“Doctor its about Breastfeeding…”

Breastfeeding – our Mandate

Public Health Agency of Canada, Health Canada and the World Health Organization recommend 6 months exclusive breastfeeding and continued breastfeeding for 2 years and beyond.

Canadian Task Force on Preventive Health Care lists Counselling on Breastfeeding as Grade A recommendation

The College of Family Physicians of Canada in it’s Infant Feeding Policy Statement (2011) reaffirms that “…breastfeeding plays a uniquely important role in the heathy development of infants and young children.”

New Zealand Exclusive BF Rates 2017

Initiation 97%

6 weeks 52%

3 months 48%

6 months 21%

Median duration 7 months

How are the rates in Canada?

• Looked at knowledge, confidence, beliefs and attitudes re BF Peds and Fam Docs

• Score 72.7% Fam Docs (Peds 63%)

• Felt their knowledge was by life experience rather than education.

• Doctors need education re Breastfeeding

Are we knowledgeable in and supportive of Breastfeeding?Pound, C et al JHL Aug 2014 vol 30(3) 298-309

Women are more likely to continue BF their infants at 4/12 if their clinician encourages them to do so. Taveras EM et al 2003

… about Breastfeeding

Breastfeeding has implications for:

• Infants

• Mothers

• Society

Breastfeeding The Lancet Series Jan 2016 https://www.thelancet.com/series/breastfeeding

Impact of Breastfeeding on Maternal and Child Health Acta Paediatrica Dec 2015 (open access)

What we could cover

Recognizing Normal BF

Poor weight gain

Breast and Nipple Pain

Tongue tie

Normal Infant Sleep

Breast Surgery

Oversupply

Induced Lactation

Medications

Recreational Drugs

How we can best support BF

Resources

Human Milk as Chrononutrition Hahn-Holbrook J et al Pediatric Research (2019) 85:936-942

Breastfeeding protecting Mothers’ Health

• ↓ risk of postpartum hemorrhage

• Delayed onset of menses↓ iron deficiency and pregnancy spacing

• ↓ risk of breast (Lambertini et al 2016), ovarian (Sung et al 2016) and endometrial cancers (Zhan et al 2015)

• ↓risk of PP weight retention(Jiang et al 2018)

Shorter BF duration associated with more severe sx depression (Castro et al 2015)

Breastfeeding is Dose Responsive

Functional competent immune system• Protective effect against type-2

diabetes• Less eczema and wheezing EBF >4/12• ↓ risk of some childhood leukemias

(with longer duration)Optimal growth and development

• ↓ prevalence of overweight/obesity –10% reduction

• Optimal IQNormal development of the mouth and jaws

• ↓ risk of dental occlusion

Breastfeeding is Sustainable

Lower health care costs

Higher work productivity and satisfaction

Environmentally friendly

No waste

• No product transportation or packaging

• No grazing land

Breastfeeding Success starts AT BIRTH:

• Delayed Cord clamping

• Skin to skin contact for at least one hour

• Early initiating of Breastfeeding

RESULTS in increased rates and duration of Breastfeeding!

Skin to Skin

Maternal Baby Separation

Facilitate BF & pumping

Both parents skin 2 skin

Supportive staff

Facilitate hand expressing for oral colostrum feeds

Skin 2 skin as soon as possible

BF as soon as possible

“Is my baby getting enough milk?”

How do we know things are going normally?Early Breastfeeding 1-5 days KEY INDICATORS

Number of times per day the infant breastfeeds

Urinary output

Stools

Other

Signs of Good Breastfeeding in the early days

Frequent (10-12) comfortable feedings in 24-hour period

Episodes of rhythmic sucking with audible and/or visible swallows

OUTPUT

• 1-2 wet diapers in 1st 2 days, then 6-8 / 24 hrs

• Transitional stools 1st 2 days, yellow by day 4

• By third day minimum 2-3 BM in 24 hours (usually 4-10 small stools/day)

• BEWARE unsettled baby does not always mean hunger!!

Adequate Feeding beyond 5 days

KEY INDICATORS

Breastfeeding at least 6 -12 times/24h

Urinary output wet cloth diapers 5-8/ 24hr

Stool Output – can vary ~ 125ml/day usually min 3-4 / 24hr green / yellow seedy

Weight loss 7-8% by day 3 is common 10% BF needs evaluation (Tomasso D & Cloud M J Obstet Gyn Neonatal Nursing 48(6), 593-603 Nov 2019)

Regains birth weight by 14 days and weight gain of 20-30 g/day until 3 months then 15-20 g/day up to 6 months World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007)

Mother Medical Factors on Milk Production

Pregnancy

Insufficient growth/tissue of breastGestational DiabetesIUGRHypothyroidism or thyroiditisGigantomastiaPre-eclampsia

Peripartum

Excessive fluid in labour

Significant PPH

Persisting engorgement

Mother/Baby separation

Retained placental fragments

Ketogenic diet?

Infant Factors on Milk Production -suboptimal Milk transfer

Peripartum

Preterm deliveryInfection HyperbilirubinemiaCongenital disease - neurological or cardiacIUGRBirth trauma- cephalohematoma

Anatomic

Cleft palate+/- lip

Small mouth/gape

High arched palate

Retrognathia

Sublingual frenulum

Torticollis

Common reasons for slow weight gain

•Poor latch/positioning• Infrequent short feeds•Casual supplementing•Failure to recognize early cues•Reduced access to breast

General Principles to Optimize Milk Production

• Frequent removal of milk – “responsive feeding” on early cues - avoid pacifiers and swaddling

• Avoid and treat engorgement (FIL)

• Maximise skin to skin contact

• Cautious use of supplements only

• Avoid hormonal contraceptives E+P/ POP? Mirena before 6 weeks

WHO hierarchy of Infant feeding

1. Breast milk at mother’s breast

2. Expressed mother’s own breast milk

3. Donor breast milk

4. Formula

ABM Clinical Protocol #13 Supplementation 2015

Documented insufficient infant weight gain due to limited milk production

REFER TO LACTATION CONSULTANT

• Improve latch and positioning

• Increase number of feeds

• Express after BF (give to baby not freezer)

• Small amount EBM, DBM or formula every feed after BM or before

• Use a feeding method to protect breastfeeding

Supplementary Feeding MethodsCup Feeding Finger feeding Paced bottle feeding

Lactation Aid

https://www.breastfeedinginc.ca/inserting-a-lactation-aid?fbclid=IwAR0mD4HB_EgXraHzbIDagoY_QA4QNQ2mFpULXsQ0JxWNDeuuyIVTu3j8Vyo

Primary Prevention of Cow’s Milk Sensitization and Food Allergy by Avoiding Supplementation With Cow’s Milk Formula at Birth A Randomized Clinical Trial Mitsuyoshi Urashima, MD.MPH,PhD1,2; Hidetoshi Mezawa, MD1,2; Mai Okuyama, MD1,2; et alOct 21 2019 https://doi.org/10.1001/jamapediatrics.2019.3544

RCT 312 infants at risk for atopy

Randomised from birth BF +/- EF or BF + CMF for at least 1st 3 days post birth 96% follow up rate

Sensitization to cow’s milk (IgE level, ≥0.35 allergen units [UA]/mL) occurred in 16.8% of BF/EF group vs 32.2% in BF/CMF by the infant’s second birthday.

Food allergy including CMA was sig lower in BF+EF (4 [2.6%] vs 20 [13.2%]) for BF/CMF

Atopy risk and Early Exposure to Cow’s Milk Formula

Galactogogues to Boost Production(self-reported)

• Herbal: fenugreek, blessed thistle, goat’s rue, fennel, Brewers yeast, shatavari, torbangun, moringa

• Foods: 500Kcal fat/protein, oats, nuts, bone broth, garlic, apricots, Electrolyte sports drinks

ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Production 2018

Prescribed Galactogogues - off-label use

Dopamine antagonists (↑ prolactin level) for > 25 years domperidone10 -20 mg tid metoclopramide 10 mg tid (↑ CNS effects)

Sulpride 50mg tid (atypical antipsychotic South Africa – not available in Canada, USA, Aus/NZ) Br Med J (Clin Res Ed) 1982;285:249

Metformin 500 mg bid (improved insulin sensitivity) Grzeskowiak L, Wlodek M &Geddes D. Nutrients 2019, 11(5), 974

ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Production 2018

Domperidone:Medications and Mothers Milk Dr Tom Hale PhD

• Primary use for gastroparesis

• Prolactin steady state (no peaks or troughs) if level post feed 100 -150 ug may not help

• Dry mouth, cramps skin rash, pruritis and headache reported

• Prolonged QTc syndrome rare but appears dose/route related and caution re use with CYP3A4 inhibitors (SSRIs, antibiotics, azole antifungals plus many more)

• Slow withdrawal to avoid sudden production drop and withdrawal syndrome

“It really hurts when I breastfeed-what can I do?”

Common Causes of Nipple & Breast Pain

• Lactational “Functional”Engorgement, blocked duct, forceful milk ejection

• Trauma

Pump trauma / misuse, ill-fitting bra

Infant Mechanics• Suboptimal positioning

• Shallow latch & nipple compression

• Ankyloglossia (tongue-tie

• Infection

Bacterial fungal viral

• DermatosisDermatitis (atopic, contact), psoriasis

• NeurovascularVasospasm, nerve response to damaged nipples, vascular constriction

• MusculoskeletalCostochondritis, uncomfortable positioning

• OtherFibromyalgia, PTSD

ABM Clinical Protocol #26 – Persistent Pain with Breastfeeding

A continuum to avoid

Engorgement – early frequent milk removal

Engorgement Blocked Duct

ABM Clinical Protocol #20 Engorgement

Strategic management of early symptoms

Therapeutic ultrasound for blocked ducts

K Mitchell

Blocked Nipple Pore

K Mitchell

Mastitis – predisposing factors

• Past history of mastitis / oversupply

• Nipple trauma

• Maternal stress /fatigue

• Milk stasis/pressure

• Untreated engorgement

• Infrequent feeds

• Abrupt change in feeding frequency(in-laws)

Localized tenderness, redness, warmth with fever, malaise > 24h

Pathogens: S aureus, E coli Streptococcus MRSA

Mastitis -Diagnostic

criteria

Mastitis Treatment

• Supportive: milk removal, feed on affected side and analgesia x 24h

• Medical: 1st line Dicloxacillin, Flucloxacillin 500mg qid 10/7* penicillin allergic Cephalexin 500mg tid or Clindamycin 500mg (vancomycin trimethoprim/sulfamethoxazole according to local sensitivities)

• Culture milk if no response in 48hr or if recurrent

• Prevention important 8.5% recur

• Complication – abscess, cellulitis, necrotising fasciitis(invasive strep)

*Cochrane Database Systematic Review 2013 Antibiotics and Mastitis

ABM Clinical Protocol #4 Mastitis (2014)

Painful Nipples

Position

Latch

Trauma

InfectionsVasospasm

Dermatitis

Pregnancy

Good latch

•Comfortable

•Asymmetrical

•Wide gape

•Slight extension of head

•Transfer audible or visible

Nipple damage

Treatment –promote healing and protect breastfeeding

• Latch technique

• Emollient (Lanolin or gel pads)

• Silver cups?

• UV light therapy?

• General health measuresK Mitchell

Nipple trauma and bacterial infection

• Correct the latch

• Antibiotics oral vs topical

• Assess production/transfer

• Continue feeding

• Risk of mastitis

• Review infant anatomy K Mitchell

Candida

Dr L Amir Dr Lisa AmirY LeFort

HSV - lesions on or near nipple

Painful typical papules

Risk of neonatal HSV

Viral swab to confirm

Discontinue BF on affected side until lesions healed (express and discard milk)

Antiviral Rx– Valaciclovir 500mg bd for 7 days

Vasospasm – white nipple after feeds

Mostly secondary to trauma or infection

Fix latch/position

Primary Raynaud’s :

• Dry heat after feeds

• B6 magnesium

• Chest wall massage

• Nifedipine 30mg SR Anderson JE et al 2004

Nipple Pain

Interventions

• Glycerine pads

• Lanolin with shells

• Lanolin alone

• EBM

• APNO

Results

• Not enough evidence for any one specific RX

• EBM or nothing equally beneficial

• Regardless of RX nipple pain reduced to mild level by 10d post partum

K Mitchell

Dennis CL et al. Cochrane Database Systematic Review 2014

Nipple Shields

• Only “band-aid” temporary solution

• Poor milk transfer risk

• Decreased milk production if not pumping

• Requires follow up

• Infant preference

The Use of Nipple Shields: A Review Front Pub Health 2015Chow S et al

“Do you think my baby could have a tongue-tie?”

Tongue Tie or Ankyloglossia

The presence of a lingual frenulum is NOT the dx of “tongue tie” which is a functional impairment of tongue mobility

Tongue tie - What is happening?

Joseph et al CMAJ 2016;4 E33Walsh et al Oto Head Neck Surg 2017; 156:735-40Kapoor et al 2017

No accepted best classification system or assessment tool for deciding what breastfeeding infant should have a frenotomy procedure

Classification Systems : Coryllos (types), Kotlow (grades)

Assessment Tools:

• HATLFF (USA)

• FDTBFD (Montreal)

• BTAT(UK)

• TABBY(UK)

• Lingual Frenulum Protocol (Brazil)

Most important functions:

• Lift (vacuum)

• Extrusion to the lower gumline

• Cupping(Amir L Int Breastfeeding Journal 2006)

BEWARE or other impacting anatomical variations - high palate, retrognathia or undiagnosed clefts

ABM Clinical Protocol #11 Ankyloglossia/ Tongue tie under revision currently

Sublingual Frenulum Incidence

• Messener et al examined 1046 healthy newborns incidence of sublingual frenulum 4.8%, M:F 2.6 :1 25% had BF prob compared to matched controls 1% (anterior)

• Haham et al 2014 – 200 healthy newborns - 38% of babies had Coryllos type III lingual frenulum & 23% type IV (posterior)

• Walker et al 2018 – 100 healthy newborns – 59% of newborns had a palpable posterior sublingual frenulum /band

Tongue tie:Many symptoms have been

attributed to the presence of the lingual frenulum (and more recently) the labial frenulum without any evidence basis.

Example of Tongue tie symptom list from popular website

mommypotamus.com

Only Nipple Pain and Decreased Milk Transfer have been shown to be

improved by performing a frenotomy (O’Shea et al 2014 Cochrane Review)

What is a Lingual frenulum?(Mills et al Defining the Neonatal Frenulum J Clin Anatomy 2019)

Frenulum is…

• “central fold of floor of the mouth fascia covered by a fold of mucosa… can be thickened…suspends floor of the mouth structures.”

Tongue tie – bottom line

The evidence from over 20 years of study tells us:

• Restriction of tongue lift due to a short extensive can impact on BF(Geddes et al 2008)

• Surgical release of such a frenulum can improve BF pain and increase milk transfer in the short term (O’Shea et al 2014)

• The procedure done with surgical scissors and by an appropriately trained individual is low risk(O’Shea 2014 and others)

• Comparative studies of laser treatment vs scissor procedures have not been done

Upper Labial Frena

• No evidence that a frenulum under the upper lip impacts on intra-oral activity including speech

• Recent imaging shows the upper lip in relaxed position during comfortable breastfeeding (N Mills doctoral unpublished)

• Presence of a labial frenum is almost universal at 98% (Maria et al 2017)

• There is no evidence for existing classification systems of “upper lip tie” correlating with BF difficulties (Shagnik Ray et al 2019)

“My baby is now 4 weeks and never sleeps..”

A “good baby” - does s/he sleep? Amy Brown PhD

Normal Newborn Sleep

Sleep cycle approx. 50min

Lighter sleep architecture (protective)

Newborn circadian rhythm is immature “sleep consolidation” from 3-6 months Heraghty et al, Arch Dis Child 2008

Normal Infant sleep

6-12 months

• 78.6% regularly wake at least once a night

• 61.4% receive one or more milk feeds

(Brown et al, Breastfeeding Medicine 2015)

Giving bottles at night can provide relief for mother but does not lengthen sleep periods (Zhang et al, 2015 and Montgomery-Downs et al 2010)

Evidence Based Sleep Information for parents and HCP www.basisonline.org.uk

“I had breast implants 5 years do you think I will be able breastfeed my baby?”

Previous Breast Surgery and Breastfeeding

• Variable milk production capacity

• Implants least problem

• Reductive surgery can mean loss of functional breast tissue and scarred ducts

• Risk mastitis or low production in reductive breasts

• Pierced nipples OK

• Encourage as partial BF better than no BF

“My baby chokes and coughs when feeding on my breast and often just gives up – while my milk continues to spray out –what can I do?”

Baby gaining well but chokes, (aspiration)gulps, unlatches, clamps, spills or unsettled/gassy.

Self-induced or idiopathic

↑ risk blocked ducts/mastitis

Copious leaking fast MER

High risk of weaning

Milk production –too much or too fast

ABM Clinical protocol Hyperlactation in progress 2020

Down-regulate milk production:

• Stop galactogogue• ↓ pumping→ massage or HE• No evidence re cabbage/binders• Block feeding

• Medications: herbs(Altoids), Pseudoephedrine 30-60 mg(Aljazah, K et al BJ Clin Pharm 2003),

Estrogen (Lopez et al Cochrane Database Systematic Review 2015)

• Cabergoline?

Oversupply/Hypergalactia/Hyperlactation Management

ABM Clinical protocol Hyperlactation in progress

“Our surrogate carrier is now 32 weeks pregnant and I want to breastfeed our baby – can you help?”

Inducing Lactation is possible

Achieve full milk supply esp if previously breastfed

Requires medical guidance - consider general health, chronic health concerns (hypertension, dyslipidaemia, clotting disorders, migraine) age, infertility/endocrine dx

Mother - determination is important factor.

Inducing Lactation

• Hormonal stimulation (E+P or P) plus galactogogue (domperidone) 1/12 prior to EDC

• Express after stopping hormones

• After birth continue expressing

• See www.asklenor.com

• Seehttp://sweetpeabreastfeeding.com/inducing-lactation--relactation.html

ABM Clinical Protocol Inducing Lactation coming 2020

Photo IABLE

“I am now 6 months along in my pregnancy and want to chestfeed my baby – can you help?” (says your patient who is a transgender man)

Chestfeeding Transgender Man or Woman

• Transgender patient – organ inventory, surgical history (top procedure), binding and androgen therapy

• Possible to “chestfeed” depending on state of breast tissue and motivation – SNS / nipple shield + whatever milk produced + supp

• Sensitivity TG man as BF inherently female act by a person who identifies a male

• Same principles TG man or woman

ABM Clinical Protocol Chestfeeding and LBGQTI in progress

” I was given a prescription for a bladder infection but I have been too afraid to take it as I am breastfeeding my 10 month old baby - what should I do?”

Medications and Breastfeeding

Consider:

• Is this medication necessary?

• What is the age of the infant?

• Does this medication get into breast milk?

• Is this medication absorbed orally?

• Weigh the risk of not breastfeeding vs exposure to medication

Concerns:

• Most medication is safe in breastfeeding

• Unjustified weaning or “Pump & Dump” advice is common

Factors affecting Infant drug levels

Maternal blood level• Dose, frequency and kinetics including bioavailability

Timing of breastfeed• Drug moves back out of milk as maternal blood levels drop

Volume of feeds• Newborn v toddler

Elimination in infant• Full term infant has 33% of adult elimination capacity• not adult levels until 7 months of age• newborn and preterm infants at increased risk of accumulation

Prescribing Principles in Breastfeeding

• Avoid: codeine, anti-neoplastic, ergotamine and MTX (may need to stop BF for hours/days I 131 ) and anti-cancer agents

• Lithium now can be taken with careful monitoring of blood levels TFTs mother and baby; care re iodine >150mcg/day

• Newer drugs (Biologics and immunomodulators) choose those with safety data Witzel S Breastfeed Med. 2014 Dec 1; 9(10): 543–546.

Medications and Breastfeeding: Bottom line

• Avoid medications if not necessary and lowest appropriate dose/route

• Choose short-acting and take after infant feeding

• Caution with premature or newborns

• Avoid breastfeeding at peak serum level(take before infant sleep)

• Have a good reference source on your desktop/mobile

• Delay unnecessary investigation radioactive dye or RAI treatment

” I am going out this weekend to celebrate my 30th - can I still breastfeed my baby when I get home?”

Recreational drugs - Tobacco

Best to not smoke while BF but not contraindicationIncreased risk SIDS (late effects ADHD ↓school performance)

https://nicebreastfeeding.com/

ABM Clinical Protocol #21Substance Use & Breastfeeding

Recreational drugs -Alcohol

➢EtOH can inhibit letdown & affect flavour

➢1-2 SD after baby 4 weeks

➢Timing with feeds

➢90 min wait per SD (intoxicated need childminder)

“Rational use of alcohol is possible during breastfeeding therefore the use of Alcohol Breast Milk Tests is a complete waste of money, time and effort. “ Dr Frank Nice PhD

Recreational Drugs - Cannabis

Tetrahydrocannabinol (THC) concentrated in breast milk and is absorbed and stored in fat and brain by the BF baby

Short-term ↓PRL and ↓ oxytocin

Long-term effects may occur (both mother and baby)

Cannabis - caution

• Exposure to cannabis smoke is potentially hazardous and toxic as is cigarette smoke

• Ingestibles slower peak levels of THC but last longer in fat

• Higher plasma levels in chronic users

• Current evidence indicates that cannabis during lactation mayadversely affect neurodevelopment, especially critical brain growth during adolescent maturation

Cannabis – bottom line so far

•Encourage to stop using cannabis while BF

• Limited data should not be seen as an endorsement nor an indication not to breastfeed

• Individualized harm reduction approach if continue to use

http://www.cmnrp.ca/uploads/documents//CMNRP_Cannabis_and_Lactation_Discussion_Guide_2019_11_06_FINAL.pdf

How we all can support a breastfeeding mother

https://www.youtube.com/watch?v=03yQs9tAe3c&list=PLoflLgxNjBdyr7i2Zx-ArwTEU2PwXWgf4&index=2

“Doctor I really want to keep breastfeeding my baby when I return to the Residency program – can you help me?”

Dr Melissa Juan-Innes Medical Post Nov 2019(ER physician and mother)

“We know breastfeeding has many benefits and we still can’t give women 20 minutes, a room, a fridge? What is wrong with our medical culture?”

Dr Michelle Cohen Medical Post Oct 2019

Along with the difficulty of obtaining adequate time and space to pump, (medical) women often face academic penalties or negative career consequences from the perception that they are taking frivolous “breaks” from clinical duties… over 35% experienced discrimination relating to motherhood status, and nearly half of those women reported discrimination on the basis of breastfeeding. (survey CWIM)

Physicians are legally as entitled as anyone to breastfeed as long as they wish!

Get to know your local Lactation Consultant

https://www.ncbi.nlm.nih.gov/books/NBK501922/

Medications and Mother’s MilkDr Tom Hale PhD

➢Current research

➢Newer medications

➢Ongoing data collection

Reputable websites

• Academy of Breastfeeding Physicians www.bfmed.org• Canadian Pediatric Society

https://www.cps.ca/en/documents/tag/breastfeeding• WHO https://www.who.int/nutrition/topics/exclusive_breastfeeding/en/• Health Canada https://www.canada.ca/en/public-

health/services/publications/healthy-living/maternity-newborn-care-guidelines-chapter-6.html

• Laleche International www.llli.org• Kelly Mom www.kellymom.com• Nancy Mohrbacher http://www.nancymohrbacher.com/

nancymohrbacher.com

Thank you!