrations of paroxetine (Paxil) and sertraline (Zoloft) usually undetectable in infant serum; fluoxetine (Prozac) and citalopram (Celexa) — can exceed 10% maternal weight-adjusted
dose; may be beneficial for postpartum depression if shown to
be effective in mother for past treatment of depression and if
infant dose via breast milk <10% of maternal weight-adjusted
dose; infant should be followed up for side effects
5. Explain the association between prolonged feed times
and fat content in breast milk.
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support,
Audio Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within
the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that
this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported
nothing to disclose.
AUDIO DIGEST PEDIATRICS 61:39
Problems to avoid: engorgement — breast often too large for
baby to latch onto; treatment entails pumping off all milk,
then pumping for comfort as needed; if pump difficult to use,
express milk by hand until breasts soften, then breastfeed; may
cause nipple pain and trauma; plugged ducts — requires massaging of hardened or indurated areas; plugged ducts can progress to mastitis; symptoms can be relieved through frequent
feeding, massage of painful areas, change of baby’s position
at breast during feeding, and use of adequately sized bra; bacterial infection — monitor patient; cover patient for Staphylococcus; consider use of mupirocin (Bactroban, Centany) on
nipples (after feeding); mastitis — characterized by fever, flulike symptoms, and red wedge-shaped lesions; antibiotics may
be required; yeast infection — nipple can appear either irritated
or normal; if baby has obvious yeast infection in mouth, treat
baby and mother; white patches in mouth distinguish yeast
infection from latch problem; nystatin ointment generally
causes no problems for mother or baby (but treating baby 4
times/day can be bothersome); if mother complains of pain,
first observe latch
Bed sharing vs co-sleeping: co-sleeping not problematic; place
infant’s bed next to mother’s bed; separate sleeping space
prevents mother from rolling onto infant; bed sharing not recommended, but practice continues; those who continue bed
sharing advised to place baby on pillow and leave no space
between headboard and wall; baby should not be placed on
waterbed; adult partner must be aware that baby in bed
Baby food: should be started at 6 mo of age; babies take less
breast milk once solid food started and therefore absorb less
iron; supplementation usually begins with iron-fortified cereal;
prolonged breastfeeding associated with anemia; baby foods
may be supplemented with beans and lentils; black-eyed peas
and black beans high in iron and fiber and easy for baby to eat
by hand
Return to work: some mothers unable to keep up with baby’s need
for milk; bottles may contain formula, breast milk, or powdered
milk; mixing satisfactory (powdered milk probably most similar
to breast milk); discuss return to work at 2-wk or 1-mo followup; ask about plan and whether mother has breast pump (prescription may be needed); mother should inquire about places
and times to pump upon returning to school or work; return to
part-time work possibly more feasible for some mothers
Contraception: medroxyprogesterone (Depo-Provera, Provera) recommended in mothers who breastfeed (should be
progesterone only, as estrogen can decrease milk supply);
ideal to wait 6 wk before administering (milk supply usually
established at 2-4 wk); can be given at 6-wk follow-up with
obstetrician-gynecologist
Milk sharing: mothers with over- or undersupply may share
milk; milk available online, but contents unable to be ascertained if supplier of milk unknown; educate parents accordingly
Medications: pseudoephedrine contraindicated (frequently used
in cold medicines; repeated or even one-time use can cause
drop in milk supply that may not recover); acetaminophen,
ibuprofen, and supportive care recommended for colds; LactMed — available as phone app; performs search for drug name
or class; provides information about use, drug concentrations,
and effects on infant, lactation, and milk supply; suggests alternatives for drugs incompatible with breastfeeding; Food and
Drug Administration (FDA) drug-labeling rules — all medicines must be labeled for presence in breast milk and potential
effects on infant
Tobacco: fat content in breast milk lower in smokers than in
nonsmokers; smokers more likely than nonsmokers to use
formula and to wean earlier; rate of sudden infant death syndrome (SIDS) similar to that in formula-fed babies if mother of
breastfed baby smokes; smoking reduces antioxidant capacity
of human milk; smoking associated with behavioral changes;
mothers who smoke encouraged to continue breastfeeding;
nicotine patch compatible with breastfeeding
Alcohol: associated with decrease in amount of milk ingested by
infant (may change flavor of breast milk); alcohol use can disrupt sleep of mother and baby, and interfere with parent-child
interaction; blood alcohol concentration diminishes over time,
thus decreasing baby’s exposure (typical wait time 2 hr for 1
beer, 1 mixed drink, or 6 oz of wine)
Caffeine: increased consumption can cause jitteriness or poor
sleep; up to 2 cups of coffee or 4 cups of tea considered
safe; high caffeine intake during pregnancy associated with
increased risk for SIDS; Nehlig study — moderate consumption
of caffeine may increase milk supply
Billing codes: include feeding problems (most frequently used
by speaker) and slow weight gain (either <28 days or >28
days); time spent with mother (eg, showing her how to position) may be billed for (visit often lasts ≥25 min); ankyloglossia — may be present if mother reports pain with breastfeeding;
if infant unable to stick out tongue or if tongue heart shaped,
consider referral to ENT specialist or pediatric surgeon; treatment involves clipping; mothers often note difference immediately after treatment
Questions and Answers
Breast reduction: more problematic than breast augmentation
for breastfeeding; can reduce significant number of milk ducts;
follow infant closely, as production of milk may be adequate
early on but then taper off
Formula as supplement: store-brand formulas cost-effective
and usually no different than brand-name formulas; any formula with cow’s milk protein recommended
Decreased milk supply after prolonged pumping — speaker
recommends metoclopramide (Reglan) and has noted no dystonic reactions in mothers, but drug can affect mood after long
periods of use; domperidone also used, but currently off market (available in Canada and some compounding pharmacies);
fenugreek not approved by FDA, and large amount required;
beer may help because of yeast content; ensure mother pumping sufficiently; Academy of Breastfeeding Medicine has protocol on supplements
Influence of diet on consistency of milk: mother not eating
well or taking care of herself due to stress advised to drink
plenty of fluids and consume adequate amount of calories; carrying bags of nuts, raisins, or chocolate for convenient calories
recommended
Nipple shields: may be given to all mothers with flat nipples
at some hospitals; however, advise mothers to use as transition tool because shield limits lip-to-breast contact; mothers
should always try breastfeeding without shield; continue to use
if infant unable to feed without shield but gaining weight
Both sides during each feed vs one side per feed: important to
feed at both sides initially to establish milk supply; afterward,
one side per feed acceptable if baby gaining adequate weight
and no engorgement or plugging observed
Discontinuing breastfeeding: mothers advised to discontinue
one feed until they no longer feel uncomfortable, after which
they may discontinue another feed
Frequent breastfeeding: may indicate low milk supply if infant
younger and appears unsated; infant who is breastfeeding frequently but gaining weight may simply be distracted during
feeding (eliminating distractions may help increase feed times)
Alternating breasts: recommended to empty breast and avoid
engorgement or plugged ducts
Foremilk and hindmilk: hindmilk higher in fat than foremilk;
baby with multiple quick feeds may not be receiving sufficient
amount of hindmilk and hence may have thin, runny stools
(hindmilk helps firm up stools); long feeds preferable, although
hindmilk likely received after ≈5 min of steady feeding
Suggested Reading
Aljazaf K et al: Pseudoephedrine: effects on milk production in women
and estimation of infant exposure via breastmilk. Br J Clin Pharmacol
2003 Jul;56(1):18-24; Altunas N et al: Validity and reliability of the
AUDIO DIGEST PEDIATRICS 61:39
infant breastfeeding assessment tool, the mother baby assessment tool,
and the LATCH scoring system. Breastfeed Med 2014 May;9(4):1915; Becker GE et al: Methods of milk expression for lactating women.
Cochrane Database Syst Rev. 2015 Feb 27; 2:CD006170; Brand E et
al: Factors related to breastfeeding discontinuation between hospital discharge and 2 weeks postpartum. J Perinat Educ 2011 Winter;20(1):36-44;
Crepinsek MA et al: Interventions for preventing mastitis after childbirth. Cochrane Database Syst Rev. 2012 Oct 17;10:CD007239; Francis
DO et al: Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics 2015 Jun;135(6):e1458-66; Kendal-Tackett
K, Hale TW: The use of antidepressants in pregnant and breastfeeding
women: a review of recent studies. J Hum Lact 2010 May;26(2):187-95;
McClellan HL et al: Nipple pain during breastfeeding with or without
visible trauma. J Hum Lact 2012 Nov;28(4):511-21; Nehlig A, Debry
G: Consequences on the newborn of chronic maternal consumption of
coffee during gestation and lactation: a review. J Am Coll Nutr 1994
Feb;13(1):6-21; Palmquist AE et al: Contextualizing online human
milk sharing: structural factors and lactation disparity among middle
income women in the U.S. Soc Sci Med 2014 Dec;122:140-7; Rozga
MR et al: Impact of peer counseling breast-feeding support programme
protocols on any and exclusive breast-feeding discontinuation in lowincome women. Public Health Nutr 2015 Feb;18(3):453-63; Thuler D
et al: Variables associated with breastfeeding duration. J Obstet Gynecol
Neonatal Nurs 2009 May-Jun;38(3):259-68.
Acknowledgments
Dr. McLeod was recorded at Pediatric Update 2015, held July 6-9, 2015, in Kiawah Island, SC, and sponsored by Georgia Regents
University Medical College of Georgia, and the Division of Professional and Community Education. For information about upcoming CME activities from Georgia Regents University Medical College of Georgia, please visit www.gru.edu/ce/medicalce. The Audio
Digest Foundation thanks Dr. McLeod and Georgia Regents University Medical College of Georgia for their cooperation in the production of this program.
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Estimated time to complete the educational process:
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Take posttest
5 minutes
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AUDIO DIGEST PEDIATRICS 61:39
BREASTFEEDING, PART 2
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To submit a test form by mail or fax, complete Pretest section before listening and Posttest section after listening.
1. The optimal time to wean a baby from breastfeeding is:
(A) At 12 mo
(B) At 18 mo
(C) When solid foods are introduced
(D) When the mother decides**
2. An effective transfer of milk is indicated by a weight gain of 20 to 30 g/day after day:
(A) 2
(B) 3
(C) 4**
(D) 5
3. The concentrations of which of the following antidepressants are usually undetectable in infant serum?
1.
2.
3.
4.
Fluoxetine (Prozac)
Citalopram (Celexa)
Sertraline (Zoloft)
Paroxetine (Paxil)
(A) 1,3
(B) 2,4
(C) 1,2
(D) 3,4**
4. All the following statements about mastitis are true, EXCEPT:
(A) May be relieved by pumping off all milk**
(B) Can occur as a result of plugged ducts
(C) Characterized by fever and flulike symptoms
(D) May require antibacterial treatment
5. Which of the following should be supplemented once babies start solid food and take less breast milk?
(A) Calcium
(B) Protein
(C) Iron**
(D) Magnesium
6. Breastfeeding mothers planning to take an oral contraceptive are advised to start _______ at _______.
(A) Progesterone; 6 wk**
(B) Estrogen; 6 wk
(C) Estrogen plus progesterone; 6 wk
(D) Estrogen plus progesterone; 4 wk
7. Which of the following medications is contraindicated in breastfeeding mothers?
(A) Ibuprofen
(B) Pseudoephedrine**
(C) Acetaminophen
(D) All the above
8. Mothers who smoke are encouraged to stop breastfeeding.
(A) True
(B) False**
9. A study showed that a moderate consumption of _______ may be associated with an increase in milk supply.
(A) Caffeine**
(B) Alcohol
(C) Nicotine
(D) None of the above
10. Which of the following statements about breast milk is true?
(A)
(B)
(C)
(D)
Supply can be boosted with only a small amount of fenugreek
Consistency not affected by caloric intake
Fat content decreased after baby feeds for ≈5 min
High fat content associated with firm stools**
Answers to Audio Digest Pediatrics Volume 61, Issue 37: 1-B, 2-D, 3-D, 4-A, 5-D, 6-B, 7-A, 8-B, 9-D, 10-D
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