Clinical Expert Series

Enabling Women to Achieve Their Breastfeeding Goals Alison M. Stuebe,

MD, MSc

In mammalian physiology, lactation follows pregnancy, and disruption of this physiology is associated with adverse health outcomes for mother and child. Although lactation is the physiologic norm, cultural norms for infant feeding have changed dramatically over the past century. Breastfeeding initiation fell from 70% in the early 1900s to 22% in 1972. In the past 40 years, rates have risen substantially, to 77% in 2010. Although more mothers are initiating breastfeeding, many report that they do not continue as long as they desire. As reproductive health care experts, obstetricians are uniquely positioned to assist women to make an informed feeding decision, offer anticipatory guidance, support normal lactation physiology, and evaluate and treat breastfeeding complications. Integration of care among the obstetrician, pediatric provider, and lactation consultant may enable more women to achieve their breastfeeding goals, thereby improving health outcomes across two generations. (Obstet Gynecol 2014;123:643–52) DOI: 10.1097/AOG.0000000000000142

I

n mammalian physiology, lactation follows pregnancy. Human milk provides nutrition and immunologic protection for the infant,1 and lactation mobilizes maternal fat stores accumulated during gestation, resetting maternal physiology.2 Disruption of this physiology is associated with adverse health outcomes for both mother and child. For mothers, not breastfeeding is associated with increased risks of breast cancer, ovarian cancer, diabetes, hypertension, and myocardial infarction. A recent cost analysis modeled the lifetime effects of breastfeeding in a cohort of women born in a single year in the United States. If relationships between improved health outcomes and breastfeeding are causal, the authors

From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina. Continuing medical education for this article is available at http://links.lww. com/AOG/A472. Corresponding author: Alison Stuebe, MD, MSc, Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 3010 Old Clinic Building, CB 7516, Chapel Hill, NC 27599; e-mail: [email protected]. Financial Disclosure The author did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14

VOL. 123, NO. 3, MARCH 2014

estimated that, compared with outcomes if 90% of mothers breastfed each infant for 1 year, current (lower) breastfeeding rates are associated with 4,981 excess cases of breast cancer, 53,847 excess cases of hypertension, and 13,946 excess cases of myocardial infarction, incurring $733.7 million in excess direct medical costs.3 For infants, not being breastfed is associated with increased risks of infectious morbidity, childhood obesity, sudden infant death syndrome, and childhood leukemia. Compared with health outcomes if 90% of infants were exclusively breastfed for 6 months, current breastfeeding rates are associated with $2.2 billion per year in excess medical costs and 911 excess infant deaths, again assuming that the relationship between breastfeeding and adverse healthy outcomes is causal.4 All major medical organizations therefore recommend 6 months of exclusive breastfeeding. The American Academy of Pediatrics recommends continuation of breastfeeding for 1 year or longer as mutually desired by mother and child.5 Although lactation is the physiologic norm, cultural norms for infant feeding have changed dramatically in the United States with breastfeeding initiation falling from 70% in the early 1900s to 22% by 1972. In the past 40 years, breastfeeding initiation has increased dramatically: in 2010, 77% of mothers initiated breastfeeding and 27% continued through

OBSTETRICS & GYNECOLOGY

643

How does lactation happen?

Hypothalamus

Dopamine (-)

Paraventricular nucleus (+)

Anterior pituitary

Posterior pituitary

Prolactin Placenta

Progesterone (-)

Milk ejection reflex

Oxytocin

Milk Milk synthesis secrection

Fig. 1. During pregnancy, placental progesterone blocks milk synthesis. After birth, falling progesterone levels trigger onset of milk production. Infant suckling stimulates release of prolactin and oxytocin, which regulate milk synthesis and milk secretion. Cortisol, thyroid hormone, insulin, and growth hormone further support milk synthesis. Illustration: Ó The American College of Obstetricians and Gynecologists.

Cortisol T3, T4 Insulin Growth hormone

Stuebe. Enabling Women to Achieve Their Breastfeeding Goals. Obstet Gynecol 2014.

1 year.6 This generational transformation affects the cultural context in which mothers breastfeed. Grandmothers who formula-fed their children may struggle with how to support breastfeeding,7 and clinicians who trained when formula feeding was the norm may struggle to advise breastfeeding mothers. These cultural forces explain, in part, why mothers face considerable challenges in meeting their personal breastfeeding goals. In a recent study, 60% of women reported that they stopped breastfeeding earlier than they desired.8 Given the differences in health outcomes associated with breastfeeding, enabling women to meet their breastfeeding goals is a major public health priority, and obstetricians should therefore approach infant feeding as a modifiable health behavior rather than a lifestyle choice. As reproductive health care experts, obstetricians are obligated to assist women to make an informed feeding decision, offer anticipatory guidance, support normal lactation physiology, and evaluate and treat breastfeeding complications.

644

Stuebe

PHYSIOLOGY OF LACTATION Lactation physiology9 begins during puberty, when estrogen stimulates breast duct growth and progesterone stimulates alveolar development. This process accelerates in pregnancy with secretory differentiation, as lactocytes develop the capacity to produce milk. After birth, progesterone withdrawal triggers secretory activation. This transition from colostrum to mature milk occurs at 30–40 hours after birth, allowing time for secretory immunoglobulin (IgA), lactoferrin, and other protective proteins concentrated in colostrum to coat the neonate’s gastrointestinal and respiratory epithelium.9 Infant suckling at the breast triggers prolactin and oxytocin release, which stimulate milk synthesis and secretion, respectively (Fig. 1). In addition, insulin, thyroxin, growth hormone, and cortisol support mammary differentiation and milk synthesis. Successful breastfeeding requires letdown, latch, and moving milk. During letdown, oxytocin triggers contractions of myoepithelial cells surrounding alveoli, transferring milk through breast ducts to

Enabling Women to Achieve Their Breastfeeding Goals

OBSTETRICS & GYNECOLOGY

the nipple–areolar complex. Letdown is triggered by the sound, sight, or smell of the infant, and it is inhibited by pain and stress. This phenomenon can be observed when a worried mother engages in conversation, smiles, or laughs, and her child begins gulping the milk that is now available at the breast. A good latch is the second key component of breastfeeding. To achieve sufficient suction, the infant takes most of the nipple and areolar complex into his mouth, forming a teat that reaches almost to the junction of the hard and soft palate.10 A well-latched infant’s lips flange out, and after feeding, the nipple should be round. A creased, “lipstick”-shaped nipple indicates compression that both reduces milk transfer and traumatizes the nipple. Finally, moving milk sustains milk production. When alveoli are full, the whey protein Feedback Inhibitor of Lactation downregulates milk synthesis,11 and prolactin uptake is reduced. To sustain lactation, mothers must therefore empty the breast every few hours, whether by feeding the infant, hand expression, or mechanical pumping.

associated with not breastfeeding, formula marketing should not occur in health care settings, and obstetricians are obligated to provide balanced, noncommercial information about infant feeding risks and benefits. Obstetric providers can assess risk factors for breastfeeding difficulties as part of the prenatal history and physical. As part of the obstetric history, obstetric providers should ask parous women about their prior infant feeding experience, including mastitis, pain, and problems with latch or milk supply. On physical examination, widely spaced, tubular breasts may indicate insufficient glandular tissue.16 Both macromastia and history of breast reduction are associated with breastfeeding difficulties17 as is breast augmentation.18 Mothers with risk factors may benefit from antenatal lactation consultation to establish a feeding plan and support system. The obstetric provider should share any concerns with both the mother and the pediatric provider to assure extra support until the milk supply is established.

Prenatal Care and Anticipatory Guidance

Intrapartum care affects breastfeeding outcomes. In the Promotion of Breastfeeding Intervention Trial,19 mothers who birthed at Baby-Friendly hospitals were more likely to breastfeed exclusively at 3 months (43.3% compared with 6.4%) and to continue to breastfeed through 12 months (19.7% compared with 11.4%). The Baby-Friendly Hospital Initiative is based on the “Ten Steps to Successful Breastfeeding”,20 a set of practices that support lactation physiology (Box 1). In observational studies, implementation of some or all of the Ten Steps enables mothers to achieve their own breastfeeding goals. In a national sample of U.S. mothers, 96.8% of those who experienced all six steps assessed in the study met their personal goal to breastfeed for at least 6 weeks, whereas among women who experienced none of the steps, only 70% met their personal goals.21 The Ten Steps may be especially important for primiparous women.22 Skin-to-skin care at birth is a key component of the Ten Steps. Skin-to-skin infants progress through nine behavioral phases, culminating with infant-led latch, suckling, and postfeed sleep.23 Routine separation of mother and infant disrupts neonatal physiology. In a Cochrane meta-analysis, routine separation of mother and infant both lowered infant glucose (mean difference 10.56 mg/dL, 95% confidence interval [CI] 8.40–12.72) and decreased breastfeeding at 1–4 months postpartum compared with uninterrupted skin-to-skin contact.24 Skin-to-skin contact is feasible after cesarean deliveries and is associated with reduced need for formula supplementation in the early neonatal period.25

Most women decide how to feed their infants early in pregnancy, and obstetric provider advice is an important determinant of feeding decisions.12 Women bring a wide range of perspectives and experience to their feeding intentions, and a three-step counseling approach is useful to begin a patient-centered conversation. Begin with an open-ended question such as “What have you heard about breastfeeding?” Then, summarize the patient’s concerns in your own words, showing that you have understood the patient’s point of view. In the third step, tailor counseling to the patient’s understanding and concerns. Infant formula marketing complicates issues of autonomy and informed consent in infant-feeding decisions. In a recent study, Parry et al13 found that advertisements about additives in formula led mothers to worry their milk was deficient. “It still makes me wonder, then, is my breast milk doing all those things too?” one mother said. Formula manufacturers have historically enlisted health care providers in their marketing efforts. An Abbott Laboratories training manual states, “Never underestimate the importance of nurses. If they are sold and serviced properly, they can be strong allies. A nurse who supports Ross is like an extra salesperson.”14 Such marketing affects feeding outcomes. In a clinical trial, women randomized to commercial formula marketing materials in prenatal care stopped breastfeeding earlier than women who received noncommercial information. This effect was particularly pronounced among mothers who were uncertain about their feeding preferences.15 Given the adverse outcomes

VOL. 123, NO. 3, MARCH 2014

Stuebe

Intrapartum Care and the Baby-Friendly Hospital Initiative

Enabling Women to Achieve Their Breastfeeding Goals

645

2. Train all pertinent health care staff in the skills necessary to implement this policy.

mothers to expect frequent feedings and teach how to recognize feeding cues. Hungry infants typically flex their fingers and arms, sucking on their hands and rooting, whereas satisfied infants relax their extremities and close their eyes. Counseling, “Your baby has a fuel gauge,” contrasting arm postures for “empty” and “full,” can enable parents to interpret the infant’s needs.

3. Inform all pregnant women about the benefits of breastfeeding.

Timing of Cord Clamping

Box 1. Ten Hospital Practices to Encourage and Support Breastfeeding* 1. Maintain a (supportive) written breastfeeding policy that is communicated to all health care staff.

8. Encourage unrestricted breastfeeding when the newborn exhibits hunger cues or signals or on request of the mother.

Early cord clamping reduces infant iron stores in the first 6 months of life, and these differences are more pronounced among exclusively breastfed infants.27 Early cord clamping also reduces rates of neonatal phototherapy in some studies. The World Health Organization recommends cord clamping at 1–3 minutes of life “unless the neonate is asphyxiated and needs to be moved immediately for resuscitation.”28 In a recent Committee Opinion, the American College of Obstetricians and Gynecologists concluded, “insufficient evidence exists to support or refute the benefits from delayed umbilical cord clamping for term infants that are born in settings with rich resources.”29

9. Encourage exclusive suckling at the breast by providing no pacifiers or artificial nipples.†

Intrapartum Risk Factors for Breastfeeding Difficulties

4. Offer all mothers the opportunity to initiate breastfeeding within 1 hour of giving birth. 5. Show breastfeeding mothers how to breastfeed and how to maintain lactation, even if they are separated from their newborns. 6. Give breastfeeding newborns only breast milk, unless medically indicated. 7. Facilitate rooming-in and encourage all mothers and newborns to remain together during their hospital stay.

10. Refer mothers to established breastfeeding support groups and services and foster the establishment of these services when they are not available. Reprinted from Breastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Committee Opinion No. 570. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:423–8. Data from Healthy Mothers, Healthy Babies National Coalition. Baby friendly hospital initiative feasibility study: final report. Washington (DC): HMHBNC; 1994 and Breastfeeding and the use of human milk. Section on Breastfeeding. Pediatrics 2012;129:e827–41. *The 1994 report of the Healthy Mothers, Healthy Babies National Coalition Expert Work Group recommended that the UNICEFWHO Baby Friendly Hospital Initiative be adapted for use in the United States as the United States Breastfeeding Health Initiative using these adapted 10 steps. †The American Academy of Pediatrics endorsed the UNICEF-WHO Ten Steps to Successful Breastfeeding but does not support a categorical ban on pacifiers because of their role in reducing the risk of sudden infant death syndrome and their analgesic benefit during painful procedures when breastfeeding cannot provide the analgesia.

Steps 5–9 support Let Down, Latch and Moving Milk by keeping mothers and infants together, feeding on demand, avoiding bottles and pacifiers, and teaching milk expression to all mothers. At birth, the neonate stomach holds 20 cc, and frequent, brief feeds of colostrum are physiologic in the first days of life.26 Colostrum provides a concentrated dose of antibodies and immune factors, priming the neonate’s gut for larger volumes of milk in the days to come. Obstetricians can counsel

646

Stuebe

Several prospective studies have quantified associations between intrapartum risk factors and delayed onset of lactogenesis, defined as milk coming in after 72 hours postpartum. Data suggest that unmedicated, spontaneous vaginal birth is associated with improved breastfeeding outcomes. In multivariate analyses, a second stage of labor longer than 1 hour, cesarean delivery, a maternal body mass index higher than 27 kg/m2, flat or inverted nipples, primiparity, and infant birth weight 3,600 g or greater were independently associated with delayed onset of lactogenesis.30 Data are mixed regarding epidural anesthesia.31 In a double-blind, randomized controlled trial, women receiving higher doses of epidural fentanyl had lower breastfeeding rates at 6 weeks postpartum, suggesting that epidural narcotics may affect breastfeeding.32 Parenteral narcotics are associated with depression of neonatal feeding behavior, and short-acting agents are preferred.31 Both late preterm and early term birth are also associated with breastfeeding difficulties, likely reflecting differences in oromotor and neurologic maturity.33

Medications and Lactation Health care providers commonly assume that information about medication safety in pregnancy can be extrapolated to lactation. However, the placenta and the breast are different organs, and the fetus and neonate have different physiologies. Clinicians can

Enabling Women to Achieve Their Breastfeeding Goals

OBSTETRICS & GYNECOLOGY

access continuously updated information through The National Library of Medicine’s LactMed database, available on the web and through apps for iOS and Android devices. Most medications are safe in breastfeeding, and, when there are concerns, an alternative medication with a better safety profile can often be identified.34 Counseling should weigh the risk of medication exposure through breast milk compared with the risks of formula feeding and should include the infant’s health care provider.34 For mothers with chronic health conditions, counseling about medication safety in lactation should be part of routine prenatal care.

Contraception Lactation suppresses fertility. Women who are fully or nearly fully breastfeeding, are within 6 months of delivery, and have not yet resumed menses have a 2% risk of pregnancy.35,36 Falling progesterone after delivery of the placenta triggers onset of lactogenesis,9 so exogenous progesterone could prevent onset of milk production. For women who have resumed menses or are not fully breastfeeding, nonhormonal methods are therefore preferred because they pose no risk of disrupting lactation or exposing the infant to exogenous hormones. For women who are neither exclusively breastfeeding nor candidates for a copper intrauterine device, and who state that they will not be able to use barrier methods consistently, patients and health care providers should weigh the risk of unplanned pregnancy compared with the potential effect of hormonal contraception on breastfeeding. World Health Organization and Centers for Disease Control and Prevention guidelines differ regarding hormonal contraception during breastfeeding.35,37 World Health Organization guidelines suggest more caution with use of hormonal contraception in the early postpartum period, whereas the Centers for Disease Control and Prevention guidelines are more liberal. The World Health Organization discourages progesterone-only contraception before 6 weeks and combined hormonal contraception before 6 months, whereas the Centers for Disease Control and Prevention states that the advantages outweigh the theoretical or proven risks for progesterone-only methods immediately after birth and for combined methods at 1 month postpartum. Two recent randomized controlled trials have quantified the effect of early progestational contraception on breastfeeding. In a secondary analysis of a randomized controlled trial of postplacental or delayed levonorgestrel intrauterine device insertion, postplacental placement was associated with lower rates of exclusive breastfeeding at 3 months (2.0%, 95% CI 0.05–10.6 compared with 19.6%,

VOL. 123, NO. 3, MARCH 2014

Stuebe

95% CI 9.4–33.9, P5.006) and any breastfeeding at 6 months (6.0%, 95% CI 1.3–16.5 compared with 23.9%, 95% CI 12.6–38.8, P5.02).38 In a randomized controlled trial of etonogestrel contraceptive implant placement at 1–3 days compared with 4–8 weeks postpartum, the authors found no difference in onset of lactogenesis or rates of any or full breastfeeding in follow-up.39 Approximately half of study participants in both groups were no longer fully breastfeeding at 2 weeks postpartum, limiting the study’s ability to detect effects on milk supply. There have been no published randomized controlled trials of early depot medroxyprogesterone acetate and breastfeeding outcomes. Given biologic plausibility and the absence of evidence of safety, authors of a recent systematic review concluded that the potential adverse effects on milk supply associated with early (less than 6 weeks) postpartum depot medroxyprogesterone acetate use should be disclosed to allow for a fully informed consent process.40 Given the paucity of high-quality evidence regarding hormonal contraception in breastfeeding and the low risk of pregnancy in exclusively breastfeeding women, it may be prudent to delay introduction of hormonal contraception, particularly among mothers with risk factors for breastfeeding difficulties.

Postpartum Follow-Up Epidemiology of Early Weaning In a recent study of mothers who initiated breastfeeding, 60% of women weaned earlier than they desired,8 and milk supply, latch problems, and pain were commonly cited reasons for weaning. As reproductive health experts, obstetricians can play a central role in the management of these lactation concerns so that more mothers can achieve their feeding goals.

Evaluation of the Breastfeeding Mother–Infant Dyad Lactation is a two-person organ system. Just as evaluation of infertility requires assessment of both the woman and her partner, evaluation of breastfeeding problems requires consideration of both mother and infant. For mothers who are expressing milk, evaluation should also include mechanical pump use, because misuse can affect milk production and cause tissue trauma. Beginning the breastfeeding history with an openended question such as “How is breastfeeding going?” encourages patients to share any concerns. For mothers experiencing difficulty, a careful history includes review of intrapartum events such as postpartum hemorrhage or possible retained placenta, early breastfeeding, nipple trauma, and mastitis. A breastfeeding review of systems (Box 2) can identify

Enabling Women to Achieve Their Breastfeeding Goals

647

Box 2. Breastfeeding Review of Systems Letdown Do you feel a tingling sensation when the infant is nursing? Do your breasts feel more full? If you pump, does production increase after the first few minutes?

Latch Is it comfortable when the infant nurses? Are the infant’s lips flanged out? Can you hear the infant swallow?

Moving Milk Are you feeding at least 8 to 12 times a day, until the infant is satisfied? Do your breasts feel softer after a feed? Are you away from your infant? Are you supplementing? Are you using pacifiers?

BREASTFEEDING COMPLICATIONS Early Postpartum Discomfort In the early postpartum period, nipple sensitivity is markedly increased,42 and many mothers experience discomfort in the initial 20–30 seconds of neonatal latch. It may be helpful to counsel that continued discomfort is a signal for the mother to adjust the infant’s position, sometimes simply by shifting his body so that he is not sliding off of the breast. A variety of ointments and dressings have been studied to reduce early breastfeedingassociated pain, and no one treatment has proven to be superior.43 At our center, we treat early discomfort with careful evaluation by an IBCLC to prevent recurrent trauma coupled with barrier ointment such as petrolatum.

Postpartum Depression disruption of normal physiology. For women with low milk supply, pertinent history includes breast growth during pregnancy, breast surgery, radiation to the chest, and endocrine disorders such as diabetes, thyroid disease, and polycystic ovarian syndrome. For women with pain, pertinent history includes Raynaud’s syndrome and pain disorders such as migraine, irritable bowel syndrome, dysmenorrhea, and dyspareunia. On physical examination of mothers experiencing breastfeeding difficulties, the clinician should assess for physiologic changes of lactation. In the normal lactating breast, increased vascular flow produces visible veins on the breast and upper chest. Glandular tissue is palpable from the axillae to the areola and feels distinctly firmer than the adipose tissue of the nonlactating breast. Nipple cracks, fissures, and exudates may suggest dermatitis or superinfection. Palpation of the breast can identify masses, fluctuance, and areas of tenderness. To assess infant latch and oromotor function, it may be helpful to collaborate with a pediatric provider or an International Board Certified Lactation Consultant (IBCLC). Such certification is the gold standard for lactation training,41 and obstetricians should identify certified individuals in their community to whom they can refer their patients. Ideally, the obstetrician, pediatric provider, and IBCLC collaborate to address breastfeeding concerns so that women can achieve their feeding goals. For infants with disorganized suck or abnormal oral anatomy, an occupational therapist or speech therapist with lactation expertise may also be helpful.

648

Stuebe

In the early postpartum period, women with breastfeeding difficulties are more likely to experience symptoms of postpartum depression,44 and women with anxiety symptoms have shorter breastfeeding durations.45 These differences may reflect neuroendocrine pathways implicated in both breastfeeding and postpartum mood disorders,46 and it is unclear whether breastfeeding problems trigger mood symptoms or mood symptoms interfere with breastfeeding. Nevertheless, obstetricians should screen women with breastfeeding difficulties for clinically significant depression and anxiety and be prepared to provide treatment, referral, or both as needed. The selective serotonin reuptake inhibitor, sertraline, has minimal secretion into human milk47 and is used as first-line therapy for postpartum depression at our institution. Some psychotropic medications are present at higher concentrations in milk. The American Association of Pediatrics’ committee on drugs states that “Mothers who desire to breastfeed their infant(s) while taking these agents should be counseled about the benefits of breastfeeding as well as the potential risk that the infant may be exposed to clinically significant levels and that the long-term effects of this exposure are unknown. Consideration should be given to monitoring growth and neurodevelopment of the infant.”34

Mastitis Mastitis is a clinical diagnosis characterized by fever, breast inflammation, and systemic symptoms. Mastitis affects from 3% to 20% of lactating women and often occurs in the setting of prolonged milk stasis or nipple trauma, both of which should be evaluated to avoid recurrent infection.48 Causative bacteria are generally flora colonizing the infant’s mouth and nose, so

Enabling Women to Achieve Their Breastfeeding Goals

OBSTETRICS & GYNECOLOGY

continued breastfeeding does not pose a risk to the infant, and emptying the breast is essential for maternal recovery. Women with mastitis should therefore continue to breastfeed. Additional treatment includes nonsteroidal antiinflammatory drugs, rest, and antibiotics that cover Gram-positive organisms. Dicloxacillin is typically used as first-line therapy, 500 mg four times a day for 10–14 days.48 Lack of response or worsening of symptoms may indicate methicillin-resistant Staphylococcus aureus infection or breast abscess. For suspected resistant organisms, collection of midstream breast milk for aerobic culture and sensitivities can guide therapy.48 Breast ultrasonography is the diagnostic modality of choice for abscess, and ultrasound-guided drainage is highly effective. In a series of 89 patients with puerperal breast abscesses, 97% resolved with ultrasound-guided drainage.49

Low Milk Supply Perceived low milk supply is a common cause of formula supplementation and premature weaning. Identifying underlying concerns and assessing the infant’s weight trajectory can help to differentiate low supply from unrealistic expectations of infant feeding. For example, engorgement normally subsides after secretory activation, but mothers may perceive resolution of engorgement as milk “drying up.” Families may perceive the infant’s desire to breastfeed on demand every few hours as evidence of insufficient supply, although feeding every 1–2 hours is physiologic.26 Furthermore, increases in feeding frequency during growth spurts may be perceived as low supply. When there is objective evidence of poor milk transfer, the differential diagnosis includes disrupted physiology and both endocrine and anatomic causes. The most common cause is insufficient milk removal, and treatment begins with restoring normal physiology with frequent, on-demand feeding, ideally working in conjunction with an IBCLC, or a pediatric or family medicine provider with lactation expertise. Sleep and serotonin trigger prolactin release,50 and working with the patient to identify social support can improve milk production. Maternal obesity and insulin resistance are associated with delayed onset of lactation,51 and disrupted insulin signaling may be associated with milk production difficulties.52 Other endocrine causes include retained placenta,53,54 thyroid disorders, and Sheehan’s syndrome. In the setting of postpartum hemorrhage, laboratory evaluation of prolactin can detect Sheehan’s syndrome with full assessment of pituitary function if prolactin levels are low. Discontinuation

VOL. 123, NO. 3, MARCH 2014

Stuebe

of hormonal contraceptives may also be helpful. Pregnancy can also abruptly reduce milk supply and should be excluded. Women with insufficient glandular tissue16 may have tubular, widely spaced breasts and disproportionately large areolae. In other cases, the breast contour appears normal, but palpation of the breast demonstrates mostly adipose tissue with only a small amount of glandular tissue. A history of breast surgery or radiation to the chest may also reduce milk production. Evidence to support galactogogues is limited.55 Dopamine suppresses prolactin release, and dopamine antagonists therefore increase prolactin levels. In some studies, metoclopramide increases milk production, but it can also precipitate anxiety, depression, and extrapyramidal symptoms. Domperidone can improve milk production with fewer central nervous system side effects, but this drug has also been associated with an increased risk of sudden cardiac death. The U.S. Food and Drug Administration recommends that breastfeeding women not use domperidone to increase milk production. There is limited evidence for herbal supplements, including Moringa oleifera,56 fenugreek, goat’s rue, and milk thistle.57 In a recent statement, the American Academy of Pediatrics concluded, “galactogogues have a limited role in facilitating lactation and have not been subject to full assessments of safety for the nursing infant.”34 Even with support from obstetric providers and qualified lactation professionals, some women will not be able to establish a full milk supply. Women who are not able to achieve their breastfeeding intentions report considerable distress,58 and the obstetrician can validate a woman’s efforts and experience. Regardless of milk production, a mother can nurture her infant at the breast. The obstetrician can also address widely held assertions that “every mother can breastfeed.” As Marianne Neifert has written,59 “The bold claims made about the infallibility of lactation are not cited about any other physiologic processes. A health care professional would never tell a diabetic woman that ‘every pancreas can make insulin’ or insist to a devastated infertility patient that ‘every woman can get pregnant.’ The fact is that lactation, like all physiologic functions, sometimes fails because of various medical causes.”

Pain Most breastfeeding-associated pain begins with trauma at the interface between the infant’s mouth and nipple– areolar complex. Tongue tie, or ankyloglossia, is associated with both pain and poor milk transfer, and in a randomized single-blind trial, frenotomy reduced

Enabling Women to Achieve Their Breastfeeding Goals

649

maternal breastfeeding-associated pain.60 Obstetric providers should collaborate with a pediatric provider, an IBCLC, or both, to assess infant anatomy and latch dynamics. Among mothers who pump, excessive suction or inappropriately fitted flanges can cause trauma, and pump use and fit should be assessed. The differential diagnosis for traumatized nipples includes irritant dermatitis, impetigo, and Candida infection. Barrier ointment such as petrolatum or zinc oxide can aid healing of irritant dermatitis. Contact dermatitis, from topical breast ointments, breast pads, or allergens in the infant’s mouth, can be treated with removal of the allergen and topical steroids.61 S aureus superinfection is common in women with sore nipples. For moderate-to-severe pain and trauma, oral antibiotics are superior to topical preparations or advice on positioning alone.62 Although breastfeeding pain has been attributed to Candida infection, a recent study found more evidence of Candida species among asymptomatic controls than among cases.63 Topical mupirocin and clotrimazole demonstrate both antiStaphylococcus and anti-Candida activity,64 so treatment with either of these agents treats both bacterial and fungal superinfection. Vasospasm is a common cause of breastfeedingassociated pain and often is misdiagnosed as Candida infection. Women with past or current nipple trauma may experience blanching or purple discoloration of the nipple after feeding and shooting, burning pain. A history of Raynaud’s symptoms may or may not be present. Patients may describe onset of pain on getting out of a warm shower or entering the frozen food section of the grocery store. A heating pad or warm gel pack applied to the breast after feedings can relieve symptoms. In women with partial relief with heat, extendedrelease nifedipine can markedly improve symptoms.65 Severe, shooting, burning pain unresponsive to heat or nifedipine may present as part of a functional pain syndrome. Patients with this condition may report a history of other pain disorders such as migraines, irritable bowel syndrome, dysmenorrhea, or dyspareunia.66 We evaluate for allodynia using a cottontipped swab to test light and sharp touch, starting at the lateral aspect of each breast at 2 and 10 o’clock and moving toward the nipple. Women with allodynia report increased sensitivity lateral to the areola, and inspection of the skin may reveal engorged capillaries in the sensitive region, suggesting vascular dysregulation. Onset of pain may coincide with visible changes in skin color, suggestive of a “mammary migraine.” We have found that such symptoms respond to central pain pathway modulators such as propranolol, tricyclic antidepressants, and serotonin–norepinephrine reup-

650

Stuebe

take inhibitor antidepressants.67 Collaboration with a pain specialist may be helpful.

Breastfeeding and the Preterm Neonate For preterm neonates, mother’s milk is medicine. Human milk contains immune modulators and antibodies that reduce risk of necrotizing enterocolitis, and human milk is associated with reduced risk of other infectious morbidity.68 Sharing this information with mothers who intend to formula-feed increases breastfeeding initiation and does not increase maternal anxiety.69 Initiating milk expression within 6 hours of birth70 and hand expression in conjunction with pumping71 are associated with greater milk production among mothers of preterm neonates. In a recent randomized trial, initiation of pumping within 1 hour of birth increased milk volume compared with initiation between 1 and 6 hours postpartum.72 Stress reduction also supports lactation.73 The obstetrician can support mothers to establish a full supply for their preterm neonate(s) by providing anticipatory guidance when preterm birth is imminent and working with hospital staff to facilitate early milk expression.

OTHER SPECIAL SITUATIONS The Academy of Breastfeeding Medicine has developed evidence-based protocols74 for management of multiple special situations, including breastfeeding infants with complications such as hypotonia, orofacial clefts, and allergic proctocolitis as well as maternal issues such as breastfeeding and drug-dependent women.

CONCLUSION After the umbilical cord is clamped, lactation forms a sustained, dynamic connection between the physiology of the mother and infant. As experts in reproductive health care, obstetricians can play a central role in supporting this physiology and treating complications that arise. Optimal management includes collaboration with pediatric providers and International Board Certified Lactation Consultants. By enabling more women to achieve their infant feeding goals, obstetricians can improve health across two generations. REFERENCES 1. Goldman AS. Evolution of immune functions of the mammary gland and protection of the infant. Breastfeed Med 2012;7:132–42. 2. Stuebe AM, Rich-Edwards JW. The reset hypothesis: lactation and maternal metabolism. Am J Perinatol 2009;26:81–8. 3. Bartick MC, Stuebe AM, Schwarz EB, Luongo C, Reinhold AG, Foster EM. Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gynecol 2013;122:111–9.

Enabling Women to Achieve Their Breastfeeding Goals

OBSTETRICS & GYNECOLOGY

4. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics 2010;125:e1048–56.

infants. The Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD003519. doi: 10.1002/14651858. CD003519.pub3.

5. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics 2012;129:e827–41.

25. Hung KJ, Berg O. Early skin-to-skin after cesarean to improve breastfeeding. MCN Am J Matern Child Nurs 2011;36:318–24.

6. Centers for Disease Control and Prevention. Breastfeeding among U.S. children born 2000–2010, CDC National Immunization Survey. 2013. Available at: http://www.cdc.gov/breastfeeding/data/ NIS_data/index.htm. Retrieved August 25, 2013.

26. Bergman NJ. Neonatal stomach volume and physiology suggest feeding at 1-h intervals. Acta Paediatr 2013;102:773–7.

7. Grassley J, Eschiti V. Grandmother breastfeeding support: what do mothers need and want? Birth 2008;35:329–35.

27. Chaparro CM, Neufeld LM, Tena Alavez G, Eguia-Líz Cedillo R, Dewey KG. Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet 2006;367:1997–2004.

8. Odom EC, Li R, Scanlon KS, Perrine CG, Grummer-Strawn L. Reasons for earlier than desired cessation of breastfeeding. Pediatrics 2013;131:e726–32.

28. World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva (Switzerland): World Health Organization; 2012.

9. Pang WW, Hartmann PE. Initiation of human lactation: secretory differentiation and secretory activation. J Mammary Gland Biol Neoplasia 2007;12:211–21.

29. Timing of umbilical cord clamping after birth. Committee Opinion No. 543. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1522–6.

10. Geddes DT, Kent JC, Mitoulas LR, Hartmann PE. Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev 2008;84:471–7.

30. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003;112:607–19.

11. Peaker M, Wilde CJ. Feedback control of milk secretion from milk. J Mammary Gland Biol Neoplasia 1996;1:307–15. 12. Taveras EM, Li R, Grummer-Strawn L, Richardson M, Marshall R, Rego VH, et al. Mothers’ and clinicians’ perspectives on breastfeeding counseling during routine preventive visits. Pediatrics 2004;113:e405–11. 13. Parry K, Taylor E, Hall-Dardess P, Walker M, Labbok M. Understanding women’s interpretations of infant formula advertising. Birth 2013;40:115–24. 14. Abbott Labs V. Segura. 907 SW2d 503, 512. Texas; 1995. 15. Howard CR, Howard FM, Lawrence RA, Andresen E, DeBlieck E, Weitzman M. Office prenatal formula advertising and its effect on breast-feeding patterns. Obstet Gynecol 2000; 95:296–303. 16. Neifert MR, Seacat JM, Jobe WE. Lactation failure due to insufficient glandular development of the breast. Pediatrics 1985;76: 823–8. 17. Cruz NI, Korchin L. Lactational performance after breast reduction with different pedicles. Plast Reconstr Surg 2007; 120:35–40. 18. Cruz NI, Korchin L. Breastfeeding after augmentation mammaplasty with saline implants. Ann Plast Surg 2010;64:530–3. 19. Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, et al. Promotion of breastfeeding Intervention trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA 2001;285:413–20. 20. World Health Organization, UNICEF. Protecting, promoting and supporting breastfeeding: the special role of maternity services. Geneva (Switzerland): World Health Organization; 1990. 21. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics 2008;122 (suppl 2):S43–9. 22. Declercq E, Labbok MH, Sakala C, O’Hara M. Hospital practices and women’s likelihood of fulfilling their intention to exclusively breastfeed. Am J Public Health 2009;99:929–35. 23. Widstrom AM, Lilja G, Aaltomaa-Michalias P, Dahllof A, Lintula M, Nissen E. Newborn behaviour to locate the breast when skin-to-skin: a possible method for enabling early selfregulation. Acta Paediatr 2011;100:79–85. 24. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn

VOL. 123, NO. 3, MARCH 2014

Stuebe

31. Montgomery A, Hale TW; Academy Of Breastfeeding Medicine. ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother, revised 2012. Breastfeed Med 2012;7: 547–53. 32. Beilin Y, Bodian CA, Weiser J, Hossain S, Arnold I, Feierman DE, et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study. Anesthesiology 2005;103:1211–7. 33. Meier PP, Furman LM, Degenhardt M. Increased lactation risk for late preterm infants and mothers: evidence and management strategies to protect breastfeeding. J Midwifery Womens Health 2007;52:579–87. 34. Sachs HC; Committee On Drugs. The transfer of drugs and Therapeutics into human breast milk: an Update on Selected Topics. Pediatrics 2013;132:e796–809. 35. World Health Organization. Medical eligibility criteria for contraceptive use: a WHO family planning cornerstone. 4th ed. Geneva (Switzerland): WHO; 2010. 36. Labbok MH, Hight-Laukaran V, Peterson AE, Fletcher V, von Hertzen H, Van Look PF. Multicenter study of the Lactational Amenorrhea Method (LAM): I. Efficacy, duration, and implications for clinical application. Contraception 1997;55:327–36. 37. Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recomm Rep 2010;59:1–86. 38. Chen BA, Reeves MF, Creinin MD, Schwarz EB. Postplacental or delayed levonorgestrel intrauterine device insertion and breast-feeding duration. Contraception 2011;84:499–504. 39. Gurtcheff SE, Turok DK, Stoddard G, Murphy PA, Gibson M, Jones KP. Lactogenesis after early postpartum use of the contraceptive implant: a randomized controlled trial. Obstet Gynecol 2011;117:1114–21. 40. Brownell EA, Fernandez ID, Howard CR, Fisher SG, Ternullo SR, Buckley RJ, et al. A systematic review of early postpartum medroxyprogesterone receipt and early breastfeeding cessation: evaluating the methodological rigor of the evidence. Breastfeed Med 2012;7:10–8. 41. U.S. Department of Health and Human Services. The Surgeon General’s call to action to support breastfeeding. Washington (DC): U.S. Department of Health and Human Services, Office of the Surgeon General; 2011.

Enabling Women to Achieve Their Breastfeeding Goals

651

42. Robinson JE, Short RV. Changes in breast sensitivity at puberty, during the menstrual cycle, and at parturition. Br Med J 1977;1:1188–91. 43. Morland-Schultz K, Hill PD. Prevention of and therapies for nipple pain: a systematic review. J Obstet Gynecol Neonatal Nurs 2005;34:428–37. 44. Watkins S, Meltzer-Brody S, Zolnoun D, Stuebe A. Early breastfeeding experiences and postpartum depression. Obstet Gynecol 2011;118:214–21. 45. Paul IM, Downs DS, Schaefer EW, Beiler JS, Weisman CS. Postpartum anxiety and maternal-infant health outcomes. Pediatrics 2013;131:e1218–24. 46. Stuebe AM, Grewen K, Pedersen CA, Propper C, MeltzerBrody S. Failed lactation and perinatal depression: common problems with shared neuroendocrine mechanisms? J Womens Health (Larchmt) 2012;21:264–72. 47. Fortinguerra F, Clavenna A, Bonati M. Psychotropic drug use during breastfeeding: a review of the evidence. Pediatrics 2009; 124:e547–56. 48. Academy of Breastfeeding Medicine Protocol Committee. Clinical protocol #4: mastitis. Revision, May 2008. Breastfeed Med 2008;3:177–80. 49. Christensen AF, Al-Suliman N, Nielsen KR, Vejborg I, Severinsen N, Christensen H, et al. Ultrasound-guided drainage of breast abscesses: results in 151 patients. Br J Radiol 2005;78: 186–8. 50. Freeman ME, Kanyicska B, Lerant A, Nagy G. Prolactin: structure, function, and regulation of secretion. Physiol Rev 2000;80: 1523–631. 51. Nommsen-Rivers LA, Chantry CJ, Peerson JM, Cohen RJ, Dewey KG. Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. Am J Clin Nutr 2010;92:574–84.

stances that induce, maintain and increase breast milk production. J Pharm Pharm Sci 2010;13:162–74. 58. Flaherman VJ, Hicks KG, Cabana MD, Lee KA. Maternal experience of interactions with providers among mothers with milk supply concern. Clin Pediatr (Phila) 2012;51:778–84. 59. Neifert MR. Prevention of breastfeeding tragedies. Pediatr Clin North Am 2001;48:273–97. 60. Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics 2011;128:280–8. 61. Barankin B, Gross MS. Nipple and areolar eczema in the breastfeeding woman. J Cutan Med Surg 2004;8:126–30. 62. Livingstone V, Stringer LJ. The treatment of Staphyloccocus aureus infected sore nipples: a randomized comparative study. J Hum Lact 1999;15:241–6. 63. Hale TW, Bateman TL, Finkelman MA, Berens PD. The absence of Candida albicans in milk samples of women with clinical symptoms of ductal candidiasis. Breastfeed Med 2009;4: 57–61. 64. Alsterholm M, Karami N, Faergemann J. Antimicrobial activity of topical skin pharmaceuticals—an in vitro study. Acta Derm Venereol 2010;90:239–45. 65. Anderson JE, Held N, Wright K. Raynaud’s phenomenon of the nipple: a treatable cause of painful breastfeeding. Pediatrics 2004;113:e360–4. 66. Chelimsky G, Safder S, Chelimsky T. FGIDs in children are associated with many nonpsychiatric comorbidities: the tip of an iceberg? J Pediatr Gastroenterol Nutr 2012;54:690–1. 67. Ossipov MH, Dussor GO, Porreca F. Central modulation of pain. J Clin Invest 2010;120:3779–87. 68. Rodriguez NA, Miracle DJ, Meier PP. Sharing the science on human milk feedings with mothers of very-low-birth-weight infants. J Obstet Gynecol Neonatal Nurs 2005;34:109–19.

52. Lemay DG, Ballard OA, Hughes MA, Morrow AL, Horseman ND, Nommsen-Rivers LA. RNA sequencing of the human milk fat layer transcriptome reveals distinct gene expression profiles at three stages of lactation. PLoS One 2013;8:e67531.

69. Sisk PM, Lovelady CA, Dillard RG, Gruber KJ. Lactation counseling for mothers of very low birth weight infants: effect on maternal anxiety and infant intake of human milk. Pediatrics 2006;117:e67–75.

53. Neifert MR, McDonough SL, Neville MC. Failure of lactogenesis associated with placental retention. Am J Obstet Gynecol 1981;140:477–8.

70. Furman LM, Minich N, Hack M. Correlates of lactation in mother of VLBW infants. Pediatrics 2002;109:e57.

54. Anderson AM. Disruption of lactogenesis by retained placental fragments. J Hum Lact 2001;17:142–4. 55. Academy of Breastfeeding Medicine Protocol Committee. Clinical protocol #9: use of galactogogues in initiating or augmenting the rate of maternal milk secretion. Breastfeed Med 2011;6: 41–9. 56. Estrella M, Mantaring J, David G, Taup M. A double-blind, randomized controlled trial on the use of malunggay (Moringa oleifera) for augmentation of the volume of breastmilk among non-nursing mothers of preterm infants. Phillipine J Pediatr 2000;49:3–6. 57. Zuppa AA, Sindico P, Orchi C, Carducci C, Cardiello V, Catenazzi P, et al. Safety and efficacy of galactogogues: sub-

652

Stuebe

71. Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, Rhine WD. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol 2009;29:757–64. 72. Parker LA, Sullivan S, Krueger C, Kelechi T, Mueller M. Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study. J Perinatol 2012;32:205–9. 73. Feher SD, Berger LR, Johnson JD, Wilde JB. Increasing breast milk production for premature infants with a relaxation/imagery audiotape. Pediatrics 1989;83:57–60. 74. Academy of Breastfeeding Medicine. Protocols. 2013. Available at: http://www.bfmed.org/Resources/Protocols.aspx. Retrieved October 2, 2013.

Enabling Women to Achieve Their Breastfeeding Goals

OBSTETRICS & GYNECOLOGY