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Breast Is Best!

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Breast Is Best! Stephanie Calkins, MD MDFPR March 24, 2008 Breast Is Best Why Breastfeed? Lactation Anatomy and Physiology What the Provider Needs to Know Problem ... – PowerPoint PPT presentation

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Title: Breast Is Best!


1
Breast Is Best!
  • Stephanie Calkins, MD
  • MDFPR
  • March 24, 2008

2
Breast Is Best
  • Why Breastfeed?
  • Lactation Anatomy and Physiology
  • What the Provider Needs to Know
  • Problem Solving in the Lactating Patient

3
Why Breastfeed?
  • Advantages for the newborn
  • Advantages for the mother
  • Advantages to society and family

4
Advantages for the Newborn
  • Natural
  • Babys body systems developed to expect
  • Intelligence and cognitive development
  • Enhanced neurodevelopmental performance
  • Effectiveness of vaccines
  • Normal development of jaw and facial muscles

5
Lower Incidence
  • Allergies and asthma
  • Bacteremia, meningitis
  • Botulism
  • Lymphoma 30
  • Constipation
  • Diabetes
  • GI infections 45
  • Eczema
  • IBD
  • Iron deficiency anemia
  • Respiratory infections 66
  • Nectrotizing enterocolitis
  • OM 50
  • SIDS
  • UTI

6
Advantages for the Mother
  • Convenience
  • Cost savings
  • Breastfeeding breaks calming effect
  • Emotional, Bonding
  • Decreased breast CA, uterine CA, ovarian CA,
    osteoporosis
  • Weight Loss (500 cal/day)
  • Lower postpartum anemia
  • Aid in child spacing

7
Advantages to society and family
  • Economic savings Formula 1,500 for first year
  • Savings in environmental burden
  • Reduced employee absenteeism for child illnesses
  • Reduced health care costs from fewer
    physician/hospital visits
  • 3.6 billion saving for annual U.S. health care

8
Anatomy
Alveolus Production unit of lactocytes
transporting nutrients from maternal blood
Terminal duct lobular units Branching ductules
and alveolar clusters
15-25 lactiferous ducts openings at nipple
Ducts Lines by myoepithelial cells that contract
with oxytocin induced let-down
Subareolar Sinuses
9
Anatomy
  • Areola
  • Hair, sebaceous,sweat glands
  • Montgomery tubercles
  • ductular opening of lactiferous ducts and
    sebaceous glands
  • secretes lubricants/scent protecting
    areola/nipple
  • Dark color ?visual signal
  • Nipple
  • 15-25 ducts
  • dermis rich w/ sensory nerve endings
  • radial/longitudinally placed smooth muscle fibers

10
Mammogenesis in Pregnancy
  • Pregnancy
  • 1st Trimester
  • Progesterone, placental lactogen, and prolactin
    increase ductal sprouting,branching lobular
    formation.
  • 2nd Trimester
  • Placental lactogen stimulate colostrum secretion
    _at_ 16 wks
  • Estradiol-17B stimulate ductal elongation,
    potentiates prolactin
  • 3rd Trimester
  • Alveolar distension w/ early colostrum with
    differentiation into secreting alveoli
  • Decreasing adipose and increasing breast
    parenchyma.

11
Lactation
  • Establishment and Maintenance of Mature milk
    requires intact Hypothalamic-pituitary axis
    regulating Prolactin and oxytocin.
  • Prolactin milk synth/secretion
  • Milk always synthesized
  • concentration not directly related to milk volume
  • Oxytocin Let-down reflex

12
Prolactin
  • Continuous secretion with surges 7-20 times daily
  • Results in continuous milk production with surges
  • Related directly to nipple stimulus
  • to intensity of nipple stimulation (i.e. twins)
  • Prolactin surge within 40 minutes of stimulus
  • Circadian surges
  • Milk volume ENTIRELY regulated by infant demand
  • A stretched alveolar cell released prolactin
    INHIBITING factor

13
Prolactin Surges
14
Prolactin Stimulators
  • Breast stimulate/nursing
  • Sleep,circadian rhythm
  • pregnancy
  • intercourse
  • neuroleptic drugs
  • histamine
  • Acetacholine
  • Fenugreek
  • TRH/TSH Norepi/Serotonin
  • Metoclopramide, domperidone
  • estrogens during mammogenesis only
  • hypoglycemia
  • phenothiazines,butyrophenones, reserpine
  • via inhibit catecholamines thereby inhib PIF

15
Prolactin suppressors
  • L-Dopa
  • Ergot
  • _at_ hypothalamus
  • clomiphene citrate
  • pyridoxine
  • MOAIs
  • Prostaglandin E F2 alpha
  • Estrogens
  • antag via inhib milk secretion

16
Oxytocin
  • Contraction of myoepithelial cells around the
    alveoli, expelling milk into ducts and subareolar
    sinuses
  • Neuroendocrine reflex
  • Sensory stimulation to CNS promotes oxytocin
    release from post. Pituitary
  • Stimulates maternal behavior
  • ?oxytocin improves bonding
  • Accompanied decreased pulses in ACTH and cortisol
    (decresses maternal stress)
  • ?oxytocin decreases PP depression
  • Uterine contractions

17
Oxytocin Inhibitors
  • Sensory pathways
  • Stress pain, cold, hypovolemia,exercise
  • Opioids
  • Alcohol
  • dose related effect on CNS
  • No inhib up to 0.45g/kg (BAL 0.1)

18
Got Milk?
19
Colostrum small amount, but close to stomach
capacity
  • Antibodies!!!
  • Immune-competent white cells
  • Ployunsaturated fatty acids
  • Vitamin K
  • Very high protein
  • Natural laxative

20
Milk Composition
  • 88 water
  • 4.5 fat
  • Makes up ½ calories in breastmilk
  • Cholesterol is optimal for brain development
  • Macronutrients
  • Lactose (principal sugar)
  • Milk fat (triglycerides)
  • Proteins cystine, taurine (brain development),
    casein
  • LOW casein versus cow milk
  • 100 amino acids, vitamins, minerals
  • Iron supplement at 4-6 months age
  • Consider vitamin D (MVI)

21
Milk Comparison
22
Protective Factors
  • Antibodies (secretory IgA)
  • Glycoconjugates (glycoproteins, glycolipids,
    glycosaminoglycans, oligosaccharides)
  • Protect against several bacteria, esp GI bugs
  • Lipids (monoglycerides and unsaturated fatty
    acids)
  • Enveloped viruses
  • Intestinal microflora
  • Probiotics

23
Anti-Inflammatory Factors
  • Antioxidants
  • Lactoferrin
  • Catalase
  • Prostaglandins
  • Histaminase
  • Aryl Sulfates
  • Tumor Necrosis Factor alpha
  • IL-1 receptor antagonist
  • IL-10

24
More About Breastmilk
  • Foremilk
  • 1/3 of the feeding
  • Starts high fat, ends up low fat
  • Hindmilk
  • Higher in fat
  • Volume milk produced
  • At 6 months 800 mL/d
  • Wet nurses 3.5 L/d

25
What The Provider Needs to Know
  • Prenatal
  • Birth
  • Hospital Discharge
  • First 2 Weeks
  • Well Child Checks

26
Prenatal
  • Discuss at first appointment!
  • Breast changes in pregnancy
  • Evaluate for problems of nipple and breast
  • Colostrum
  • Breastfeeding class
  • The working mom

27
Potential Contraindications
  • HIV, human T-cell leukemia, HSV lesions
  • Maternal drug abuse
  • Medications antineoplastic, anticonvulsants,
    ergot alkaloids, amiodarone, lithium
  • Galactosemia (Absolute)

28
Birth
  • Include breastfeeding in birth plan
  • Immediate/early skin contact
  • Position and correct latch on in first hour

29
Hospital Discharge
  • Encourage patient to commit to 2 weeks
  • Supply and demand production
  • Adequate intake
  • Engorgement and sore nipples
  • Contraception wait 6 weeks until hormones
  • Lactation consult?

30
First 2 Weeks
  • Correct latch on and feeding
  • Begin weight regain 4-5 days
  • Exceed birth weight 10-14 days
  • Avoid other nipples
  • Jaundice
  • Breastfeeding support group
  • Lactation consult?

31
Well Child Checks
  • Breastfeeding success in first 6 weeks strongest
    indicator for long term success
  • Ask every time!
  • Growth spurts
  • What about solids?
  • What about other nipples?
  • How long?

32
Signs of Adequate Breastfeeding
  • 8-12 feedings/day, on demand
  • Mouth wide open before latch on
  • Latch entire nipple, most of areola
  • Tongue under nipple
  • Audible/visible swallowing
  • Movement of TMJ
  • 6-8 wet diapers per day
  • Adequate weight gain

33
Problem Solving
  • Incorrect latch on
  • Sore nipples
  • Engorgement
  • Blocked ducts
  • Mastitis
  • Thrush
  • Going back to work
  • My babys hungry all the time

34
Dr. Newmans All-Purpose Nipple Ointment
  • Mupirocin 2 ointment (15 g)
  • Nystatin Ointment 100,000u/ml (15 g)
  • Betamethasone 0.1 ointment (15 g)

35
Other Nipple Treatments
  • Candidiasis
  • Gentian Violet qd 3 days to nipple
  • Fluconazole 100 mg qd x 10 days
  • Topical
  • Hydrocortisone 1
  • Polysporin ointment
  • Miconazole cream

36
Poor Weight Gain case
  • Birthweight 8/1
  • 9/2 3957 g, 811.3
  • 9/7 4042 g, 814.3
  • 9/9 9 lb 1.5 oz
  • Goal weight gain 30 g/day
  • 110-150 kcal/kg/d 20 kcal/oz in formula
  • 22 oz/day, 8-10 feedings

37
Dietary protein-induced colitis
  • 3 month old presents with bloody, mucousy stools
  • Colitis caused by cows milk proteins
  • Mom needs to avoid lactose/dairy, casein, whey,
    soy
  • Or switch to protein hydrolysate formula
  • Most sensitivities resolve in 1-2 years

38
Breast Milk Jaundice
  • Begins in 3-5 days
  • Peaks in 2 weeks
  • increased concentration of beta-glucuronidase in
    breast milk
  • Beta-glucuronidase deconjugates intestinal
    bilirubin, increasing its ability to be absorbed
    (ie, increasing enterohepatic circulation)

39
Breastfeeding Failure Jaundice
  • increased enterohepatic circulation together with
    a reduced enteral intake is thought to be
    primarily responsible for increased total serum
    bilirubin

40
Birth Control
  • Avoid estrogen-containing products
  • Progestin only preferred
  • Progestin receptors not present in
    lactatingtissues

41
Antibiotics
  • Penicillins
  • Cephalosporins
  • Zithromax (except early postpartum)
  • Avoid erythromycin
  • Fluoroquinolones (use cipro cautiously)
  • metronidazole

42
Antidepressants
  • Sertraline preferred SSRI
  • Venlafaxine
  • buproprion

43
Analgesics
  • Codeine
  • Hydrocodone
  • Morphine
  • Fentanyl levels are low
  • Ibuprofen
  • Acetaminophen

44
Herbal Remedies
  • Probably safe
  • Echinacea
  • Fenugreek
  • Calendula
  • Ginseng
  • Evening primrose oil
  • St. Johns Wort
  • Gingko Biloba

45
Antihypertensives
  • Aldomet, hydralazine are fine
  • Preferred beta blockers
  • Propranolol, matoprolol, labetalol, sotalol
  • Preferred calcium channel
  • Nifedipine, verapamil, nitrendipine
  • Preferred ACE inhibitors
  • Captopril, enalapril, benazepril
  • Avoid during last trimester and preterm infants

46
X-rays
  • X-rays PASS through the body
  • No hazard to breastmilk

47
References
  • Breastfeeding A Guide for the Medical Profession
  • Neville, Margaret, PhD, The Evidence for
    BreastfeedingAnatomy and Physiology of
    Lactation, Pediatric Clinics of North America,
    vol. 481, Feb. 2001
  • Newman, Jack MD, The Ultimate Breastfeeding Book
    of Answers, 2000.
  • Sinusas, Keith MD and Gagliardi, Amy MA, Initial
    Management of Breastfeeding, American Family
    Physician, Sept. 15, 2001 vol646.
  • Thomas W. Hale, Ph.D. , Medications and Mothers
    Milk.
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