Contraception and Breastfeeding:
Obstetrician and Pediatrician Collaboration
WEBINAR
AUGUST 27, 2015
4:00PM EASTERN/3:00 PM CENTRAL/2:00PM MOUNTAIN/1:00PM PACIFIC
FACULTY:
LORI FELDMAN-WINTER, MD, MPH
MODERATOR:
JOAN YOUNGER MEEK, MD, FAAP
PAMELA BERENS, MD, FACOG
Today’s Faculty
Lori Feldman-Winter, MD, MPH, FAAP
Pamela Berens, MD, FACOG
Lori Feldman‐Winter, MD, MPH, is Professor of Pediatrics at Cooper Medical School of Rowan University and the Division Head of Adolescent Medicine at The Children’s Regional Hospital at Cooper in Camden, NJ. Dr. Feldman‐Winter is recognized for her work related to breastfeeding education programs and nutrition policy. She was the Physician Champion of the New Jersey Baby Friendly Hospital Initiative a project of AAPNJ and the New Jersey Department of Health. She is the Chair of the Policy Committee for the American Academy of Pediatrics Section on Breastfeeding, AAP representative to the United States Breastfeeding Committee, and was National Faculty Chair for the National Initiatives for Children’s Healthcare Quality (NICHQ) Best Fed Beginnings Project. She is consultant and Physician Lead to the Kellogg funded Communities and Hospitals Advancing Maternity Practices (CHAMPS) Project, and the New Jersey Hospital Association’s Mother‐Baby Hospital Initiative. Pamela Berens, MD is a generalist OB/GYN working as Professor and Vice‐Chair of Clinical Affairs at the University of Texas Medical School at Houston. She is active in clinical practice as well as both medical student and resident education. Her area of academic and educational focus is surrounding pregnancy and postpartum care, breastfeeding and breastfeeding
complications. She is active in the Academy of Breastfeeding Medicine, lectures for the Texas Department of State Health Services on lactation and maternal health and serves as one of the co‐physician leads for the Texas Breastfeeding Learning Collaborative. She also participates in the ACOG Breastfeeding Expert Work Group formed in 2014 and assists with various endeavors to promote breastfeeding and educate Obstetricians further about the topic. She has written book chapters and published research on breastfeeding topics primarily relating to the maternal perspective and maternal breastfeeding complications. Objectives
 Define the rationale for the World Health Organization recent recommendations on birth spacing
 Describe the latest evidence examining the relationship between different methods of birth spacing on breastfeeding
 Delineate the newer methods of contraception, including the differences between standard combined oral contraception and long acting reversible contraception methods
 Identify areas of controversy regarding use of contraception in breastfeeding mothers regarding effects on breastfeeding, milk supply and infant growth
Disclosures
Dr Feldman‐Winter:
I have no financial relationships with any commercial or proprietary entity that produces, markets, resells, or distributes healthcare‐related products and/or services consumed by or used on patients, relevant to the content I am presenting.
Dr Berens: I have the following financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity:
Royalties: Pharmasoft Publishing
Speaker for: Texas Department of State Health Services
Why Should the Pediatrician Know about Contraception?
Because Pediatricians…
 Care for the dyad
 Monitor neonatal weight gain
 Identify that weight faltering may be related to milk production
 Promote exclusive breastfeeding
 Protect against unnecessary supplementation that would undermine LAM or 6‐week wait period
 Collaboration between pediatrician and OB/GYN is KEY!
Caring for the Dyad
Medical Home: collaborate and coordinate care with maternal providers
Understand what affects health and well‐being of the baby is related to the mother and visa versa
Ideal child spacing > 18‐24 months is beneficial for baby: neonatal mortality, LBW, SGA, and premature delivery
Photo Credit: Centers for Disease Control and Prevention
Physiology
of
Lactation
Pituitary releases
prolactin and oxytocin.
Stimulation of
nerve endings
in mother’s
nipple/areola
sends signal
to mother’s
hypothalamus/
pituitary.
Hormones travel
via bloodstream
to mammary gland
to stimulate milk
production and
milk ejection
reflex (let-down).
Infant suckles
at the breast.
Copyright © 2003, Rev 2005 American Academy of Pediatrics
Anatomy of Breast, Baby's Mouth, Latch and Suckling
Photo Credit: American Academy of Pediatrics
Prolactin Surge with Every Nursing
Ellison PT. Breastfeeding Fertility, and Maternal Condition. In Breastfeeding Bio‐cultural Perspectives. Chapter 11;312
Breastfeeding
Myo‐epithelial Cells Surrounding a Lactating Alveolus
Photo Credit: M. Neville
Autocrine control
Daly & Hartman 1995 (2), Figure 3
Lactogenesis I and II
Onset of Breast Fullness
22% had delay in L II: primiparity, Cesarean delivery, long stage II labor, maternal BMI >27 kg/m2, flat or inverted nipples, infant BW>3600
Dewey KG, et al. Pediatrics. 2003;112(3):607‐619
Weight Loss Birth to Day 3
Excess weight loss associated with: Primiparity, long duration of labor, use of labor medications in multiparous, SIBB at birth
Dewey KG, et al. Pediatrics. 2003;112(3):607‐619
Reasons for Sub‐optimal Breastfeeding Behavior (SIBB)
Position problems
Technique
The Latch
•
•
•
•
Late preterm
Post‐dates (disorganized)
Nipple‐mouth disproportion
Ankyloglossia
Milk production and transfer
Disorganized, sleepy, over‐medicated
Dewey KG, et al. Pediatrics. 2003;112(3):607‐619
Lactogenesis II:
‐ change in quality and quantity of milk
‐ reproductive and metabolic hormones involved What if there is a delay in LII?
 Retained Placenta (estrogen and progesterone)
 Exogenous progesterone
 Absent prolactin  Abnormal insulin state (shunting nutrients)
 Abnormal thyroid function hormones (thyroid hormones necessary for mammary responsiveness to GH and prolactin)
Hovey RC. et al. J Mammary Gland Biol Neoplasia. 2002;7:17‐38.
Risk Factors for Delayed or Failed Lactogenesis II
.
Primiparity
Psychosocial stress/pain
Hormonal contraceptive administration first week postpartum
Maternal obesity
Previous failed Lactogenesis II and/or Low Milk Supply
Diabetes
Breast surgery/injury
Hypertension
Retained placental fragments
Stressful labor and delivery
Cigarette smoking
Unscheduled cesarean delivery
Hypothyroidism, hypopituitarism
Pre‐lacteal feeds; delayed first breastfeed episode
Ovarian theca‐lutein cyst
Low perinatal breastfeeding frequency
Postpartum hemorrhage with Sheehan's syndrome
Insufficient mammary glandular tissue
Polycystic ovarian syndrome
Hurst N. J Midwifery Women’s Health. 2007;52(6):588‐594.
Safe and Healthy Beginnings Toolkit
Tool for Clinicians for Breastfeeding Support
Checklist includes questions about LII
Breastfeeding Assessment Checklist for Mothers seen in primary care practices:
• If this is the first visit after being discharged from the hospital, have you noticed an increase in milk supply?
• Have you experienced firmness, swelling and tenderness of your breasts?
Monitor Weight Loss then Gain
Weight loss nomograms normalize
initial weight loss during Lactogenesis I
Vaginal births
C-section births
F L A H E R M A N V. E T A L PEDIAT RICS 1 3 5 : 2 0 1 5
Bottom Line on Weight Loss
One cannot use weight loss alone to indicate supplementation
Must use clinical assessment, including breastfeeding, milk transfer, LATCH
6‐7 % is the mean, may be less in more Baby‐Friendly environments
10% is probably excessive if there is no other reason (lots of IV fluid at time of delivery, C‐section, no latch or suckling in first few days)
Persistent weight loss may indicate problems with LII
Endocrinology of Lactation: Lactogenesis
Progesterone production inhibits stage II lactogenesis / suppresses milk synthesis. • Progesterone stimulates generation of corepressor. This corepressor binds to a promoter region of casein gene, inhibiting transcription. Loss of progesterone @ delivery decreases this inhibitory corepressor –
• Prolactin binding increases
• Casein production increases
• Milk yield increases
Requires elevated prolactin, cortisol, insulin levels
Endocrinology of Lactation: Interesting Information…..
Post‐partum Prolactin:
• The pattern and level of PRL DO NOT predict amenorrhea or fertility!
• Plasma PRL levels do not correlate with volume of milk production
• Suckling suppresses PIF, dopamine. Dopamine binds to lactotrophs & suppresses PRL
Estrogen: • High doses of PP estrogen has been used to inhibit lactation (10‐20% failure rate)
• E2 can block PRL action
Progesterone: • Progesterone antagonizes PRL at its receptor and decreases PRL binding
Endocrinology of Lactation: Gonadotropins
Breastfeeding amenorrhea and infertility– theory:
• Dysfunction of GnRH pulse generator
Prolactin inhibits pulsatile secretion of GnRH
Treating amenorrheic, lactating women with pulsatile GnRH fully restores pituitary secretion and normal ovarian cyclic activity
Lactation & Return to Fertility
Nursing Intensity Model • Focuses on the frequency / intensity of breastfeeding to predict return of fertility
Metabolic Load Model
• Focuses on the return to a positive energy balance to predict return of fertility
VALEGGIA, AM J HUM BIOL, 2009
Return to Fertility after Childbirth
Non‐Breastfeeding:
Breastfeeding:
(If bf < 28d. – no difference)
Menses: 7‐9 wks, up to 90% by 12 wks
Menses: variable
Mean ovulation – d. 45.2 Mean ovulation – d. 189
• (25‐72)
50% ovulatory prior to menses (though 80% abnormal)
88% normal luteal function by 3rd cycle
• (34 – 256)
1st Vag. Bleeding w/in 6 mos.
• 45 ‐ 63% anovulatory (41% of those had LPD – short, low E2 & P)
The Immediate Post‐Partum Period
Contraception: Considerations
Discuss risk / benefits of options
Can it be delayed until post‐partum visit when breastfeeding is well established?
Does dyad have other risk factors for premature breastfeeding cessation / insufficient milk supply? Not all options are equal / not all patients are at similar risk
The Immediate Post‐Partum Period
Contraception: Considerations
 LAM – used reliably effectiveness approaches 98% 1st
6 months
 Provide easy access for back‐up contraception if using LAM and supplement begins or menses resume
 Avoid early introduction of estrogen containing products (IF choosing estrogen option – consider introducing lower estrogen option later after well established milk supply) Intrauterine Device
Hormonal and non‐hormonal options available
Requires provider insertion and removal
Cost (Gets better if longer IPI planned)
Slight increased risk of perforation in lactation
Often placed 6 wks pp May be placed 10 min. post‐placental delivery with higher risk of expulsion by 6 months when placed early pp Risks: Perforation, failure (similar to permanent options), expulsion (2‐10% 1st yr)
Intrauterine Device
Non‐hormonal
Copper IUD (Paragard T380A), 10 yrs
No hormonal effect on lactation
No change noted in serum or milk copper concentrations
Efficacy: PU 0.6% TUF: 0.8%
Intrauterine Device
Hormonal
Levonorgestrel‐releasing IUD: Mirena:5 yrs
• Delivers approx 20 μg/d levonorgestrel
• Data suggest no change in lactation and limited infant exposure
• Efficacy: PU: 0.2% TUF: 0.2%
Liletta:3 yrs
• 19 µg/d levonorgestrel
Skyla: 3 yrs
• 14 µg/d levonorgestrel
Intrauterine Device: Perforation
Kaislasuo, et al 2012 (Both types):
• 0‐1.2/1,000 devices, 55% inserted < 6 mos PP
• 32% breastfeeding @ insertion
–
Of those BF (90% inserted < 6 mos PP)
Van Grootheest, et al 2011
• Perforation (Levonorgesterol), 701 perforations
•
8.5% detected @ insertion (Abdominal pain or routine visit mostly likely time of diagnosis)
• 42% breastfeeding @ time of Dx of perforation (192/462)
Progesterone Only Contraception (POC)
POP (progesterone only pill, “mini”‐pill) ‐ daily
Progesterone releasing IUD (prev. discussed) – 3‐5 yrs
Etonorgesterol implant (Nexplanon) – 3 yrs
Depo‐medroxyprogesterone actetate (Depo‐provera) injections – 3 months
Progesterone Only Contraception: side effects
Vaginal atrophy may require use of lubricants
Common side effect of irregular menstrual bleeding Other hormonal SE: HA, breast tenderness, depression, acne, wt gain, ovarian cyst formation
Progesterone Only Contraception
Etonogestrel Implant 68 mg (Implanon/Nexplanon), 3 yrs
Releases avg 40 μg/d etonogestrel (active metabolite of desogestrel)
Non‐latex, Not biodegradable
Nexplanon – radiopaque (barium sulphate added to core)
Efficacy: PU:0.5% TUF: 0.5%
MOA: Suppression of ovulation via altered hypothalamic‐pit‐ov axis (1°), thickened cervical mucous
Progesterone Only
Contraception
Depo Medroxyprogesterone (DMPA)
Poor oral bioavailability & low milk levels
WHO review suggested no adverse effects during lactation on overall growth
Has been found to elevate prolactin levels
150 mg IM or 104 mg Sub‐Q q 3 mos
Efficacy: PU: 0.3%, TUF: 3%
MOA: Consistently blocks LH surge & ovulation, unreceptive endometrium, thickens cervical mucous
SE: similar to others but
• Can’t be removed
• Delayed return to fertility
Theoretic concern regarding early pp use (12‐48 hrs): More later
Progesterone Only Contraception
Progesterone Only Pill (POP)
Efficacy: PU: 0.5%, TUF: 8%
Smaller amount of circulating progestins (25%) compared to combined OCP
MOA: Thickens cervical mucous, creates unreceptive endometrium, inhibits ovulation (not main mechanism)
If > 3 hrs late need back‐up contraceptive
Progesterone Only Contraception:
Systematic review 2010 POC’s initiated after initial postpartum period
5RCT’s, 38 observational studies No adverse effects on breastfeeding through 12 months (some studies no adverse effects 6 mos‐6 yrs)
No adverse effects on infant immunoglobulins, sex hormones
KAPP, N 2010
Progesterone Only Contraception: Considerations: Early Use
1997 Kennedy review on theoretical concerns re: early introduction of DMPA w/drawal of progesterone “lactogenic trigger”
Hannon, prospective cohort
• 95 dyads (43 DMPA, 52 non‐hormonal ‐ NHC) 16 wk f/u (weekly phone) • Similar duration of lactation:
- BF (@ least 1x/d) 42% DPMA vs 30% NHC
• Similar % of exclusive bf @ f/u & time of introduction of supplement • Limitations: Low exclusive bf rates, No assessment of infant wt or milk supply, In hospital formula use: 51% DPMA vs 42% NHC
HANNON, PR 1997
Progesterone Only Contraception: Considerations: Early Use
Halderman: Early Prog: 319 prospective, non‐randomized trial: 102 DMPA, 77 POP, 2 implants, 138 Non‐hormonal contraception (NHC)
• 91% BF @ d/c
2 wks – no stat difference: % bf, % exclusive, % supp
4 wks ‐ % bf: P=0.02
• 79% DMPA
• 76% hormonal
• 83% NHC
• No stat difference % exclusive or % sup
6 wks‐ 23.5% had discontinued BF
• 64.5% of those still BF were supplementing
Conclusion: “No detectable adverse impact” initiated within 72 hrs of delivery. Did not assess infant growth, milk supply or amount of supplement
HALDERMAN, 2002
Progesterone Only Contraception: Considerations: Early Use
Systematic Review of early postpartum DMPA
3 studies compared < 6 wks with > 6 wks DMPA
All low quality, inadequate control for confounders
BROWNELL, E 2011
Progesterone Only Contraception: Considerations: Mirena IUD
Breastfeeding
Immediate Insertion
Delayed Insertion
P value
6‐8 weeks PP
15/50
16/46
0.62
3 months
7/50
13/46
0.13
6 months
3/50
11/46
0.02
CHEN, ET AL CONTRACEPTION 2011
Combined Hormonal Contraception (CHC’s): also contain estrogen
Oral Contraceptive Pills (multiple options), daily
• Monthly cycle
• Extended cycle
• Continuous
Contraceptive patch (Ortho Evra), weekly
Contraceptive ring (Nuvaring), monthly
Combined Hormonal Contraception: Options
Not ideal initial choice for early postpartum use
Potential negative impact on milk supply
Effect more pronounced @ higher estrogen doses
Consider lowest estrogen option instituted as late as possible after lactation well established
VTE risk 2‐5x that of pregnancy postpartum. Highest risk within 6 weeks but concern for increased clot risk persists through 12 weeks*
*KAMEL, N ENGL J MED 2014
Combined Hormonal Contraceptive Options: OCP’s
Combined oral contraceptive pills (OCP’s)
Lowest estrogen option possible 10μg though contemporary OCP’s may contain doses as high as 35μg
Efficacy‐ PU: 0.3%, TUF: 8%
MOA: Progestin inhibits LH surge (no ovulation), endometrium unresponsive (progestin), thickens cervical mucous (progestin), inhibits FSH and formation of dominant follicle (estrogen),potentiates effect of progestational agent (estrogen)
Combined Hormonal Contraceptive Options: OCP’s
Estrogens:
• Ethinyl estradiol
• Estradiol valerate (only 1 OC avail in US uses)
Progestagens:
• Multiple options available
• Impact of various options not well studied
• Drosperidone – slightly higher clot risk. ? Concern re: spirolonlactone‐like effect and theoretic unfavorable effect on milk supply ?
Combined Hormonal Contraceptive Options: Contraindications/ Considerations
Absolute:
• h/o DVT/PE
• Breast or E2 dependent CA
• Undiagnosed Bldg
• h/o MI/Stroke
• Pregnancy
• Liver adenoma, CA, fcn
Relative:
•
•
•
•
•
+ cig > 35
DM
SS or Sc ds
50+
FHx of premature CV death
•
•
•
•
•
Migraines w aura
HTN
GB ds
Hyperlipidemia
Gilbert’s
Potential for drug Interactions: Barbiturates, Benzodiazepines, Griseofulvin, Primidone, Carbamazapine, Phenytoin, Rifampin
Combined Hormonal Contraceptive Options: OCP’s
Combination OC’s
Cochrane review 2008: OC’s <= 20μg vs > 20μg
No difference in efficacy for 11 COC pairs studied
COC’s <=20μg experienced more discontinuation and bleeding disturbances
GALLO, MF 2005
Combined Hormonal Contraceptive: Options: Patch
Transdermal patch applied weekly
Delivers approx 20μg/d ethinyl estradiol & 150μ/d norelgestromin Black Box: Slight increased risk of VTE No deleterious effects on breastfeeding infants noted
Efficacy: PU: 0.6% TUF: 0.8%
? Decreased efficiency in women > 90kg
Combined Hormonal Contraceptive Options: Ring
Vaginal ring (Nuvaring), 3 wks
Releases avg of 0.120mg/d etonogestrel and 0.015mg/d ethinyl estradiol
Bioavailability of vaginally administered ethinyl estradiol approx 55% compared to oral administration
No deleterious effects on breastfed infants noted
SE’s & MOA similar to OC’s
Combined Hormonal Contraceptive Options
Systematic review
3 RCT’s, 4 observational trials
3 RCT’s reported decreased mean breastfeeding duration and increased supplement rate (1 additional multi‐
country trial found no difference)
No documented adverse infant health effects
KAPP, N 2010
Contraception
Post‐Coital Options
 Copper IUD: Most effective. Place within 5 days
 Emergency Contraceptive Pills: Effectiveness best when initiated ASAP but within 72 hrs of exposure. May still be useful up to 120 hrs
 Progesterone only option slightly more effective than COC, also less likely to negatively impact lactation
 Pharmacokinetics of 1.5mg levonorgestrel* (single dose)
• 12 exclusively BF mothers
• M:P ratio 0.28
• Estimated infant exposure 1.6μg on the day of dosing
 Alternatively can use 0.75mg levonorgestrel 12 hours apart
*GAINER, E 2007
Permanent Contraception
Vasectomy (no impact on breastfeeding)
Postpartum tubal ligation (prior to hospital discharge)
• Potential to impact early mother‐infant interaction
• Avoid during the immediate hour postpartum to allow skin to skin time & breastfeeding initiation
• Attempt to alter surgery time to fit needs of family
• Will likely require brief narcotic use for pain control
Interval tubal ligation (usually 6+ weeks postpartum with BF established)
• Laparoscopic
• Hysteroscopic (may be done in office setting)
Lactational Amenorrhea Method of Contraception
“Exclusive” breastfeeding, <6 months PP, amenorrhea
Overall 98% effectiveness
• No longer than 6 hour interval
• No more than 5‐10% feedings supplemental
• Best 8+ feedings/24 hours
Unclear Impact of pumping / manual expression instead of direct feeding
Lactational Amenorrhea Method of Contraception: Additional Considerations
Exclusive breastfeeding < 6 months with return of bleeding*: • 25% risk of pregnancy
• < 2% risk for group with amenorrhea
• Similar basal PRL levels
Risk of pregnancy with 1st ovulation during amenorrhea**:
• Bottle feeding:
• Breastfeeding in 1st 6 mos:
• Breastfeeding 6‐12 mos:
1/4
1/28
1/5
* RODRIGUEZ D, ET AL. CONTRA 1988; **DIAZ S, ET AL, FERTIL STERIL 1992
Lactational Amenorrhea Method of Contraception
Cochrane review 2 Controlled studies: (LAM vs fully BF & amenorrhea)
• Life table pg rate @ 6 mos: 0.45 vs 2.45%
5 Uncontrolled studies: • LAM 0‐7.5%
• Fully BF & amenorrheic 0.8‐1.2%
Life table risk of menstruation@ 6 mos:
• 11‐39.4% VAN DER WIJDEN, COCHRANE DATABASE: CD001329 (2003)
Physiologic Methods
Withdrawal
• Typical use failure (TUF): 27%
• Perfect use (PU): 4%
Natural Family Planning / “Fertility Awareness” ‐ Varies: PU 0.3‐5%
Billings Ovulation Method (OM)
Creighton model
Marquette Method
Symptothermal Method
Above 4 methods can be used even if a woman has not had return of menses due to lactation
• Rely on various combination of cervical mucous, temperature and/or hormonal monitoring. Require abstinence during fertile periods
•
•
•
•
•
FEHRING, RJ 2011, FEHRING, RJ 2008, FEHRING 2009, AREVALO, M 2004, FREUNDL, G 2010
Barrier Methods
Spermicide: PU: 18% TUF: 29%
Contraceptive sponges: PU:9/20% TUF:16/32%
Male Condoms: PU:2% TUF: 15%
Female Condoms: TUF: 12‐22%
Diaphragm w spermicide: PU:6% TUF:16%
Cervical cap: PU:9‐26% TUF: 16‐32%
Barrier Methods
No impact on milk production
Reduced efficacy compared to other options may be acceptable in some situations of reduced fertility afforded by lactation
Vaginal lubrication may be beneficial due to postpartum / lactational mucosal atrophy
STI protection
Hormonal Contraception and Lactation: Direct Comparisons
RCT: 63 women using POP (35µcg) and 64 women using COC (35µcg ethinyl‐estradiol) from 2 to 8 weeks PP
No difference in continued BF @ 8 wks (63.5% POP vs 64.1% COC)
Stopped BF for perceived IMS: 44% in POP group vs 55% in COC group
Of those who stopped pills: 23% in POP group and 21% in COC group did so because they perceived a negative impact on milk supply…..
ESPEY, OBSTET GYNECOL, 2012
Contraception and Lactation: Direct Comparisons
Infant milk ingestion D 42‐63 using deuterium as a marker
40 fully breastfeeding women (10 per group)@ d42:
• COC (30µcg ethinyl‐estradiol and 150µcg levonorgesstrel)
• Mirena IUD
• Implanon
• Paragard
No difference in milk intake. No difference in infant growth through 9 weeks. BAHAMONDES; FERTIL STERIL 2013
Breastfeeding & Birth Control: Future Research and Considerations
Need well designed studies on contemporary contraceptive options
Must account for:
• amount breastfeeding
• infant weight gain
• amount supplement used
When introducing estrogen containing options – consider waiting until supply established and consider lower estrogen, reversible options
Uncertain impact of early introduction of progesterone only options within initial 48‐72 hrs
Breastfeeding & Birth Control:
Additional Considerations
 Breastfeeding patterns and plans (short and long term goals, ?LAM)
 Child’s age / time postpartum / Singleton? / Term or preterm?  Maternal age / future child bearing
 Previous contraceptive experiences
 Partner interactions
 Medical conditions impacting contraception AND / OR lactation
 Prior lactational experience….Did she meet her prior BF goals? If not, was supply a potential reason?
WHO and CDC: Medical Eligibility Categories:
ACADEMY OF BREASTFEEDING MEDICINE PROTOCOL: ADAPTED FROM WHO AND CDC
SUMMARY CHART JUNE 2012
Ideal Birth Spacing
WHO recommendation: interval of at least 24 months to prevent maternal and infant adverse health outcomes
Duration < 18 months leads to increased risk of neonatal mortality, LBW, SGA, and premature delivery
Recommended interval after termination or spontaneous abortion is 6 months
Assessment of Methods During Lactation
Outcomes of interest:
• Quantity of milk
• Milk composition
• Initiation, maintenance, and duration of breastfeeding (any and exclusive)
• infant growth
• Timing of contraception and effect on lactation
Secondary outcomes:
• Efficacy of contraception and birth interval
Assessment of Methods During Lactation
2 POP vs. placebo
3 progestin IUD (2 vs. non‐hormonal IUD, one vs. different timing)
2 progestin implants (one vs. delayed method then depo at 6 weeks, one vs. different insertion times)
2 COC vs. placebo
2 COC vs. POP
6 high quality studies
1 trial resulted in negative effect of COC on milk volume
Remaining 5 trials showed no effect on duration of breastfeeding
Weight gain best with DMPA, then insertable progestin, then no method. Other than COC progestin only methods appear safest and no evidence to avoid early timing
Role of the Pediatrician
Promote, protect and support exclusive breastfeeding, for many reasons in addition to protecting optimal child spacing
Avoid unnecessary supplementation at any time to prevent disruption of normal hormonal physiology
Work with OB colleagues to select the most appropriate method of contraception
Exclusive Breastfeeding in the US
22%
http://www.cdc.gov/
breastfeeding/data/n
is_data/index.htm
Understand the Evidence Non‐hormonal options exist but may be problematic
• LAM, need exclusivity of breastfeeding
• Copper IUD not for everyone
Timing may be everything
• Progestin only methods may be fine as long as there is a waiting period for milk supply to be established
• DMPA requires a shot every 3 months, insertable methods are more reliable (IUD or insertable etonogestrel)
Research Questions
Are there better ways to identify if LAM is active and effective (if there are long stretch between feeds, one or few supplements)?
Is delay of 6 weeks for POC’s better than initiating immediately postpartum? (RCT using insertable methods needed)
Are POC’s better than CHC’s in preventing decrease in milk supply and preserving weight gain?
What is the Absolute vs. Relative risk of using hormonal methods (immediate and after 6 weeks)? Practice Suggestions
1.
2.
3.
4.
5.
6.
Pedi and OB work together to promote, protect and support exclusive breastfeeding & discuss adequate child‐birth spacing.
Explain potential risks and benefits of using combined hormonal contraceptive options including those specific to breastfeeding. Explain potential risks, benefits and timing concerns when using LARC for a breastfeeding mother.
Educate on the risks, benefits and considerations related to LAM for child birth spacing and proactively counsel regarding back‐up alternatives when LAM no longer applies.
Consider health system issues such as insurance coverage and availability of alternative contraception when making recommendations and encourage easy contraceptive access.
Strive for effective Pediatric and Obstetric provider communication on issues potentially affecting milk supply. Thank You and Questions
You may now ask questions by using the Question box on the right hand side of your screen. If you need further assistance, please email [email protected] and don’t forget to sign up for the next Webinar – Maintaining Breastfeeding Beyond the First Week. To register, visit ‐
https://attendee.gotowebinar.com/register/6511942645879081474. This information will also be emailed to you following the Webinar. Please don’t forget to complete your post‐survey to receive CME Credit for this Webinar. Resources:  Guidelines on Perinatal Care, 7th Edition, AAP/ACOG
 Breastfeeding Handbook for Physicians, 2nd Edition, AAP/ACOG
 ACOG Breastfeeding webpage http://m.acog.org/About‐
ACOG/ACOG‐Departments/Breastfeeding
 AAP Breastfeeding webpage http://www2.aap.org/breastfeeding/
 Academy of Breastfeeding Medicine Clinical Protocol #13: Contraception During Breastfeeding http://www.bfmed.org/Resources/Protocols.aspx