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Debunking Mother’s Milk Myths:Challenging Cases in Breastfeeding

Colorado Lactation Conference

September 20,2018

Maya Bunik, MD, MPH, FABM, FAAP

Professor, Pediatrics

I have no conflict of interests and no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of

commercial services discussed in this CME activity.

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Faculty Disclosure

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Objectives

1)To review cases of common challenges in early

breastfeeding management: tongue tie, low milk supply,

early weight loss, maternal medications, reflux,

oversupply and mastitis

2)To understand how to respond to common myths and

concerns about feeding issues

3)To understand misconceptions about how

breastfeeding and fussiness relate

4)To recognize the importance of screening for

postpartum depression and other maternal mental

health issues as part of the breastfeeding evaluation.

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Background

▪ Breastfeeding provides optimal nutrition for infants

and an intimate maternal-infant bonding experience

that establishes the relational tone for parenting and interactions

▪ Pregnancy-related mood disorders and maternal

mental health are inextricably connected to a mother’s experience of breastfeeding

▪ The breastfeeding relationship is often complicated

by challenges in the first few weeks of life that are challenging for busy pediatricians/providers

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Googling ‘Breastfeeding Problems’ results in over 36 million hits.

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Breastfeeding in Primary Care

▪ High risk infants bring unique set of challenges:

prematurity, sleepy at breast, reflux, increased

caloric needs, post-traumatic stress in mothers, multiples, etc.

▪ Busy pediatric practice, full templates, hard to decipher issues over the phone

▪ Variable training in lactation among office staff

▪ Mixed information on the internet, limited time to address

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It’s Complicated!

Baby J 5 weeks old:

‾ Frenulum clipped at 15 days

‾ Thrush also treated in mother and infant

‾ Continued maternal breast pain and

redness of nipples

‾ Very fussy baby

‾ Mom won’t leave the house for fear of

fussiness

‾ Breastfeeding is all that calms him

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Baby Tongue Tied?

• Anterior type is easily recognized by providers

• Evaluate suck with finger and rub gums to see if can extend forward and laterally

• Release procedure safe

• Main indications: maternal pain and poor milk transfer

O’ Callahan C et al IJPO 2012

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What is the Evidence?

• Assessment/selection is important because 50% will not require release

• 2-3 weeks of age is best timing for intervention• Release procedure is most likely overdone• Abundance of misinformation is available online

blogs, mothers’ groups, etc. • Infant may have still have feeding issues--common

assumption is that it was ‘fixed’• Complications are rare but should be done by

trained professional• Out of pocket costs for vulnerable families

Systematic Review Breastfeeding Medicine Sept. 2017

It’s More Than Complicated!

Baby G 18 days old:

‾ Mother with previous fetal loss x 2, panic

attacks this pregnancy necessitated

Lexapro, Clonazepam

‾ EPDS=10

‾ Sleepy feeds

‾ Fussy behavior

‾ Request from Psychiatrist to add Abilify 1 mg

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Toxnet-Lactmed

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Escitalopram (Lexapro)

Summary of Use during Lactation:Escitalopram is the S-isomer of the antidepressant, citalopram. Limited information indicates that maternal doses of escitalopram up to 20 mg daily produce low levels in milk and would not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months. Based on limited data, escitalopram appears to be preferable to racemic citalopram during breastfeeding because of the lower dosage and milk levels and general lack of adverse reactions in breastfed infants

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One case of necrotizing enterocolitis was reported in an breastfed newborn whose mother was taking escitalopram during pregnancy and lactation, but causality was not established. Monitor the infant for drowsiness, especially in younger, exclusively breastfed infants and when using combinations of psychotropic drugs. Mothers taking an SSRI during pregnancy and postpartum may have more difficulty breastfeeding and may need additional breastfeeding support. Breastfed infants exposed to an SSRI during the third trimester of pregnancy have a lower risk of poor neonatal adaptation than formula-fed infants.

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Clonazepam (Clonidine)

Summary of Use during Lactation:

Because of the high serum levels found in breastfed infants, possible infant side effects, and the possible negative effects on lactation, other agents may be preferred, especially while nursing a newborn or preterm infant.

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Aripiprazole (Abilify)

Summary of Use during Lactation:

Limited information indicates that maternal doses of aripiprazole up to 15 mg daily produce low levels in milk, but until more data become available, an alternate drug may be preferred, especially while nursing a newborn or preterm infant. Aripiprazole can lower serum prolactin in a dose-related manner and can affect the milk supply variably.

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So who are you going to call?

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Infant Risk Warm Line806-352-2519

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‾ Sleepy feedings at breast (2-3 x a day),

so had hungry/fussy periods

‾ Tried formula x 1 because more fussy,

then had emesis ED visit

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Ended up fortifying breastmilk feeds to 24 calories

BF infants should be transferring 3 ounces at a nursing session.

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Milk volumes for Breastfed Infants

• When was infant last fed and how much

• Presence of night feedings

• 11 +/- 3 times in 24 hours

• Diurnal variations

• 1-1.5 ounces at birth to 4.5 ounces at 1 year

• Analogy of adult drinking a whole milk latte?

• What is said to a vulnerable mother about how much milk is transferred may cause hardship

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Kent JC Pediatrics 2006,

Neville MC Am Clin Nutr 1988

Dewey KG Journal of Peds GI, 1984

Baby S-Case of Low Milk

34 yo mom who BF previous child x 8 months, had some issues with supply when she returned to work

Presents with her 9 day old does not feel any engorgement (never did postpartum) only pumping 1 ounce in 24 hours

• Hashimoto’s Thyroiditis on meds, TSH checked recently

• Citotec (Misoprostol), 400cc blood and clots

• Referred for ultrasound

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Low Milk Supply?--EVERY MOTHER WORRIES

• Primary glandular insufficiency (<5% of women)

• Breast surgeries and associated scarring

• Severe postpartum birth complications usually involving hypertension, blood loss or retained placenta

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Low Milk Supply?--EVERY MOTHER WORRIES

• Inadequate early milk removal, poor latch, sleepy behavior at breast = reversible causes

• Early bottle supplementation and may need nipple shield

• Medications such as oral contraceptives or pseudoephedrine decongestant

• Infertility, Polycystic Ovarian Syndrome

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All infants with early weight loss need

to be supplemented and moms put on triple feeding regimen.

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Early 10% Weight Loss

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FIGURE 3 from Flaherman V Pediatrics 2013

Vaginal 5%

Cesarean 10%

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It is easy to suggest supplementationbut harder to be creative and individualize

feeding plans…

Infant may need more follow-upand TIME

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Fussy babies are usually hungry.

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Crying as a problem

▪ 25% of infants are diagnosed with colic

▪ One of the most common causes for visit with PCP in first month

▪ 25% of calls to postpartum help lines

▪ Calming a fussy infant is a major reason for bed-sharing

▪ Mothers attribute illnesses to colic (diarrhea, fever, vomiting)

▪ Infants are given unnecessary treatments

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Rosen LD PCNA 2007

Osman H et al BMS Public Health 2010

Hauck FR et al Pediatrics 2008

Chinawa JM et al Niger J Clin. Pract. 2013

Crying as a problem

▪ Preterm infants are associated with crying more than term infants

▪ Breastfeeding infants reported to cry more than formula fed infants

▪ Common reason for supplementation in exclusively breastfed infants

▪ Infants perceived as "fussy" are more likely to receive complementary foods before 4 months

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Thomes KA J Obstet Gynecol Neonatal Nurs 2000

Lucas A et al Early Hum Dev 1998

Water H et al Pediatrics 2011

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Crying as a problem

Excessive crying often coincides with the

establishment of the breastfeeding

relationship (3-4 weeks) creating a

complicated constellation of symptoms that

are difficult for pediatric providers to treat.

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Length of time crying greatest between 4-8 weeks,

peaks at about 6 weeks

Chart courtesy of: http://www.purplecrying.info32

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Heinig MJ 200633

Cultural Reasons for Los Dos or combination feeding

‘Best of Both’: By giving both breast milk and formula, the baby is sure to get the ‘best of both’-healthy aspects of breast milk and the vitamins in formula.

Breastfeeding can be a struggle’: Breastfeeding is natural but is associated with hardship (batallar)

‘Not in Mother’s Control’: I want to breastfeed but things can happen that are beyond my control.

‘Family and Cultural Beliefs’: Latino parents and grandparents want what is best for the baby and give strong messages about cultural beliefs (familismo)Bunik M et al. Breastfeed Med 2006

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More on Las Dos Cosas

▪ Insufficient milk is common ‘milk dried up’ and

formula is the remedy RATHER THAN THE CAUSE

▪ Don’t think of formula as risky

▪ Fatalistic—milk does not satisfy as baby ages

especially after 3 months

▪ Never heard from medical providers about exclusivity or duration recommendations

M.Bartick and C.Reyes Breastfeeding Medicine 201235

Case of Baby W

4 month old with weight loss/drift and feeding for short periods—’through 2 let-downs’ and then sleepy, bottle refusal.

• MOC did not continue thyroid rx postpartum, on minipill, MJ use. Giving infant Vit D and probiotic.

• Also missed feedings getting 6-7x rather than 8 (road trip, moving, 2yo toddler brother, infant does not complain or cry).

• Stools are dark and occur every 3-4 days but no blood

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Case of Baby W

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Medical ‘Causes’

▪ Missed feedings, long stretches of sleep (8x a day minimum)

▪ Sleepy or late preterm infant

▪ Early exposure to fast flow of bottle feeding and refusing breast

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Medical ‘Causes’

▪ Fussy during nursing, pulling away, arching,

associated with post-nursing spitting up Reason: may have reflux

▪ Baby getting too full, reflux due to overabundant milk supply

▪ Mother taking medications Reason: certain

medications may have side effects of stimulants

in baby; caffeine or energy drink intake, illicit drugs

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Pre and post test weights

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Medical ‘Causes’

▪ Crying related to burping or passing of gas or stool due to immature intestinal tract

▪ Baby has phases of increased gassiness Reason:

mother ate gas-producing foods, e.g. onions,

broccoli, cabbage, beans, turnips, chocolate, apricots, rhubarb, prunes

▪ Baby may have an underlying congenital disorder associated with poor feeding.

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Swaddling is associated with poor motordevelopment and increased risk of SIDS.

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Fear of Swaddling and SIDS

• Swaddling risk increased with infant age and was associated with a twofold risk for infants aged >6 months

• Can be a useful tool to avoid unnecessary supplementation

• 283 articles screened, 4 studies

43Pease AL et al. Pediatrics 2017

Babies with reflux should be put on

Zantac and then moms should also eliminate milk and soy from diet.

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Case of Heme Positive Stool

3 month old on Zantac and some mucousy green stools.

Seen by GI specialist.

• Told to eliminate all dairy soy nuts egg wheat etc at same time

• FOC has allergies

• Still some mucus in stools but no blood

• Fussiness45

Reflux (50% of infants)▪ Reflux: onset early in life (85% by 7 days of life), present

for several days or weeks, no discomfort during reflux, no diarrhea, hungry, looks well, acts happy.

▪ Infant stomach is an untied water balloon

▪ Vomiting: uncomfortable during spitting up, new

symptom starting today or yesterday, associated

diarrhea, projectile or forceful spitting up, spit-up contains bile, or baby looks or acts sick.

▪ Volume: Vomiting is usually large volume of stomach

contents, usually forceful and the baby is uncomfortable. Spitting up (reflux) usually involves smaller amounts.

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Slanting position with nursing

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Allergic colitis and the elimination diets

▪ Fussiness and spitting up

▪ Visible blood or mucus in stool

▪ Recommendation to avoid dairy/soy in mother’s diet

▪ Ask about family history of allergies

▪ cbc, albumin, stool hemoccult

▪ Elimination diets are difficult

Rowe J et al J Allergy Clin Immunol 2007 119:1164

Greer FR et al Pediatrics 2008 121:18348

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Case of Mom Pumping 70 ounces (!!!?)

Mom presents with infant for milk supply issues, pumps 5x a day gets 12 ounces+ at times

• Infant started refusing breast because of forceful flow

• Mom was also encouraged to ‘pump and dump’ while was on antibiotics for mastitis

• Very uncomfortable and wants to get baby to breast

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Overactive Let-down

▪ Laid-back Nursing: Try to feed baby leaning back

▪ Take a Break: Mother should interrupt

feeding and let baby recover, waiting until the spray of milk stops.

▪ Occasionally told to pump off the foremilk (5

min)

▪ Try Offering Only One Breast Per Feed

▪ Avoid Pumping to Stockpile

▪ Difficult to convince mother to cut her supply50

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Pacifiers: A place in BF Management

Pacifier use in healthy term breastfeeding infants, started from birth or after lactation is established

• No significant effect on the prevalence or duration of exclusive and partial breastfeeding up to four months

• Evidence to assess the short-term breastfeeding difficulties faced by mothers and long-term effect of pacifiers on infants' health is lacking.

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Cochrane Systematic Review Jaafar

SH 2011, 2016

Recovering from ‘Lactastrophe’

▪ 33 day old with slow weight gain

▪ Born at 37 weeks

▪ Sleepy at breast

▪ Early jaundice so received supplementation via bottle with breastmilk

▪ Reflux symptoms

▪ Not getting better so started on dairy elimination diet

▪ Maternal stress, in tears in your office

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Social-emotional Factors

▪ Elevated pregnancy-related depression screen at first visit

▪ MOC delivered a still born baby girl one year prior

▪ MOC participated in support group for infant loss and individual therapy prior to delivery

▪ Family-level stress (mild marital discord and extended family stress)

▪ MOC experiencing significant guilt

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What We Do: The Trifecta Model

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Baby

Breastfeeding Dyad2. Psychosocial assessment and

support:• Evaluate family adjustment • Assess pregnancy-related

depression/Administer EPDS

• Acknowledge and support partner’s involvement in feeding routines

• Discuss sibling adjustment• Self-care:

• “Baby out of the building”• Enjoyable activities• Help with childcare

Family

Community

Intervention

Intervention

1. Comprehensive functional breastfeeding assessment and intervention:

• Physical exam• Medical history• Psychosocial history • Pre-post feeding weights • Assess latch• Evaluate milk transfer• Observe infant regulation • Post hospitalization feeding

plan• Evaluate baby growth and

milk supply

3. Follow-up recommendations, future planning, and referrals:• Communication with

medical home• Discuss return to work• Pumping• Childcare• Planning feeding and

sleep routines• Community referrals if

needed:• Fussy Baby

Network• Mental health

referral• Occupational

therapy

Lactation Consultant + Pediatrician + Psychologist

Dunn, 2012Bunik J Hum Lact 2016

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Maybe marijuana is safe because the baby seems unaffected at birth.

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I do not want to take any chemicals for my bipolar and marijuana which is a natural substance has helped me. Is there a problem if I do it once a day and breastfeed?

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Prenatal Counseling regarding MJ

• 4% report using MJ in past month (Ko 2015)

• WIC 30% use in pregnancy for nausea and mood stabilizing

• Assist mothers with abstinence approach like with tobacco and alcohol

• Maybe a mixed approach by providers due to personal feelings about this drug

• Self report of drug use is unreliable (Beatty 2012)

• Cannot define who is a chronic vs “recreational” user by toxicology screens

• Can be laced with harmful substances (Gilbert 2014)

Specific Aims for CDPHE Pilot Study

• Determine length of time THC is detected in breast milk of mothers who have a positive urine toxicology screen at the time of birth

• Inform recommendations on when to safely return to breastfeeding.

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Median Milk THC and Plasma THC-COOH by Week

Milk THC Milk THC

Plasma THC-COOH Plasma THC-COOH

Reported Use Reported Abstention

Con

ce

ntr

ation

(n

g/m

l)

Con

ce

ntr

ation

(n

g/m

l)

Week Week

LLQLLQ

Pharmacokinetic Modeling

Estimated Time to Elimination > 6 weeks

Wymore PAS 2018

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We are only starting to put together the picture

Pharmacokinetic Modeling

Estimated Time to Elimination of THC in

Breast Milk

< 3% Probability of +Utox

Baker T and Hale Obstet Gyn 2018

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Mastitis comes with fever, pain and redness of the breast.

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Mastitis is not always like this!

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Mastitis Can Be Subtle

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Conclusions• Awareness that breastfeeding often gets

the blame

• Multiple causes, complicated detective work and emotional support for ‘lactastrophe’ cases

• Use of growth charts and test weights as a guide

• Maternal mental health screening and support, make your own ‘Trifecta’

• Maintaining exclusivity of breastfeeding is important in the process of care advice and evaluation

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THANK YOU. Questions?

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“I've learned that people will forget what you said, people will forget what

you did, but people will never forget how you made them feel.” Maya Angelou