8: Lactation, Breastfeeding, and the Postpartum Period

CHAPTER 8 Lactation, Breastfeeding, and the Postpartum Period


Breastfeeding is the optimal form of nourishment for a newborn baby. A policy statement by the American Academy of Pediatrics recommends exclusive breastfeeding as the ideal nutrition for the first 6 months of life, followed by introduction of iron-enriched solid foods during the second half of the first year. The group also encourages breastfeeding for at least 12 months and longer if desired by both mother and baby.1


Although the benefits of breastfeeding may be self-evident, they are also increasingly demonstrated by science. Researchers have documented numerous benefits associated with breastfeeding, including the superior nutritional composition of breast milk,2 positive immunologic effects,3 and reduced incidence of feeding intolerance and necrotizing enterocolitis in preterm infants,4 as well as significant psychological benefit for both mother and infant.


Healthy People 2010 reaffirms the U.S. Surgeon General’s goals to increase the use of breastfeeding in the United States to 75% of infants at the time of hospital discharge and to increase the use of breastfeeding at the age of 6 months to 50%.5



DURING PREGNANCY


The decision to breastfeed is almost always made while a woman is pregnant; most women have made their choice by the time they are in the last trimester of pregnancy.6 Many factors influence the mother’s decision, including her attitude toward and knowledge of breastfeeding, demographic specifics, support from the baby’s father, and the attitude of the woman’s health care provider.7 It is extremely important that a woman receive enough information during prenatal visits for her to make a truly informed decision about whether to breastfeed her baby.


A woman should undergo a careful and thorough breast examination to help determine her ability to provide milk to her newborn. During pregnancy, the weight of a woman’s breast normally doubles. Women who fail to note an increase in breast size during pregnancy are more likely to have difficulty with lactation.8 Women with inverted nipples may also experience difficulty with lactation because it is harder for the infant to latch onto the breast. Milk cups, also known as breast shells, may be used during the last months of pregnancy to apply steady pressure around the base of the nipple in hope of causing it to project forward. Although these devices are widely recommended, studies have shown that they do not increase the likelihood of a woman’s ability to nurse for longer than 6 weeks after birth.9


Previous breast surgery can affect a woman’s ability to nurse. If surgery involved cutting tissue surrounding the areola, the incision may have severed the milk ducts or nerve supply necessary for lactation. Breast reduction or enlargement may also negatively affect a woman’s ability to breastfeed.10 Tubular breasts, severe differences in breast size, and a history of breast irradiation have also been linked to poor lactation.8 For all these reasons, a woman should have her breasts carefully examined during pregnancy.



BIRTH


The United Nations Children’s Fund, along with the World Health Organization, inaugurated the Baby-Friendly Hospital Initiative worldwide in 1991. Baby-Friendly USA was created in 1997 to carry out this campaign in the United States. This program centers on 10 Steps to Healthy Breastfeeding that are to be followed by hospitals and clinics where maternity services are offered (Box 8-1).11



Box 8-1 Steps to healthy breastfeeding



image Have a written breastfeeding policy that is routinely communicated to all health care staff.

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

image Inform all pregnant women about the benefits and management of breastfeeding.

image Help mothers start breastfeeding within 1 hour of delivery.

image Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.

image Give newborn infants no food or drink other than breast milk unless medically indicated.

image Practice rooming-in, allowing mothers and infants to remain together 24 hours a day.

image Encourage breastfeeding on demand.

image Give no artificial teats or pacifiers to breastfeeding infants.

image Foster the establishment of breastfeeding support groups and refer mothers to them at the time of hospital discharge.

Adapted from Kyenka-Isabrrye M: UNICEF launches the Baby-Friendly Hospital Initiative, Am J Matern Child Nursing 17:177-179, 1992.


Although these initiatives represent important steps in the right direction, at the end of 1998 only 17 hospitals and birth centers in the United States had been designated “baby-friendly.” A woman should be encouraged to visit the facility where she will give birth and inquire about the breastfeeding policies of the institution.



BREASTFEEDING



Positioning the Baby


A variety of techniques can be used to enhance the breastfeeding experience. Correct positioning reduces the risk of physical discomfort to the mother and enhances the transfer of milk to the baby.


The cradle position is used most often by nursing mothers (Figure 8-1). The mother sits in a comfortable chair and places a pillow on her lap to lift the baby to the height of her breast. The baby is supported by the mother’s arm that is closest to the nursing breast. The baby’s body is turned to face the breast, with the head, shoulders, and hips in proper alignment. While the baby is learning to suckle, the mother uses her other hand to support the breast, with the thumb on top and four fingers underneath, well behind the areola so as not to interfere with the baby’s feeding.


image

Figure 8-1 The mother in this photo is demonstrating the cradle position while breastfeeding.


(From Murray SM, McKinney ES, Gorrie TM: Foundation of maternal-newborn nursing, ed 3, Philadelphia, 2001, WB Saunders.)


When ready, the mother lightly touches her nipple to the baby’s lips to stimulate suckling. The baby should take the entire nipple and at least half an inch of the surrounding areola and breast into the mouth. This is necessary to ensure adequate milk intake because the baby must compress the large storage reservoirs beneath the areola to effectively drain them. Also, nipple tenderness will be diminished if the baby takes an ample amount of breast tissue into the mouth while suckling.


Other positions include the cross-cradle, reclining, and football holds. The last two options work well for women who have had cesarean deliveries. The breastfeeding mother should feel comfortable with at least two positions to ensure a successful nursing experience once she has been discharged from the birth facility.



Feeding Schedules


Knowing how often to nurse a newborn is not as easy as one might assume. A newborn commonly nurses 8 to 12 times a day for 10 to 15 minutes per breast, although this varies from baby to baby.1 A woman may interpret frequent nursing as a sign that her milk supply is insufficient. During the first few weeks of a baby’s life, the interval between nursing sessions may be just an hour. The health care provider should explain that this is normal as long as the baby has frequent wet diapers (six to eight per day by day 5) and is gaining weight. Frequent feeding is important to prevent weight loss, increase breast-milk production, and reduce the risk of jaundice. A newborn should not go longer than 5 hours between feedings. Older babies can wait for longer periods between feedings as they learn to suckle more efficiently.


During the first few days of life, the baby will be taking in colostrum from the breast. This yellowish fluid is filled with antibodies, vitamin A, minerals, and other beneficial substances. Colostrum is sufficient nutrition for the newborn, and supplementation is not necessary. The milk supply usually arrives 3 to 5 days after birth. The more the baby suckles, the more milk is produced. When the baby nurses, the pituitary gland is stimulated to release the hormone prolactin, which signals the milk glands to discharge milk. The pituitary gland also releases the hormone oxytocin, which stimulates the “letdown” reflex that forces milk through the breast. Many women feel a tingling sensation when this letdown occurs, and milk leakage is common if the baby is not at the breast.


Crying is a late sign of hunger, so parents should be alert to earlier hunger cues: The baby may suck on fingers, flex arms or legs, make mouthing movements, or turn the head from side to side. A baby normally nurses from both breasts during a feeding. The first breast is usually nursed more vigorously than the second, so the starting breast should be alternated from one feeding to the next. Nursing from just one breast increases the risk of engorgement in the breast that is not emptied. Use of a bottle should be avoided until breastfeeding is well established; suckling the breast is more difficult for the infant than sucking a bottle nipple, and a bottle preference may develop.



Adequate Milk Production


Inadequate milk production is the No. 1 reason nursing is discontinued and other foods and liquids are added to the infant’s diet before 4 months of age.12 In a small percentage of women, milk production is inadequate, and the baby experiences weight loss or poor weight gain as a result. Seeking out a lactation consultant who is generally well trained in nursing difficulties and who will spend time with the mother and baby is often beneficial.


Health care providers should be alert to slow weight gain and development and should thoroughly review the clinical picture. The mother’s breasts should be examined, her medications, alcohol, and cigarette consumption reviewed, and, if necessary, her thyroid and pituitary hormones checked; a discussion of stress should be undertaken as well. An observation of nursing technique should be conducted. The baby should be checked for gastroesophageal reflux, neurologic disorders, a short frenulum, urinary tract infection, congenital heart disease, and allergies, depending on the clinical picture.


Despite adequate weight gain and development, many women believe that they are not producing enough milk to satisfy their babies. This may be more a result of infant growth spurt than of poor milk supply. Infant growth spurts occur in normal, healthy infants with appropriate weight gain. These spurts normally occur during the first 12 to 16 weeks of life and are characterized by a fussy baby who feeds constantly but pulls away from the breast while nursing and is irritable before and after being fed. This irritability is more likely the result of the discomfort of rapid growth than of a feeling of hunger.13 After the growth spurt, which usually lasts 3 to 7 days, the baby again becomes content with 8 to 12 feedings per 24 hours. During the growth spurt the mother should make sure that the baby is positioned correctly during breastfeeding and is fed on demand. Both baby and mother need plenty of extra rest.



Infant Weight Gain


Because a nursing mother cannot measure the amount of milk her newborn is ingesting, the most accurate assessment of breastfeeding volume is the baby’s weight. Loss of as much as 10% from birth weight is considered acceptable. The breastfed baby should regain the birth weight by 10 to 14 days of age. Weight gain of 1 oz per day for the first 2 months of life is normal. An inadequate supply of breast milk should be suspected if a baby does not gain 5 to 7 oz per week during the first 2 months of life. A knowledgeable professional should examine the baby by 4 or 5 days of age. Early intervention can help ensure adequate transfer of breast milk to the baby, proper positioning, and early detection of any serious health problems that might exist. A wait-and-see approach often spells failure for the nursing mother. Incremental weight gain normally declines between the third and twelfth months of life.



Stool and Voiding Patterns


A newborn baby should pass a black-green (meconium) stool during the first day of life. The baby may pass several of these stools before the mother’s milk arrives, usually by day 5. The stools then change from black-green to yellow and take on the consistency of yogurt with seedy curds. Babies should have four or more yellow stools per day during the first 2 months of life. Fewer stools should raise the suspicion of an inadequate milk supply.14 Once a baby reaches the age of 2 to 3 months, stool frequency varies greatly. Some babies continue to pass stools several times a day, whereas others go several days or up to a week before passing a large, loose stool. Newborns should pass stools more frequently: A 2-week-old who only passes stools once every 3 or 4 days should be carefully examined. A newborn may only urinate one or two times in a 24-hour period during the first 2 or 3 days of life. Once the mother’s milk arrives, the infant should have six to eight wet diapers per day, soiled with light-yellow or colorless urine. The presence of reddish urate crystals in the diaper is normal during the first of days of life, but this phenomenon signifies inadequate milk intake in an older infant.14



Jaundice in the Breastfed Newborn


Jaundice is a yellowing of the skin and whites of the eyes caused by the buildup of a metabolic product called bilirubin. Jaundice may be the result of breast milk itself or of inadequate milk intake. Breast milk jaundice usually begins around 7 days of age and can last for several weeks, even as a baby is thriving and gaining weight and appears healthy. It is believed that a substance in human breast milk increases the absorption of bilirubin across the intestinal wall. This excessive unconjugated bilirubin causes the yellow discoloration of the skin and eyes. As long as the baby is gaining weight and appears healthy, there is no reason to discontinue nursing or to supplement breast milk with other liquids.


Sometimes, however, the diagnosis of breast milk jaundice is made in a baby who is not getting enough milk. A recommendation of more frequent nursing will not help if the baby is not able to efficiently remove milk from the breast. One way to determine whether the baby is not getting enough milk is to weigh the baby before and after nursing on a scale that is accurate to within 2 g. The prenursing weight is subtracted from the postnursing weight to yield the amount, in milliliters, of breast milk the baby has taken in during the feeding (breast milk weighs approximately 1 g/mL). If the baby is not taking in enough milk, the mother should use a good electric pump to express her remaining milk. This supply can be fed to the baby until he or she learns to nurse more effectively.



BREASTFEEDING PROBLEMS AND SOLUTIONS



Nipple Pain and Superinfection


Nipple pain is a common problem in breastfeeding mothers. During the first few days of nursing, the nipple can become sore due to the baby’s suckling. This soreness usually improves by the end of the first week. Nipples that remain sore or become cracked should be evaluated and treated. Abnormal sucking, improper nursing technique, or both must be corrected as early as possible. The baby is nursed first on the least sore breast and then placed on the other breast when he or she is sucking less vigorously. The mother should be encouraged to nurse more frequently but for shorter periods. If nursing is simply too painful, she can use a pump to express her milk until the nipples have healed.


It is common for health professionals to recommend the use of a nipple ointment to help soothe sore or cracked nipples. While these creams may help soothe and heal cracked nipples, little evidence exists to support the benefit of such ointments and creams to prevent sore nipples. The authors of one randomized study found no difference between nursing mothers who used a nipple ointment (n = 123) and those who did not (n = 96) with regard to the incidence of sore and cracked nipples and duration of breastfeeding.15 Interestingly, it was noted that the incidence of sore nipples was increased when babies were given pacifiers and bottle-fed before hospital discharge.


The best prevention involves teaching new mothers proper breastfeeding techniques. Breast shells and application of lanolin in association with instruction in breastfeeding technique have been found more effective than moist wound dressings in treating cracked nipples.16 Breast shells protect the nipple from contact with clothing, which can further irritate the skin.



Green tea (Camellia sinensis).


Tea is an established natural remedy for sore or cracked nipples. It was found in one study that teabags applied four times daily were as effective as water compresses and superior to no treatment in women with sore nipples 36 hours after delivery.17 One advantage of tea over a simple water compress involves the prevention of infection. The antimicrobial activity of water extracts of C. sinensis has been long known and was first documented in a Western medical journal more than 90 years ago.18 The antimicrobial effects are direct (bacteriostatic and bactericidal) and indirect (by way of inhibition of certain bacterial enzymes).19 Tea is bactericidal to Staphyloccus aureus at concentrations lower than those found in a typical cup of tea.20 Topical preparations containing tea were shown to be as effective as oral antibiotics (cephalexin) for S. aureus infection of the skin in one randomized clinical trial.21 This finding is consistent with previous work demonstrating antimicrobial effects of C. sinensis, including preliminary data suggesting that compounds within the herb have some effect against methicillin-resistant S. aureus.22 It is likely that many compounds within tea are active, but the principal ones are thought to be catechins. Teabags are readily available in many households, so this is an inexpensive and easy-to-use treatment.




TEAS


Tea, a familiar drink, is a substance we may not consider an herb, let alone an herbal remedy. It has been used medicinally as a “tonic” (stimulant and digestive remedy) in many parts of Asia for 5,000 years.


Tea remains popular throughout the world and is still the most frequently consumed beverage after water. The word tea, although commonly used to describe the infusion that results when the dried leaves and leaf buds of the shrub Camellia sinensis are steeped in boiling water for 5 to 15 minutes, is also used as a generic term to describe any infusion made from other plants (e.g., herbal teas, red tea). Green tea is one of the three main types of tea prepared from C. sinensis.


Around the world, approximately 2.5 million tons of tea are manufactured annually. Black tea, which accounts for nearly 80% of production, is prepared by drying and then fermenting the leaves. This is the type of tea most widely drunk in Europe, India, and North America. Oolong, a specialty tea that is only partly fermented, accounts for just 2% of production and is drunk mostly in southeastern China and Japan.


Green tea accounts for nearly 20% of production and is consumed mainly in China and Japan. The leaves are steamed or pan-fried, then dried without fermentation. By dry weight, approximately 36% of green-tea leaves is polyphenols—principally flavonols (mostly catechins), flavonoids, and flavondiols. About 4% is plant alkaloids, including caffeine, theobromine, and theophylline. Other constituents include proteins, carbohydrates, phenolic acids, minerals (including fluoride and aluminum), and fiber. The precise composition of green tea (and all teas) varies with the geographic origin of the leaf, the time of harvest, and the manufacturing process. The constituents of black tea differ from those of green tea as a result of the oxidation process that occurs during fermentation; however, both are considered healthy additions to the diet.


When green tea is taken for medicinal purposes, 1 or 2 tsp of the dried herb are steeped in a cup of boiling water for about 15 minutes. While many prefer to drink their green tea “straight,” recent research shows that the addition of milk does not alter its medicinal properties.


The medicinal use of green tea has not been reported to carry adverse side effects. A cup of black or green tea contains 10 to 80 mg of caffeine, depending on the type of tea and the method of preparation. Excessive caffeine consumption may cause nervousness, insomnia, and irregularities in heart rate. Herbal handbooks advise pregnant women, nursing mothers, and patients with cardiac problems to limit their intake of tea.22a This is likely due to the presence of caffeine.


The consumption of teas (infusions) made from the African red bush (Aspalathus linearis) has long been a popular pastime in South Africa. The Afrikaans name for red bush, rooibos, is becoming increasingly familiar to consumers in the United States. Many tea drinkers have embraced red tea because it is caffeine-free and lower in tannins than black or green tea but carries similar health benefits.


Data on rooibos are accumulating. It has been demonstrated that rooibos is rich in many of the ingredients of interest in the area of cancer prevention among the natural constituents of plants that protect the body against oxidants.22b Many scientists believe it is important that antioxidants come from rich mixtures of biologically active compounds in plants rather than from isolated synthetic antioxidants: Studies of the isolated synthetic antioxidant β-carotene did not show this substance to be protective against cancer. The results of studies of mixtures of herbal constituents, as found in teas, appear promising, however.


Red tea contains significant levels of antioxidants, which may explain its apparent health-promoting properties. Polyphenol antioxidants such as flavonoids are present in similar amounts in red and green tea. The antioxidant effect of green tea is thought to be conferred in part by these phenolic components.


Studies comparing rooibos with other teas have revealed that rooibos contains levels of known antioxidants similar to those of green tea. However, rooibos appears to contain active antioxidant components that are not present in green and other teas, such as additional polyphenols, including certain flavonols and flavones. These antioxidants may account for the association of teas with anticancer and other beneficial effects. These effects are seen over long periods of tea consumption. Botanically, as a legume, rooibos contains other plant chemicals that may help account for its observed short-term effects in calming the nervous and gastrointestinal systems.


The method of preparation of rooibos can influence its activity; the water-soluble component of rooibos also appears to be therapeutically active. Because rooibos contains no caffeine, unlike green and other teas, larger amounts of rooibos can be consumed without side effects. Red tea is more appropriate for children and others who must limit their caffeine intake. Studies of red tea indicate that consumption of this beverage is an effective way of obtaining the benefits of many of the plant chemicals that appear to help protect against cancer.



Calendula (Calendula officinalis).


Herbalists often recommend calendula ointment to encourage healing and retain moisture in chafed nipples. Animal studies have shown that ointment containing 5% calendula extract speeds the healing of wounds.23 The ointment has mild antibacterial properties that may help prevent infection of the nipple. Many calendula-based creams and ointments are available commercially, including those sold as 10% homeopathic dilutions. Although no case reports of adverse effects from the topical use of calendula have been published, the use of some nipple creams, especially papaya cream, has been associated with an increased risk of mastitis.24



Nipple Infection


If nipple pain is severe or does not respond to the aforementioned remedies, bacterial or yeast infection should be suspected. One study demonstrated that women with babies younger than 1 month of age who complained of moderate to severe nipple pain and presented with deep cracks or discharge had a 64% chance of having an infection, most caused by S. aureus.25 A randomized trial of women with S. aureus–infected nipples found that after 5 to 7 days of treatment, only 8% of the women showed improvement with “optimal breastfeeding treatment alone,” 16% experienced improvement with the use of topical mupirocin, 29% improved with topical fusidic acid, and 79% showed improvement with oral antibiotics (P < 0.0001). Mastitis developed in 12% to 35% of mothers who were not treated with systemic antibiotics, compared with 5% of mothers treated with systemic antibiotics (P < 0.005).26


Bottom line: preventing infection is key! Topical antimicrobials may be used but if infection does not rapidly clear, the use of oral antibiotics may be necessary.



Candida albicans and thrush.


A woman with infection of the nipple caused by the yeast C. albicans characteristically presents with breast pain before and after nursing that is described as deep, burning, shooting, or stabbing. A statistically significant correlation (P < 0.05) was found between nipple candidiasis and three factors: vaginal candidiasis (P = 0.001), previous antibiotic use (P = 0.036), and nipple trauma (P = 0.001).27 Medical therapies have not been thoroughly evaluated, but standard antifungal therapies such as nystatin are commonly used to treat thrush.



Tea tree oil (Melaleuca alternifolia).


Tea tree essential oil is the most popular herbal preparation used for the treatment of yeast and fungal infections. In one study 25 subjects with acquired immunodeficiency syndrome and fungal infections of the mouth and throat who had failed to respond to therapy with fluconazole (400 mg/day for at least 14 days) were randomly assigned to receive an alcohol-free mouthwash containing tea tree oil (Breath-Away [Melaleuca]; Idaho Falls, Idaho). Participants were instructed to swish a small amount of the preparation around the mouth for 30 to 60 seconds, then expel it. They were told not to rinse their mouths for at least 30 minutes afterward and repeat four times a day. Fifteen of 25 subjects (60%) demonstrated a response to the mouthwash after 4 weeks: 28% were cured, and 32% had fewer signs and symptoms of infection. However, the authors noted that the response at the end of 2 weeks was not impressive and that for best results, tea tree oil must be used for at least 4 weeks.28


Among infants with candidiasis or thrush, a healthy baby with an intact immune system would likely respond more quickly to tea tree oil therapy than a sicker infant. Also, a baby would be unable to spit the rinse out, and safe doses for very young babies are not known. Several case reports describe ataxia and drowsiness in young children who have consumed 10 mL or less of the essential oil of tea tree. Although this amount is obviously greater than that which would be found in a diluted mouthwash, the oral application of tea tree oil in infants with thrush is probably best avoided until more information about efficacy, safety, dosage, and most appropriate form of administration becomes available. If a mother chooses to apply tea tree oil to the nipple area after nursing, she should wash the breast before nursing again.



Grapefruit seed extract.


Grapefruit seed extract, which is used to treat a variety of bacterial and fungal infections, is growing in popularity as a treatment for thrush. It is also recommended as a wash for pacifiers and toys to prevent reinfection. Several sources recommend mixing four or five drops of grapefruit seed extract in 1 cup of water, then applying it with the finger into the child’s mouth four to six times a day. The antimicrobial activity and purity of commercial grapefruit seed extract have been subjects of controversy. The authors of one in vitro study noted both bactericidal activity and toxicity of grapefruit seed extract at a dilution of 1:128. The same extract lacked toxicity but was reported to retain bactericidal activity at a dilution of 1:512. The researchers stated that the antibacterial effects resulted from disruption of the bacterial membrane, resulting in cell lysis, after direct contact with the extract.29


However, a study of six commercial grapefruit seed extracts found that five contained benzethonium chloride, a synthetic antimicrobial often used in cosmetics and other topical preparations, as well as the preservatives triclosan and methylparaben.30 The one extract that contained none of these additives was devoid of antimicrobial activity. This information is consistent with the findings of other researchers, who have found benzethonium chloride31 and triclosan32 in samples of liquid and powdered grapefruit seed extract. In summary, it is unclear whether grapefruit seed extract has antimicrobial activity (antifungal activity has not been documented) and that considerable adulteration of this “natural” product with synthetic antimicrobial/preservative agents seems to be widespread. Toxicity at even lower dilutions has been suggested. For all of these reasons, practitioners should avoid recommending this extract for the treatment of oral thrush in the infant or nipple thrush in the mother.



Myrrh (Commiphora molmol).


Limited data suggest that tincture of myrrh is efficacious in the treatment of oral candidiasis. German health authorities have approved the use of myrrh for inflammations of the oral and pharyngeal mucosa. Local antiseptic activity is well documented,33 and myrrh can be found in toothpaste and mouthwash products throughout the United States. One German pediatric textbook recommends that a diluted tincture of myrrh (1:1) be applied with a cotton swab to areas of thrush.34 A dilution of 1:2 or 1:3 is generally recommended because myrrh tinctures are generally prepared with 80% to 90% alcohol to appropriately extract the gum resin. Although only very small amounts of the tincture are used in the mouth, the alcohol may irritate the tissue if the tincture is used undiluted. Myrrh appears to be quite safe when used in this fashion; oral doses of up to 3 g/kg have been shown to cause no significant harm. Likewise, long-term administration of 100 mg/kg per day was not associated with side effects.35

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. 5: Endometriosis
  2. 6: Menopause
  3. 18: Urinary Tract Infection
  4. 17: Cervical Dysplasia and Cancer

Stay updated, free articles. Join our Telegram channel
Tags:
Nov 4, 2016 | Posted by in OBSTETRICS | Comments Off on 8: Lactation, Breastfeeding, and the Postpartum Period

Full access? Get Clinical Tree
Get Clinical Tree app for offline access