Volume 4, Number 4, July/August 1975

JOGN Nursing

Journal of The Nurses Association of The American College of Obstetricians and Gynecologists

Controversial Questions About Breastfeeding M A R I E SCOTT BROWN, RN, PhD

Many articles have been written on h o w the nurse can help the mother establish and maintain lactation. This article deals rather wi th some specific controversial questions current in the professional and lay literature. T o most of these questions there are, as yet, no conclusive answers, but it is important that the nurse be aware o f the recent thought and research concerning them so that she can deal intelligently with her patient’s questions.

The nursing literature has dealt extensively with the breastfeeding mother-baby pair, particularly with the nursing management of lactation. This is important since mothers, particularly those nursing their first babies, often need a great deal of support and teach- ing from the nursing staff. It is surprising, however, that so little is known about many other aspects of a topic of such interest to the nursing, medical, and nutrition professionals as well as to the lay public. Yet the mother will often question the nurse about these controversial or little-known aspects of breast- feeding. Because of the scarcity of good research on the subject, it is difficult for the mother (and often for the nurse) to sort fact from fiction. For this reason it is important that the nurse keep abreast of research and opinion on these matters in order to answer ques- tions intelligently. For most of these questions “the answer” is not yet available; but some research on them is, and it is the intent of this article to summarize the work that has been done on these questions so

that the individual clinician can form her own con- clusions.

Question 1: Will breastfeeding make my breasts change in size?

This question frequently is asked by mothers con- sidering breastfeeding. It is probably even more fre- quently considered silently and may play an important part in the decision the mother-to-be reaches con- cerning breast- or bottle-feeding. Yet it has received very little scientific investigation. The one study avail- able showed that breastfeeding for very short periods of time was more likely to increase than decrease breast size: 60 percent of the mothers who breastfed for less than two weeks said their breasts became larger while 24 percent said theirs became smaller. However, of the mothers who had breastfed longer than two weeks, 50 percent said that their breasts decreased in size and only 14 percent reported an increases1

July/August 1975 JOGN Nursing

Bibliography for Question 1

1. Oslti, F. A.: “Breast Feeding and Its Effect on the Shape of the Breast.” Am Pediatr Soc Abstr 1968

Question 2: I have heard that there is some connection between breastfeeding and breast cancer. What is known about this?

This question covers two issues dealt with in the literature related to breastfeeding: one concerning the mother and one concerning the infant. The first is the question of whether breastfeeding protects a woman from breast cancer. Studies related to this question have appeared in the literature since the early 1920’s, but the final answer has still not been reported.

It has been known for some time that countries in which women breastfeed almost exclusively have very low rates of breast cancer1 and that this rate increases as acculturation, with the introduction of bottle-feed- ing, occurs. In these countries it is also usual for women to have their first child earlier, and this differ- ence in timing, rather than in feeding method, may be the relevant factor.

Findings from actual studies have been divided. Some support the hypothesis that breastfeeding pro- tects against breast cancer,2.3 while others offer ev- idence to refute it.4t5 Of particular interest is a study by Levin, et al., which found that women who nursed their infants for more than 17 months have a decreased rate of breast cancer while those nursing less than 17 months have an increased occurrence of the disease? In a review of all the studies available, MacMahon, et al., concluded that, at this time, evidence is insuffi- cient to support the hypothesis that breastfeeding pro- tects a woman from breast ~ a n c e r . ~

The second question concerns whether a mother can pass a cancer-causing agent through her milk to her offspring. The fact that women who have strong famil- ial histories of breast cancer are a t greater risk of con- tracting the disease has generally been assumed to be due to a common genetic predisposition. In more re- cent years, however, the question of an environmental cause, i.e., transmission of the cancer-causing agent through the woman’s milk to her child, has arisen. Researchers have isolated, in the milk of some women,8-10 a particle which proved very ~imi1arll-l~ to an oncogenic virus mice transmit through their milk. The particle was found in 60 percent of the women with a strong family history of breast cancer but in only five percent of the women with no such history. lo

On the other hand, epidemiologic studies do not support the environmental explanation. The rate of breast cancer in this country, for instance, has increased

at the same time that the frequency of breastfeeding has decreased.14J5 Also supporting the idea that the basis of the familial tendency is genetic and not en- vironmental is the fact that the risk of breast cancer is increased whether the positive family history is ma- ternal or ~ a t e r n a l . ~

It does seem clear that factors other than virus par- ticles may be important,16 and at this time there is no conclusive evidence that an oncogenic virus passed through the breast milk is a cause of breast cancer.

Bibliography for Question 2 1. Schaefer, 0.: “Cancer of the Breast and Lactation.” Can

Med Assoc J 100:625426, 5 April 1969 2. Kaplan, S. D., and R. M. Acheson: “A Single Etiological

Hypothesis for Breast Cancer?” J Chron Dis 19: 1221-1230, 1966

3. Wynder, E. L., I. J. Bross, and T. Hirayama: “A Study of the Epidemiology of Cancer of the Breast.” Cancer 13:559- 601, 1960

4. MacMahon, B., and M. Feinleib: “Breast Cancer in Rela- tion to Nursing and Menopausal History.” J Natl Cancer lnst 24:733-753, 1960

5. Shapiro, S., P. Strax, L. Venet;and R. Fink: “The Search for Risk Factors in Breast Cancer.” Am J Public Health 58:820-835, 1968

6. Levin, Morton L., Paul R. Sheehe, Saxon Graham, and Oliver Glidewell: “Lactation and Menstrual Function as Related to Cancer of the Breast.” Am J Public Health 54(4) , April 1964

7. MacMahon, B., T. M. Lin, C. R. Lowe, A. P. Mirra, B. Ravinihar, E. J. Salber, D. Trichopoulos, et al.: “Lactation and Cancer of the Breast-A Summary of an International Study.” Bull W H O 4223185, 1970

8. Feller, W. F., and M. C. Chopra: “Studies of Human Milk in Relation to the Possible Viral Etiology of Breast Cancer.” Cancer 24:1250, 1969

9. Moore, D. H., N. H. Sarkar, C. E. Kelly, N. Pillsbury, and J. Charney: “Type B Particles in Human Milk.” Tex Rep Biol Med 27:1027, 1969

10. Moore, D. H., J. Charney, B. Kramarsky, E. Y. Lasfargues, N. H. Sarkar, M. Brennan, J. H. Burrows, S. M. Sirsat, J. C. Paymaster, and A. B. Vaidya: “Search for a Human Breast Cancer Virus.” Nature 229:611, 1971

11. Schlom, I., S. Spiegelman, D. Moore: “RNA-Dependent DNA Polymerase Activity in Virus-Like Particles Isolated from Human Milk.” Nature 231:97, 1971

12. Schlom, I., D. Colcher, S. Spiegelman, S. Gillespie, D. Gil- lespie: “Quantitation of RNA Tumor Viruses and Virus- like Particles in Human Milk by Hybridization to Poly- adenylic Acid Sequences.” Science 179:696, 1973

13. Axel, R., J. Schlom, and S. Spiegelman: “Presence in Hu- man Breast Cancer of RNA Homologous to Mouse Mam- mary Tumor Virus RNA.” Nature 235:32, 1972

14. Feinleib, M., and R. J. Garrison: “Interpretation of the Vital Statistics of Breast Cancer.” Cancer 24: 1109, 1969

15. Meyer, H.: “Breast Feeding in the United States.” Clin Pediatr 7:708-715, 1968

16. Gerwin, B., et al.: “DNA Polymerase Activities of Human Milk.” Science 180:198, 1973

Question 3: I have heard that breastfeeding protects the infant against all kinds of diseases including asthma, eczema, celiac syndrome, infection, and cav- ities. Are these claims true?

16 July/August 1975 JOGN Nursing

Protection afforded by breastfeeding against various diseases has long been considered one of the greatest advantages of nursing. Certainly the most thoroughly studied of the claims is that breastfeeding protects the child against infections. Antibodies against viruses and bacteria-large amounts of IgE and IgA and lesser amounts of IgG and IgM-are present in breast milkl-ll but are not absorbed through the gastrointestinal mu- cosa.l0 It would seem that they would be effective against diseases which enter the body through the gas- trointestinal system, and this is born out by clinical studies showing a lower incidence of diarrheal and other gastrointestinally transmitted diseases in breast- fed infants.

Mechanisms of protection against infection other than antibodies have also been reported. Lactoferrin, an inhibitor of Escherichia coli and staphylococci that is present in human milk,16 protects against multiplica- tion of Candida albicans.17 The large amounts of lyso- zymes in breastmilk have been postulated to provide general bactericidal protection.6J8 Clinical studies seem to support the idea that breastfed infants are more resistant to non-enteric infections, and the presence of lactoferrin and lysozymes may be the reason. Breast- fed infants have a lower rate of respiratory diseases and their complications such as otitis media.1g-21

It does appear, then, that breastfeeding provides significant protection against infections, both enteric and respiratory, although the exact mechanism of this protection is unknown.

Breastfed infants may be spared the development of allergies that seem to be associated with formula feed- ing. Lowe and Cormia state that eczema is seven times greater in children receiving formula than in those receiving breast milk.22 Others support this idea with clinical observation^.^^^^^ However, there have been no well-controlled studies on this subject, and the idea that breastfeeding “protects” against allergies re- mains only a theory.

The observation that nursing provides resistance to dental caries was made by Tank in 1965. He studied 246 children over a period of two years and found a significantly lower incidence of caries in the breast- fed children.25 This is particularly interesting in light of the fact that fluoride, a known caries-inhibitor, is not transmitted in breastmilk (see Question 4).

Several authors have reported their clinical impres- sion that breastfed infants show no signs of celiac syn- drome until taken off breast milk.26,27 However, this impression has not been validated by research, and it seems that rather than preventing occurrence, nursing only delays symptoms.

Bibliography for Question 3 1. Hodes, H.: “Colostrum: A Valuable Source of Antibodies.”

Ob-Gyn Observer 3:7, 1964 2. Michaels, R. H.: “Studies of Antiviral Factors in Human

Milk and Serum.” J lmmnol 94:262, 1965 3. Schubert, J., and A. Grunberg: “Zur Frage der Uebertra-

gung von Immun-Antikorpern von der Mutter auf das Kind.” Schweiz Med Wschr 79: 1007, 1949

4. Arnon, H., M. Salzberg, and A. L. Olitzk: “The Appear- ance of Antibacterial and Antitoxic Antibodies in Ma- ternal Sera, Umbilical-Cord Blood and Milk. Observations on the Specificity of Antibacterial Antibodies in Human Sera.” Pediatrics 23:86, 1959

5. Kenny, J. F., M. Boesman, and R. Michaels: “Bacterial and Viral Coproantibodies in Breast-Fed Infants.” Pe- diatrics 39:20?, 1967

6. Adinolfi, M., A. A. Glynn, M. Lindsay, and C. M. Milne: “Serological Properties of yA Antibodies to Escherichia Coli Present in Human Colostrum.” lminunology 10:517, 1966

7. Sabin, A. B., A. H. Fieldsteel: “Antipoliomyelitic Activity of Human afid Bovine Colostrum and Milk.” Pediatrics 29:105, 1962

8. Mata, L. J., R. G. Wyatt, “Host Resistance to Infections.” Am J Clin Nutr 24:976, 1971

9. Hanson, L. A., R. Borssen, J. Holmgren, U. Jodal, B. G. Johansson, and B. Kaijser: “Secretory IgA.” In Immuno- logic Incompetence, edited by B. M. Kagan and E. R. Stiehm. Chicago, Year Book Medical Publishers, 1971, p 39

10. Ammann, A. J., E. R. Stiehm: “Immune Globulin Levels in Colostrum and Breast Milk, and Serum from Formula and Breast Fed Newborns.” Proc SOC Exp Biol Med 122: 1098, 1966

11. Bennich, H., S. G. 0. Johansson: “Structure and Function of Human Immunoglobulin.” A d s lmmzcnol 13:1, 1971

12. Winberg, J., G. Wessner: “Does Breast Milk Protect Against Septicaemia in the Newborn.” Lancet 1 1091-1094, 29 May 1971

13. Hinton, N. A., R. R. MacGregor: “A Study of Infections Due to Pathogenic Serogroups of Escherichia Coli.” Can Med Assoc J 79:359, 1958

14. Svirsky-Gross, St.: “Pathogenic Strains of Coli (0, 111) Among Prematures and the Use of Human Milk in Con- trolling the Outbreak of Diarrhea.” Ann Paediatr 190: 109- 115, 1958

15. Neter, E.: “Enteritis due to Escherichia Coli: Present-Day Status and Unsolved Problems.” ] Pediatr 55:223, 1959

16. Johansson, B. G.: “Isolation of an Iron-Containing Red Protein from Human Milk.” Acta Chem Scand 14:510, 1960

17. Kirkpatrick, C. H., I. Green, R. R. Rich, and A. L. Schade: “Inhibition of Growth of Candida Albicans by Iron Un- saturated Lactoferrin: Relation to Host Defense Mechanisms in Chronic Mucocutaneous Candidiasis.” ] lnject Dis 124: 539, 1971

18. Miller, T. E.: “Killing and Lysis of Gram Negative Bac- teria Through the Synergistic Effect of Hydrogen Per- oxide, Ascorbic Acid and Lysozyme.” ] Bacteriol 98: 949, 1969

19. Gyorgy, P., S. Dhanamitta, and E. Steers: “Protective Effects of Human Milk in Experimental Staphylococcus In- fection.” Science 137:338-340, 1962

20. Mellander, O., B. Vahlquist, and T. Mellbin: “Breast Feed- ing and Artificial Feeding.“ Acta Paediatr (Suppl48) 116:65, 1959

21. Robinson, M.: “Infant Morbidity and Mortality: A Study of 3266 Infants.” Lancet 260:788-794, 1951

22. Lowe, L., F. Cormia: “Atopic Eczema.” In Current Therapy 1967. Philadelphia, W. B. Saunders CO., 1967

23. Glaser, J.: “The Dietary Prophylaxis of Allergic Diseases in Infancy.” ] Asthma Res 3:199-208, 1966

July/August 1975 ] O G N Nursing ‘7

24. Rose, A. H., A. Rose, Jr.: Bronchial Asthma: I t s Diagnosis and Treatment. Springfield, Ill., Charles C Thomas Publ., 1963

25. Tank, G.: “Relation of Diet to Variation of Dental Caries.” J Am Dent Assoc 70:394-403, 1965

26. Di Sant’Agnese, P., W. Jones: “The Celiac Syndrome (Mal- absorption) in Pediatrics.” J A M A 180: 308-316, 1962

27. Anderson, D., E. Mike: “Diet Therapy in the Celiac Syn- drome.” ] Am Diet Assoc 31:340-346, 1955

Question 4: I have heard that I will have to be very careful of things that may come through in my breast milk, For instance, I have heard that many drugs, pesticides, and environmental contaminants such as lead are transmitted. On the other hand, I have also heard that useful substances such as fluoride and Vitamin D are not, Is this true?

The literature certainly supports the idea that most drugs are transmitted through the breast milk. The more relevant question is which of them are toxic enough and come through in doses large enough to warrant discontinuation of either the drug or breast- feeding. For the vast majority of drugs, this question is unanswered.

Of the antibacterial drugs, it has been found that streptomycin,l novobiocin,2 peni~illin,~ erythromy- cin: chloramphenicol,5 sulfanilamide and sulfapyri- dine,B metronidazole (Flagyl) and tetra~ycline,~ and isoniazid* are excreted in breast milk. Of these only isoniazid is thought to be secreted in predictable doses high enough to be of any therapeutic value to the in- fant. The quantity of antibiotics secreted is not suffi- cient to be useful, but is probably enough to start a sen- sitization in the child. Tetracycline, of course, may stain the teeth not only in utero but until the child is about 14 years of age. Sulfa drugs may harm the neonate because they replace bound bilirubin resulting in in- creased levels of unconjugated bilirubin. Metronidazole (Flagyl) also has been suspected of harming the breast- fed infant,D and the possibility of ototoxic damage must always be considered with drugs such as streptomycin, gentamycin, and ranamycin. Chloramphenicol should also be considered dangerous to the neonate because of the fatal “gray baby syndrome” associated with its use.

Analgesics such as salicylic acid,1° morphine,ll pro- poxyphene ( D a r ~ o n ) , ~ and phenylbutazone (Butazoli- din) l2 are secreted through the milk without apparent damage to the infant.

The effects of some psychotherapeutic drugs have been studied. Alcohol in moderate amounts does not adversely affect the child, but very large quantities may inebriate an infant.13 Therapeutic doses of bar- biturates seem to have no effect on the ~h i1d . l~ Chlor- promazine (Thorazine), trifluoperazine (Stelazine) ,

and prochlorperazine (Compazinem) are excreted in the milk of nursing dogs, without producing clinical symptoms in the puppies.15 Dextroamphetamine sulfate (Dexedrine) also passes through in the breast milk but, again, without apparent effect on the nursling?

Hormones appear to be more dangerous in this re- gard. Thiouracil has been found in levels up to 12 times greater in the breast milk than in the mother’s blood serum, and levels this high may cause goiter in the in- fant.lB Cortisone retarded the growth and development of nursling rats who received it via brea~tmi1k.l~ The question of the effects of oral contraceptives is not completely answered. It is known that lactation may be inhibited if the pill is given early in the postpartum period (i.e., before seven weeks). Immediate breast changes in a male nursling have been reported, but long-range effects are u n k n o ~ n . ~

Because the research in this area is so scant, it is difficult to reach practical conclusions. According to Catz and Giacoia, breastfeeding mothers should not be given radioactive drugs, anticoagulants, antimetab- olites, cathartics, iodides, atropine, ergot, tetracycline, Flagyl, and thiouracil. They further recommend that other medications be given with caution: oral contra- ceptives, sulfonamides, reserpine, steroids, diazepam, diuretics, nalidixic acid, barbiturates, and codeine- containing cough syrups.? Any nurse who deals often with breastfeeding mothers should have available a copy of this review article. Poison control centers can be called for information on unusual drugs.

DDT is excreted in human breast milk in greater amounts than in cow’s milk,ls-22 but because the mean concentration in human milk has dropped radically since the first studies in the early 1950’s,9 the presence of the contaminant in breast milk is no longer con- sidered dangerous to infants.

Vitamin B deficiency in the mother may adversely affect her but this deficiency is seldom a prob- lem in the United States. Vitamin D is not transmitted through the breast milk, even in well nourished women, and many clinicians feel it should be supplemented. It was previously believed that fluoride was transmitted through breast milk in sufficient quantities to protect the infant’s growing dentition, but more recent re- search has proven this fal~e.2~-~6 Because most breast- fed infants consume minimal amounts of water, it has been recommended that fluoride be s~pplemented.~?

1

Bibliography for Question 4 . Fujimori, H., S. Imai: “Studies on Dihydrostreptomycin

Administered to the Pregnant and Transmitted to their Fetuses.” J Jap Obstet Gynecol SOC 4:133, 1957 (or Int Abstr Surg 111:289, 1960, or Surg Gynecol and Obstet Sept 1960)

I 8 July/August 1975 JOGN Nursing

2. Teixeira, G. C., R. B. Scott: “Further Clinical and Labora- tory Studies with Novobiocin. I. Treatment of Staphylo- coccal Infection in Infancy and Childhood. 11. Novobiocin Concentrations in Blood of Newborn Infants and in the Breast Milk of Lactating Mothers.” Antibiot Med 5:577, 1958

3. Knowles, J. A.: “Excretion of Drugs in Milk-A Review.” J Pediatr 66:1068, 1%5

4. Rasmussen, F.: “The Mechanism of Drug Secretion Into Milk.” In Dietary Lipids and Postnatal Development, edited by C. Galli, G. Jacini, and A. Pecile. New York, Raven Press, p 231, 1973

5. Smadel, J. E., et al.: “Chloramphenicol (Chloromycetin) in the Treatment of Tsutsu-gamushi Disease (Scrub Typhus).” J Clin Znvest 28:1196, 1949

6. Hawkins, F., J. S. Lawrence: The Sulphonamides, New York, Grune & Stratton, Inc., pp 95-96, 1951

7. Catz, C. S., G. P. Giacoia: “Drugs and Metabolites in Hu- man Milk.” In Dietary Lipids and Postnatal Development, edited by C. Galli, G. Jacini, and A. Pecile. New York, Raven Press, 1973, p 247

8. Ricci, G. and Copaitich: “Modalita di Eliminazione Dell’ isoniazide Somministrata per via Orale Attraverso il Latte di Donna.” Rass Int Clin T e r 53-54:209, 1954-1955

9. Arena, J. M.: “Contamination of the Ideal Food.” Nutr T o - day Winter 1970, pp 2-8

10. Kwit, N. T., R. Hatcher: “Exception of Drugs in Milk.” A m J Dis Child 49:900, 1935

11. Terwilliger, W. C., R. A. Hatcher: “Morphine and Quinine in Human Milk.” Surg Gynecol Obstet 58:823, 1939

12. Leuxner, E., and R. Pulver, as cited in J. A. Knowles: “Excretion of Drugs in Milk-A Review.” J Pediatr 66:1068, 1965

13. Sapeika, N.: “The Excretion of Drugs in Human Milk-A Review.” J Obstet Gynaecol Br Commonw 54:246, 1947

14. Greenhill, J. P.: “Local Changes in the Puerperinum.” In Obstetrics, 12th edition. Philadelphia, W. B. Saunders Co., p 349, 1960

15. Flanagan, T. L., et al.: “Spectrophotometric Method for the Determination of Chlorpromazine and Chlorpromazine Sulphoxine in Biological Fluids.” J Med P h m a c o l Chem 1:263, 1959

16. Williams, R. H., G. H. Kay, and B. J. Jandorf: “Thiouracil: Its Absorption, Distribution and Excretion.” J Clin Znvest 23:613, 1944

17. Mercier-Parot, L.: “Disturbances in Post-Natal Develop- ment of Rats after Maternal Administration of Cortisone During Pregnancy or Lactation.” Comp Rend 240:2259, 1955

18. Quinby, G., J. Armstrong, and W. Durham: “DDT in Human Milk.” Nature 207:726, 1965

19. Egan, H., R. Goulding, J. Roburn, and J. OG.: “Organo- Chlorine Pesticide Residues in Human Fat and Human Milk.” Br Med J 10 July 1965, pp 66-69

20. Curley, A., and R. Kimbrough: “Chlorinated Hydrocarbon Insecticides in Plasma and Milk of Pregnant and Lactating Women.” Arch Environ Health- 18:156, 1969

21. Ritcey, W. R., G. Savary, and K. A. McCully: “Organo- chlorine Insecticide Residues in Human Milk, Evaporated Milk and Some Milk Substitutes in Canada.” Can J Public Health 63:125, 1972

22. Wilson, D. J., D. J. Locker, C. A. Ritzen, J. T. Watson, and W. Schaffner: “DDT Concentrations in Human Milk” A m J Dis Child 125:814, 1973

23. Fehily, L.: “Human Milk Intoxication due to & Avita- minosis.” Br Med J 2:590, 1944

24. Ericsson, Y.: “Fluoride Excretion in Human Salvia and Milk.” Caries Res 3:159, 1969

25. Ericsson, Y., and U. Ribeluis: “Increased Fluoride Ingestion by Bottle-Fed Infants and Its Effect.” Acta Paediatr Scand 59:424, 1970

26. Armstrong, W. D., I. Gedalia, L. Singer, J. A. Weatherell, and S. M. Weidmann: “Distribution of Fluorides.” In Fluorides and H m m Health, World Health Organization Monographs Series No. 59. Geneva, World Health Organi- zation. D 93. 1970

27. Foman,‘S.: Infant Nutrition. Philadelphia, W. B. Saunders, Publisher, 1974

Question 5: I would very much like to breastfeed the child whom we are planning to adopt. Is this possible?

Many cases of lactation in nonpregnant women are reported in the literature. Organic brain damage has been described as causative in some cases,l as have en- docrine disorders.2 However, the stimulus of sucking alone can cause the flow of milk. Lactation in virgins is also r e c ~ r d e d ; ~ - ~ in most of these situations, the virgin suckled an infant. Manual expression alone can produce significant amounts of milk, as in the case of a psychotic woman described by Von Fra~denberg.~ Lactation has even been observed in men but was al- ways associated with physical abnormalities.*JOJ1

The nutritional content of such milk has not been fully evaluated, but von Fraudenberg found a very abnormal nutrient content in the case he report^.^ This possibility certainly requires further investigation.

Adopting mothers have at least partially breastfed i n f a n t ~ . ~ ~ J ~ Lactation in these cases began between one and six weeks after the first sucking stimulation. However, production of milk in such circumstances is very difficult.

There is a device available to help the nursling stimulate the breast while receiving formula, until the mother’s milk supply is established.” A disposable bag containing the supplemental formula is connected to a soft flexible plastic tube. The tip of the tube ends at the nipple and is placed in the baby’s mouth while he sucks the nipple. In this way, the nipple receives extra stimulation but the baby does not become frustrated by a dry breast. This device also may be useful for relactation in situations of prematurity or when mother and baby have been temporarily separated because of illness.

The manufacturer of this device also publishes two booklets-Induced Lactation: A Guide for Counsel- ing and Management and A Brief Discussion of A d o p tiue Nursing: An Introduction to the Topic-that may be of help to the nurse working in this area.

Bibliography for Question 5 1. Riese, W.: Klin Wschr 7, 1928 2. Krestin, D.: Lancet 1:928, 1932

* J. J. Avery Inc., Box 6459, Denver, CO 80206.

July/August 1975 J O G N Nursing ‘9

3. Briehl, W., E. W. Kulka: Psychoanalyt Quart 4:484, 1935 4. Knott, J.: Am Med 13:372, 1907 5. Bentolilla, J.: Biol lnst Clin Quir, B. Aires, 3:712, 1927 6. Del Castillo, E. B., A. Lanari: Sem Med, B. Aires, 2:303,

7. Mead, M.: Sex and Temperament. Routledge, London,

8. Jago, W. J.: East Afr Med J 4:114, 1927 9. Von Fraudenberg, E.: Ann Paediatr 157:241, 1941

1933

1935

10. Staemler, M.: Klin Wschr 19:1231, 1940 11. Lisser, H.: Endocrinology 20:567, 1936 12. Avery, J. J.: “A Brief Discussion of Adoptive Nursing.”

13. Hormann, E.: Relactation: A Guide to Breastfeeding the J. J. Avery, Inc., Denver, Colorado,. 1973

Adopted Baby. Massachusetts, La Leche League, 1971

Question 6: I have heard the term “breast-milk jaun- dice.” What is this and what dangers does it present to the baby?

Some breastfed infants develop hyperbilirubinemia between the fifth and 14th day of life.14 This is usually transient; but prolonged, severe unconjugated hyper- bilirubinemia has been reported. In many cases jaun- dice was clearly shown to be related to the breastmilk: When jaundiced infants were switched from human to cow’s milk and back again, bilirubin levels corre- sponded to these change^.^ Although it was believed that certain women secrete in their milk a particular type of pregnanediol that inhibits glucuronide conju- gation (a mechanism essential for the excretion of bili- rubin) in the baby,5*0 this finding is contr~versial .~*~ “Breast milk jaundice’’ is still poorly understood; how- ever, most investigators agree that the condition is harmless and fear of it should not deter the woman who wants to nurse her infant.4*9Jo

Bibliography for Question 6

1. Rosta, J., Z. Makiol, and T. Feher, et al.: “Steroid Inhibi- tion of Glucuronization.” Acta Paediatr Acad Sci H w g 1 1 : 67-69, 1970

2. Ramos, A., M. Silverberg, and L. Stern: “Pregnanediols and Neonatal Hyperbilirubinemia.” Am J Dis Child Vol. 3, April 1966

3. Newman, A. J., and S. Gross: “Hyperbilirubinemia in Breast-Fed Infants.” Pediatrics 32:995, 1963

4. Gartner, L. M., and I. M. Arias: “Studies of Prolonged Neonatal Jaundice in the Breast Fed Infant.” J Pediatr 68:54, 1966

5. Arias, I. M., and L. M. Gartner: “Production of Unconju- gated Hyperbilirubinaemia in Full-Term Newborn Infants Following Administration of Pregnane 3a, 20B-diol.” Nature 203:1292, 1964

6. Arias, I. M., L. M. Gartner, S. Seifter, and M. Furman: “Prolonged Neonatal Unconjugated Hyperbilirubinemia As- sociated with Breast Feeding and a Steroid Pregnane 3 (alpha) 20 (beta-) diol, in Maternal Milk that Inhibits Glucuronide Formation in Vitro.” J Clin Invest 43: 2037, 1964

7. Adlard, B. P. F., and G. H. Lathe: “Breast Milk Jaundice: Effect of a 3-a 20-B-pregnanediol on Bilirubin Conjugation by Human Liver.” Arch Dis Child 45:186, 1970

8. Hargreaves, T., R. F. Piper: “Breast Milk Jaundice, Effects of Inhibitory Breast Milk and 3a, 2OB-pregnanediol on Glucuronyl Transferase. Arch Dis Child 46:195, 1971

9. Stiehm, E. R., J. Ryan: “Breast Milk Jaundice.” Am Dis Child 109:212, 1965

10. Foman, S.: Infant Nutrition. Philadelphia, W. B. Saunders, Publishers, 1974

The author’s current address is Marie Scott Brown, RN, PhD, Assistant Professor, Maternal-Child Nursing, School of Nursing, University of Colorado Medical Center, 4200 E. Ninth Avenue, Denver, CO 80220.

Marie Scott Brown is Co-Direc- tor of a federal program--in progress a t the University of Colorado School of Nursing, Denver-to facilitate the prep- aration and use of expanded- role nursing practitioners. She also practices maternal-child and pediatric nursing at Colo- rado General Hospital and is engaged in research on pre-

natal predictors of parenting and on biofeedback as a mechanism of control in labor. She is Education Editor f o r the Journal of Pediatric Nursing and sits on the Pub- lications C o m m i t t e e of the National Association for Pedi- atric Nurse Associates and Practitioners. Doctor Brown has written extensively on neonatology and childhood illness. Her series of articles on physical examination (published in Nursing ’73, Nursing ’74, and Nursing ’75) culminated in the book Pediatric Physical Diagnosis for Nurses (McGrawHil l , 1973), coauthored by Mary Alexander. Doctor Brown also recently produced six audiocassettes on “History Taking of a Sick Child” (September 1974) for the Nursing Scientist Tape Series. She received her BS in nursing f rom Marqwette University, Milwaukee, Wis- consin, her MS in Nursing and M A and PhD degrees from the University of Colorado, where she has taught since 1971. She has worked as a Pediatric Nurse Practi- tioner for the Denver Visiting Nurse Service and the Den- ver Public Schools, and as a Rural Public Health Nurse for the Frontier Nursing Service, Hyden, Kentucky. She is a member of the Maternal Child Specialty C o m ’ t t e e and the Nurse Clinician Specialty Committee of the Col- orado Nurses’ Association. She is also a member of N A A C O G , A N A , the Association for Applied Anthro- pology, and the Ambulatory Pediatric Association and has participated in major meetings of those associations.

2 0 July/August 1975 JOGN Nursing