Chapter 7 Lactation Conditions & Interventions

Nutrition During Lactation: Conditions & Interventions

Introduction

Successful management of breastfeeding relies on informed, consistent, and individualized support from health care professionals for the mother-infant breastfeeding pair. Support should be provided both in the hospital and after discharge to ensure that any potential issues are addressed promptly and effectively.

Common Breastfeeding Conditions

Breastfeeding can present various challenges, and common issues include the following:

• Sore, flat, or inverted nipples

• Letdown failure

• Hyperactive letdown

• Hyperlactation

• Engorgement

• Plugged duct

• Mastitis

• Low milk supply

Sore Nipples

• Prevalence: This condition is reported as the second highest reason for breastfeeding discontinuation among mothers.

• Symptoms: Early, mild discomfort is common during the initial days of breastfeeding, usually subsiding after the first week but can last up to one month postpartum if not properly managed.

  • constant dryness

• Prevention: Proper positioning of the baby on the breast is crucial. Mothers should position their nipples at the junction of the hard and soft palate, allowing for a deeper latch that minimizes discomfort.

  • mother may be experiencing infection

Types of Sore Nipples

• Mild: Transient discomfort is normal.

• Severe: Discomfort that persists or worsens requires immediate evaluation by a lactation consultant.

Prevention Strategies

• Ensure optimal position and latch.

• Regularly consult with a certified lactation consultant (IBCLC) for guidance.

Main Causes

• Poor positioning/latch.

• Infection or skin issues such as thrush.

• Pumping errors including using the wrong flange size.

• Inadequate breast care or hygiene practices.

Management Techniques

• Air-dry nipples and apply warm compresses to relieve pain.

• Consider using a breast pump to express milk and relieve pressure temporarily.

Flat or Inverted Nipples

• Latch Importance: Ensuring that the nipples are positioned deep in the infant's mouth is essential for effective breastfeeding.

Techniques to Achieve Optimal Latch:

• Gently draw out the nipple using your fingers before breastfeeding.

• Use a breast pump for a few minutes prior to breastfeeding to encourage nipple elongation.

• Monitor infant weight gain closely to ensure breastfeeding feasibility.

Hoffman Technique for Inverted Nipples

• Position thumbs on either side of the areola, pressing inward to draw the nipple outward, then repeat the action four times.

• This motion helps facilitate a better latch during breastfeeding.

Letdown Failure

• Definition: A rare condition where milk does not eject from the breast when the baby latches, can be psychologically distressing for breastfeeding mothers.

  • not common

• Causes: Usually attributed to reduced levels of oxytocin, often due to stress or distractions during nursing.

  • oxytocin helps with passage of milk or letdown

• Management Strategies:

  • Consider using synthetic oxytocin nasal spray to stimulate letdown.

  • Implement relaxation techniques prior to nursing sessions.

  • Decrease caffeine intake which can contribute to anxiety and stress.

Hyperactive Letdown

• Impact on Infant: This condition can lead to coughing, choking, or gulping by the infant due to an overwhelming flow of milk.

• Symptoms: Infants may exhibit signs of distress, such as arching their backs during feeding.

• Management Recommendations:

  • Wait for the milk flow to diminish before offering the breast to the infant.

  • Consider expressing milk until the flow slows down before nursing to avoid overwhelming the baby.

Hyperlactation

• Overview: This condition is characterized by excessive milk production, leading to a variety of complications for both mother and baby.

• Symptoms in Mother:

  • Breasts may feel full and may not drain completely, leading to plugged ducts.

  • Mothers may experience milk leaks between feeding sessions or pain during letdown.

• Symptoms in Baby:

  • Infants may spit up frequently, experience poor weight gain, and have difficulty maintaining a good latch during feeding.

  • baby can develop colitis; green explosive tool

• Management Strategies

  • Consider nursing only on one side while expressing for comfort on the opposite side.

  • Use cabbage leaves or cool compresses to help reduce milk production; cabbage leaves have anti-inflammatory properties and can help reduce swelling of breast

Engorgement

• Causes: Engorgement arises from an oversupply of milk or inadequate breastfeeding frequency by the infant.

• Consequences: It can lead to discomfort, pain, restricted milk flow, and difficulties with latching.

• Interventions:

  • Engage in hand expression or use a breast pump to relieve pressure.

  • Take analgesics to manage pain associated with engorgement.

  • Apply warm compresses to the breasts prior to nursing, and cold compresses between feedings to assist in relieving discomfort.

  • Frequent nursing encourages a healthy supply-and-demand process to regulate milk supply.

Plugged Duct

• Definition: A localized blockage of milk flow due to milk stasis, which can create a painful lump in the breast.

• Symptoms: A painful knot in one breast without the presence of fever or systemic illness.

• Treatment Options:

  • Engage in gentle breast massage and apply warm compresses to the affected area.

  • Use anti-inflammatory medications to alleviate pain if necessary.

  • Ensure complete emptying of the breasts during feeding sessions and consider changing nursing positions frequently.

  • Lecithin (1T/ d) a day no more than that

Mastitis

• Definition: Inflammation of breast tissue that may be caused by infection or non-infectious factors, requiring urgent intervention.

• Prevalence: Occurs in 1-33% of breastfeeding women, most commonly observed during the 2-3 weeks postpartum period.

• Symptoms: Characterized by localized pain, the presence of a hard lump in the breast, fever, and flu-like symptoms.

• Causes: Mastitis can arise from complications like engorgement, plugged ducts, tight clothing, or cracked nipples that facilitate bacterial entry.

• Treatment Strategies:

  • Continue nursing or express milk regularly to help alleviate symptoms and prevent worsening inflammation.

  • Utilize the same interventions as for engorgement while considering anti-inflammatories, ample rest, and hydration.

  • Antibiotics may be necessary if symptoms do not resolve within 24 hours, and medical evaluation may be required to prevent abscess formation.

Comparisons of Breast Problems

Table 7.1: This table outlines the characteristics of engorgement, plugged ducts, and mastitis, highlighting their symptoms and necessary medical interventions.

• Engorgement: Gradual onset, characterized by swelling and discomfort due to inadequate milk emptying; treatable with nursing or pumping.

• Plugged Ducts: Localized pain with a distinct knot; typically resolves with care and massage.

• Mastitis: Accompanied by systemic symptoms like fever and malaise; may necessitate antibiotics and medical treatment.

Low Milk Supply

• Overview: Consistently cited as the most common reason for the cessation of breastfeeding among mothers, whether related to actual low supply or perceived issues.

• Causes: Factors contributing to low milk supply include inadequate emptying of the breasts, infrequent nursing or pumping, and psychological factors such as stress.

• Treatment Protocols:

  • Utilize hospital-grade electric pumps every 2-3 hours to stimulate milk production effectively.

  • Pump after breastfeeding sessions to ensure that breasts are emptied completely, which helps encourage further milk production.

  • Evaluate maternal food and fluid intake, encouraging adequate hydration and nutrition, while promoting rest and relaxation to optimize supply.

  • Advise against the use of estrogen-rich birth control during lactation as it may negatively affect milk supply.

  • Medications to increase prolactin

Maternal Medications

• Overview: Most medications are excreted in breast milk, and it is critical to understand their potential impacts on the breastfeeding infant.

• Considerations: Factors influencing medication safety include the pharmacokinetics of drugs, the drug exposure index, dosage, duration, and the infant's health and age.

  • drug strength, dose, duration

  • drug metabolism

Drug Categories

• Cytotoxic drugs: Generally contraindicated during lactation due to potential harm.

• Drugs of abuse: Should never be used during breastfeeding as they can adversely affect the infant.

• Radioactive compounds: These are also not recommended for use while breastfeeding; mothers should seek alternatives.

  • during mothers with cancer should prepare breastfeeding accordingly

• Drugs with unknown effects: Caution should be exercised when considering these medications.

• drugs with significant effect:

• Compatible Medications: A list of safe medications should be referenced for breastfeeding mothers.

• Food & Environmental Agents: Most have no adverse effects on breastfeeding but should still be approached with consideration.

Maternal Medications - Oral Contraceptives

• Evidence: Research suggests that combined oral contraceptives (OCs) may reduce breast milk volume, negatively impacting breastfeeding success.

• Recommendation: Avoid using combined oral contraceptives for the first six weeks to six months postpartum to safeguard milk supply.

Resources on Drugs and Medications

Table 7.2: Contains references for clinical reports on drug transfer into milk, comprehensive guides on medications during pregnancy and lactation, and additional useful links for healthcare providers and families. Recommendations for Drug Use during Lactation

• Avoid interrupting breastfeeding unless absolutely necessary; opt for alternative drugs if possible.

• When medications are necessary, aim to minimize infant exposure by adjusting drug timing and selecting those with the least transfer into breast milk.

• Contraindicated drugs include chemotherapy agents, radiation treatments, and illicit drugs, as they pose significant risk to breastfeeding infants.

• ESTROGEN SHOULD BE AVOIDED

• DONT STOP BREASTFEEDING CHOOSE ALTERNATIVE

Herbal Remedies

• Risks: Herbal remedies are often not regulated, and few controlled studies exist to substantiate their safety during lactation.

• Commonly Used Herbs: Certain herbs are believed to increase milk supply (e.g., fenugreek, milk thistle), but their safety remains uncertain.

  • FENUGREEK peanut family and baby may have reactions

• Reduction of Milk Flow: Caution should be employed with common herbs such as sage, as they may decrease milk production.

Alcohol and Other Drugs

• Alcohol: The concentration in breast milk aligns with maternal plasma levels, peaking within 30-90 minutes following consumption without food, with food 60-90 minutes

  • ALCOHOL quickly passes to breast milk

  • blood level = milk level

  • don’t drink when breastfeeding

  • alcohol remains in body longer with an increase in body weight and number of drinks

• Effects on Infant: Alcohol can inhibit milk ejection, altering the infant's feeding behaviors; thus, planning ahead of consumption is crucial.

• Nicotine: Notably higher levels are found in breast milk compared to maternal blood, posing risks of respiratory and gastrointestinal disturbance in infants.

  • baby exposed to secondary smoke is worse for baby can lead to

    • otitis media

    • exacerbation of asthma

• Marijuana: Transfers readily into breast milk and may adversely affect infant brain development and is thus contraindicated during breastfeeding.

  • obtained by second hand smoke

  • causes impaired brain development and reduced motor development

• Caffeine: Moderate caffeine intake is considered safe, but excessive consumption may result in increased wakefulness in infants.

  • no long term effects on baby

Environmental Exposures

• Overall Considerations: While environmental risks exist, the benefits of breastfeeding generally outweigh potential negative impacts associated with environmental toxins.

• Sources of Exposure: These may include air pollution, household cleaning products, and occupational hazards that mothers should be aware of.

• STILL BREASTFEED: UNLESS EXPOSURE IS EXCESSIVELY HIGH DUE TO OCCUPATION

  • Table 7.8: Outlines standards and recommendations for mothers to minimize exposure to environmental toxins, such as refraining from smoking and adopting better food safe practices.

Neonatal Jaundice & Kernicterus

• Jaundice: A visible yellowing of the skin caused by elevated bilirubin levels, occurring in a significant percentage of both full-term and preterm infants.

• Kernicterus: A severe condition resulting from untreated elevated bilirubin levels that can affect brain development and function.

Bilirubin Metabolism

• Overview: Bilirubin is a natural byproduct of the degradation of hemoglobin; newborns typically have higher levels due to immature liver function.

Types of Jaundice

• Physiological: Peaks around day 5 in newborns and generally resolves on its own shortly thereafter.

• Pathological: Begins within the first day after birth and may necessitate medical intervention due to rapid increases in bilirubin.

  • GALACTOSE METABOLISM DEFECT = STOP BREASTFEEDING

Hyperbilirubinemia and Breastfeeding

• Types of Jaundice:

  • Early jaundice is linked to poor feeding practices, while late jaundice can arise from components in breast milk contributing to elevated bilirubin levels.

Risk Factors for Severe Hyperbilirubinemia

Table 7.9: Lists conditions such as maternal diabetes and Rh sensitization that can increase the likelihood of severe hyperbilirubinemia in newborns.

Prevention and Treatment of Severe Jaundice

Table 7.11: Stipulates the importance of early nursing, monitoring infant feeding cues, and the role of exclusive breastfeeding in mitigating jaundice.

Phototherapy for Jaundice

• AAP Recommendations: The American Academy of Pediatrics endorses phototherapy as a treatment option for jaundice, and it is compatible with continued breastfeeding.

  • LIGHT IS ABSORBED IN BILIRUBIN CHANGING IT TO A WATER SOLUBLE PRODUCT

Breastfeeding Multiples

• Overview: Supporting mothers in breastfeeding twins, triplets, or more requires specialized strategies and careful organization but can be achieved with proper support systems in place.

Infant Allergies

• Overview: Food allergies in infants are linked to various maternal factors, including dietary habits during pregnancy, breastfeeding duration, and exposure to allergens.

• Food Intolerance: This condition can lead to colic in infants, often necessitating dietary changes from the nursing mother to alleviate symptoms.

Allergy Preventive Effects of Breastfeeding

Table 7.12: Discusses potential protective effects of breastfeeding, such as lower allergen content in breast milk and the transfer of maternal immunity to the infant, which may help reduce allergy risks.

Late Preterm Infants

• Infants born between 34-37 weeks gestation often face unique breastfeeding challenges due to physiological immaturity, necessitating tailored support and guidance.

  • SEVERAL complications; cardio-respiratory instability, poor temperature control, lover glycogen and fat stores immature immune system

Preterm Infants

• Recommendation: The use of fortified human milk is advised for the growth and development of preterm infants, coupled with strategies for addressing milk supply and storage issues effectively.

  • protein, vitamins C<D<E<K<B6

  • transition baby to breast

Medical Contraindications of Breastfeeding

• Breastfeeding is generally not recommended for infants diagnosed with galactosemia or for mothers facing specific infectious or drug-related concerns that could impact infant health.

Human Milk Collection & Storage

Table 7.14: Provides guidelines outlining safe storage durations for expressed milk in various environments to ensure milk safety and quality.

Milk Banking

• Human milk banks play a pivotal role in providing milk for infants unable to breastfeed, particularly those who are premature or ill.

• women are carefully screened before they can donate extra milk to milk banks

Key Points

• Breastfeeding multiples, as well as late-preterm and preterm infants, demands additional support and tailored strategies.

• Neonatal jaundice is relatively common; however, it requires monitoring and intervention if signs of early or severe jaundice appear.

• Lactating women can consume moderate amounts of caffeine and alcohol, but with caution and preventive measures in place.

• The use of herbal remedies, nicotine, marijuana, opioids, and street drugs should be strictly avoided during the breastfeeding period.

• Understanding common breastfeeding complications is crucial; these should not deter mothers from pursuing a successful breastfeeding experience.