Updated July 2021 - lacted.org

Updated July 2021

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Breastfeeding and Protectionfrom Infant Illness

• The Planners and Instructor has no conflicts of interest to disclose

• Nursing contact hours, continuing education recognition points (CERPs) for IBCLE, or CPEUs for registered dietitians, are awarded commensurate with participation and complete/submission of the evaluation form.

Objectives

• Describe 4 major categories of factors that play a role in infant growth and illness protection

• Explain mechanisms of how bioactive proteins in breastmilk work to protect infants

• Explain the effect of breastfeeding on infant gut microbiome

• Define entero-mammary circulation of parental antibodies

• Explain how vaccinations of the lactating parent enhance breastmilk immunity

• Describe how human milk responds to infant illness

• Describe how infant vaccination response is enhanced by human milk

• Identify parental and infant conditions that necessitate special consideration during breastfeeding

WaterProteinCarbsDHA/ARAFatVitaminsMinerals

WaterProteinCarbs

DHA/ARAFat

VitaminsMinerals

Comparing Breastmilk and Formula = Comparing Apples and Oranges

PLUS:Hormones AntibodiesActive white cellsEnzymesAnti-viral proteinsAntibacterial agents

Human MilkFormula

++OligosaccharidesAnti-allergy factorsCarotenoidsProtaglandinsCytokinesPeptidesEtc!!!

Formula Human Milk

Provides Nutrition

• Provides nutrition• Matures many infant organs

• Gut• Brain• Immune system• Bone marrow

• Provides direct immunologic protection• Kills pathogens

• Maintains an optimal infant gut microbiome

• Moderates infant’s response to infection• Reduces inflammatory response

AllergiesAsthmaEczema

Anti-Inflammatory

Severe bacterialinfectionsEar infectionsGastroenteritis

Anti-Infective

Hormonal

Lower insulin levelsLess diabetesLess obesity

Immune-Modulating

Certain cancersArthritis

Higher IQRetinal maturity

Brain maturity

Neurological

Safety

Decreased SIDSImproved bonding

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Special Properties of Human Milk

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LactoferrinLactadherinLysozymeAntibodies- IgABile-salt stimulating lipaseMilk fat globule

Anti-infection Factors

Anti-infection factors play many roles, and work in various ways:➢ Take iron away from bacteria➢ Directly kill pathogens in

many ways

Ped Clinic North Am 2013 Feb; 60(1) 8

CarotenoidsMelatoninGlutathioneSuperoxide DismutaseCatalase

Anti-Oxidants

Reduced risk of and severity of:✓ Necrotizing enterocolitis in

prematures✓ Lung disease✓ Retinopathy of prematurity✓ Intraventricular hemorrhage

Iran J Pharm Res 2010 Autumn 9(4)

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Hepatocyte growth factorEpidermal growth factorNeuronal growth factorInsulin-like growth factorsVascular endothelial growth factorErythropoietin

Growth Factors

Maturation of several organ systems:➢ Brain development➢ Liver ➢ Growth of blood vessels➢ Heart➢ Gut ➢ Red blood cells

Nutrients 2019, 11, 1307 10

LeptinAdiponectinResistinGhrelinObestatinNesfatinApelin

Adipokines

Influence metabolism and infant growth:➢ Modify weight gain➢ Influence lean body mass➢ Influence metabolic programming➢ Regulate food intake➢ Regulate energy expenditure➢ Play a role in risk of adult diseases

such as type 2 DM, obesity, insulin resistance

Nutrients 2019, 11, 1307

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Transforming growth factor βInterleukin 7Interleukin 10

Cytokines

Anti-inflammatory effects:

➢ Reduce auto-antibodies that inflame tissues

➢ Reduce allergy responses➢ Kill germs➢ Strengthen mucosal barriers

Nutrients 2019, 11, 1307 12

Stem cellsT cellsMacrophagesLymphocytes

Cells in Breastmilk

6% of cells in breastmilk are stem cells➢ These are programmable to

become other organ cells, such as bone marrow cells

Leukocytes help to directly fight infection

Nutrients 2019, 11, 1307

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>100 types of bacteriain breastmilk

Probiotics

Bacteria in breastmilk:➢ Colonize the infant gut➢ Secrete factors that alter the

infant’s immune response➢ Develop infant immune system➢ Secrete factors that advance brain

maturity➢ Reduce risk of ‘bad’ bacterial

growth in the infant gut➢ Proliferate from oligosaccharides

in breastmilk

PLOS ONE 15(2) Feb 21, 2020 14

Oligosaccharides

Oligosaccharides in breastmilk:➢ Feed healthy bacteria in the infant

gut➢ Snatch pathogens in the infant

gut (and poop them out)➢ Reduce inflammation in the infant

gut

Ped Clinic North Am 2013 Feb; 60(1)

© IABLE 15

Entero-Mammary Circulation of Antibodies

Predominantly sIgA

© IABLE 16

Do Antibodies Survive the Infant Gut?

© IABLE 17

✓ IgA is the most important immunoglobulin from breastmilk to function in the infant gut

✓ IgA must survive the acidic stomach environment

Levels of antibodies in the stomachs of premies and term infants, 2 hours after being fed

Nutrients 2018,10,631

Maternal Vaccinations During Pregnancy

Vaccine 32 (2014) 1786-1792

The following vaccines given during pregnancy have been shown to increase IgA in breastmilk against these pathogens:▪ Meningitis- at least 6 mo pp▪ Pneumococcal- at least 6 mo pp▪ Influenza- at least 7 mo pp

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© IABLE 19

Milk from breast nursing ill child Milk from breast nursing well child

Changes in Human Milk During Infant and/or Maternal Illness

• During infant and maternal illnesses, white cell counts in breastmilk increase• Influenza• Gastrointestinal illness• Measles• Maternal hayfever• Mastitis• Bronchiolitis

• Retrograde flow (splash back) after milk ejection allows pathogens from the infant’s mouth to enter the breast, and stimulate immune response

Amer Soc of Nutr Adv Nutr 6:2015Ped Res 71(2) Feb 2012

Breastmilk’s Effect on the Infant Response to Vaccination➢ Breastfeeding for > 6 months increased

antibody levels after chickenpox vaccine- Braz J Infect Dis 2018 22(1) 41-46

➢ Breastfeeding for > 6 mo increased likelihood of complete tetanus immunity after 15 mobooster- Vaccine 2012;30:6521-6

➢ Breastfeeding > 6 mo associated with higher antibodies to H Influenza type 2/tetanus toxoid conjugate vaccine – J Infect Dis 1994 1004;170:76-81

Situations and Illnesses that Require Special Consideration and Caution with Breastfeeding

Infant Illnesses Requiring More Evaluation Before Fully Breastfeeding

• Infant galactosemia type 1• Cannot bfeed

• Can partially bfeed• Maple syrup urine disease

• Phenylketonuria (PKU)

• All metabolic diseases require special consideration• For most infants, partial breastfeeding is possible

and desired

• Long chain fatty acid oxidative disorders• 50% of calories come from LCTFA

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Parental Relative Contraindications to

Breastfeeding

• HIV

• Herpes or shingles on nipple/breast• Milk fine from unaffected side

• Active, untreated TB• Expressed milk is fine

• Brucellosis

• Ebola virus

• A few meds, mainly chemotherapy

• Most drugs of abuse

© IABLE 26

ART suppresses HIV viral load (RNA) to undetectable levels

WHO 2016 for low resource countries:Breastfeed for 12-24 mo with full ART adherence

75% of providers were asked by a WLWH if she could breastfeed29% reported caring for WLWH breastfeeding against medical advice

J Int AIDS Soc 2019 Jan; 22(1)

U=U CampaignUndetectable = Untransmittable

Sfaf.org

J Intern Med 2020 Jan; 287(1) 19-31

• Even if viral load is undetectable, still slight risk of transmission• HIV DNA lives in cellular components in milk, activated during mastitis

• Infant side effects from ART• Long term side/effects of ART thru breastmilk unknown• Risk of HIV resistance if transmission occurs, and exposed to low dose ART

• Maternal non-compliance• Depression, emotional stress

• Ideal frequency of monitoring for viral load unclear

Expressed Breastmilk Changes in Refrigerator

• Drop in pH• Due to break down of fats

• The higher the free fatty acids, the lower the pH

• ? change function of milk enzymes

• Decrease in total protein

• Decrease in triglycerides

• Decrease in lactose

• Change in odor

• Increase in bacteria

• Decrease in vitamin C and E

Indian Ped vol 49 Oct 2012

Nutrient Changes in Freezer

•Decline in lactoferrin by 3 mo• Major protein that fights infection

• J Perinatol 2016 36, 207-209

•Decline in IgA, lysozyme, but not leptin• Pediatr Neonatol 2013 Dec; 54(6) 360

•Decrease in overall antimicrobial activity• JPGN 51(3) Sept 2010 p. 347

•Decrease in vit C and E•Decrease in fat and total calories over 3 mo

• Breastfeeding Med 7(4)2-12 p. 295

•Overall fresh frozen milk has more active properties than pasteurized milk

Fats, Lipase, and Smelly Milk

• Lipase is an enzyme

• Breaks down fat to fatty acids• Continues during

refrigerator and freezer storage

• Oxidation of the fatty acids is major cause of off odor in frozen milk

• NOT due to excess lipase

Odor of Refrigerated EBM

• Caused by fat oxidation (rancid)• After lipolysis

• 7 pooled samples, each from 4-5 mothers• Each sample ÷ 3, 1 fresh, 1 in frig for 1 day, 1 in frig for 3 days

• 12 trained noses

• Pooled samples differ less than individual

• Increased odor over time

• Not terrible• Similar to odors of eggs, cheese

• Odors from formula are similar in strength/quality

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Odor of Frozen EBM Due to Oxidation

• Fatty acids are oxidized

• Triglycerides may be more available from frozen milk micelles

• Off-odor is worse in frozen milk than refrigerated milk• More time in freezer to oxidize

• Limit oxygen exposure during storage

Spitzer J, Buettner A. C Food Chem 2010; 120Spitzer J, Doucet S. Food Qual Prefer 2010:21

Conclusions• There are several categories of bioactive substances in human milk that protect the

infant from infection, while further maturing the immune system and other organs.

• Several bioactive substances in human milk reduce an infant’s inflammatory response to illness

• Human milk is responsible for establishing an infant’s healthy gut microbiome

• Lactating parents develop antibodies to pathogens in the environment and transmit them to the infant via the enteromammary circulation

• Pregnant people who receive immunizations demonstrate enhanced immunity to these vaccines via their breastmilk

• The concentration of inflammatory cells in breastmilk increase in response to infant and/or maternal illness.

• Breastfeeding for at least 6 months heightens an infant’s response to several vaccinations.

• Human milk antibodies survive the acidic environment of the breast/chestfed infant

• There are very few maternal and infant contraindications to breast/chestfeeding

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Parental Diet, Supplements, and the Fussy Term Breastfed Infant



Objectives

• Recite at least 5 reason why a term breastfed infant may be fussy

• Define colic, and explain 2 possible theories for colic

• Describe the symptoms and signs of allergic proctocolitis

• Explain initial steps in maternal dietary management when an infant has signs of allergic proctocolitis

• Describe GI symptoms of cows milk protein sensitivity in breastfed infants

• Explain the possible relationship between hyperlactation and infant bloody stools

• Explain the relationship between cows milk protein sensitivity and GERD in infants

COLIC

Image from Pexel

Infant is less than 3

months old

At least 3 days/week

3 hours/day

Crying For:

Wessels’ Criteria Pediatrics 1954; 14:421-35

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Infant is any age

Not feeding or

gaining well

Crying All Day

Image from Unsplash

What Causes Colic?

Migraine?

Gut Dysbiosis?

Neurologic Immaturity?

Likely Multifactorial

JPGN 62 (5) 2016

What Interventions Help Colic in Breastfed Infants?2016 Meta-analysis of many studies

JPGN 62 (5) 2016

• Not well studied

• No evidence of effectMaternal Dietary

Elimination

• Not consistently effectiveSimethicone (gas drops)

• Modest evidence of being mildly effective

• Studies are not strongFennel (gripe

water)

• Most effective therapy

• Works for bfed, not formula fed infants

• HMOs in bmilk are food for L Reuteri

Lactobacillus Reuteri (probiotic)

Parental Diet and Infant GI

Upset

Cows Milk Sensitivity

Allergic Proctocolitis

GERD

Hyper-lactation


• Infant usually not very fussy

• Infant gaining weight well• Infant feeds well• Blood streaked stools

J Allergy Clin Immunol 135(5) May 2015

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• Caused by infant immune reaction to food proteins in breastmilk

• Typical age of onset is 2 weeks-5 months

• 60-80% are exclusive breast/chestfed

• The gut flora may be different in these infants

Allergol Immunopathol (Madr) 2018;46 (1): 1-2 ©IABLE

Treatment is Parental Elimination Diet

No need for stool cultures, blood tests, unless there are other

symptoms

Recommendations for Parental Elimination Diet

Breastfeeding Med 6(6) 2011 Protocol #24

• Stop cows milk• Most likely culprit

• If no change at 2 weeks, stop soy

• If no change, add back dairy and soy

• Eliminate something else, one at a time

• eggs, nuts, peanuts, citrus fruits, wheat, corn, strawberries, chocolate

• Families need education on how to read food labels to avoid substances of each allergen

Photo by sheri silver on Unsplash

Infantproctocolitis.org

©IABLE

A parent reports at 2 mo postpartum that their

exclusively bfeeding baby tends to be fussy,

strains with stooling, and fusses with feeding.

No spitting up, and no bloody stools.

Reasonable advice includes:

A.This is normal colic behavior, it will improve

B.This is likely due to GERD, suggest ranitidine

tx

C.Stop cows milk protein in the parent’s diet

D.Gripe water for fussiness/colic

©IABLE

Association of Cows Milk Protein in Parental

Diet and Infant Infrequent Stools and Fussiness

➢ Cows Milk Sensitivity assoc with gastric motility disorders,

including infrequent stools, delayed gastric emptying, GERD

➢ 28-78% success rate in resolving infrequent stools and

GERD by eliminating dairy from parent’s diet

➢ Increased eosinophilic infiltration of anal sphincter causes increased

anal pressure at rest (due to cows milk sensitivity)

J Allergy Clin Immunol 135(5) May 2015

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Role of Hyperlactation and Bloody Stools

• Commonly observed with blood streaked stools

• If blood streaked stools are not resolving with elimination of typical proteins, address hyperlactation

© IABLE 20

Hyperlactation = Over-Production

• Production of excessive milk• Breast discomfort

• Parent compelled to express beyond what the baby is taking (assuming normal infant growth)

• No defined clinical criteria • No set # of “ounces per day” or

weight gain criteria

ABM Clinical Protocol #32 Bfeeding Med 15(3) 2020

© IABLE 21

▪ Struggle during initial let-down with gasping, choking, fussiness

▪ Rapid weight gain▪ 1 lb/week

▪ Excessive gas and explosive/green stools

▪ Freq stools occurring during feeding

▪Usually refuses second breast

▪ Baby may refuse to nurse on breast with larger production

Symptoms and Signs in Baby

ABM Clinical Protocol #32 Bfeeding Med 15(3) 2020 © IABLE 22

• Parents induce hyperlactation• Concern re low production

• Routine pumping after nursing, ie to stash milk for work/ donate

• Use of galactagogues when unnecessary• Individuals who only pump and don’t nurse• Haakaa use

• PhysiologicThe Guernsey phenomenonUnclear why breasts don’t respond to feedback of fullness

• Anatomic• Large storage capacity

Etiology of Hyperlactation

© IABLE 23

Management of Hyperlactation

• Behavioral Strategies• Block feeding

• Decrease/stop pumping

• Medication/Herb Use

© IABLE 23 © IABLE 24

• Feed from 1 breast for a 3-hr block of time, ieall feeds from noon to 3pm are from the L, 3 to 6pm from the R

• The full breast increases=> production drops

• Usually noticeable drop in supply by 36 hrs

Block Feeding

• If resting side is too full, pump minimally to comfort

• Do not try more than 4 hour blocks

• Excessive drop?-nurse from both sides!

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© IABLE 25

Reduce or Eliminate Pumping

• Coach parents• This can be tough

• Gradually reduce pumping times/volumes over days-wks

• Just stopping not safe

© IABLE 26

Pseudoephedrine• Decongestant

• stimulates alpha- and beta- receptors, causing vasoconstriction

• Unclear mechanism in decreasing milk production

• ? slight decrease in prolactin levels (13%)

• 24% drop in milk production after single 60mg dose

Br J Clin Pharmacol 2003; 56/ Breastfeed Med. 2020;15

DosingStart with 30mg and assess effects, watch for infant fussinessRepeat in 8-12 hrs as neededIf 30mg not effective, increase to 60mgDo not prescribe regularly, ONLY as needed

© IABLE 27

Sage Tea or Extract

• Phytoestrogen effect

• Sage Tea

– 1 tbsp of dried sage into 8 oz of hot water, steep

for 3 minutes, then drink.

• Sage extract (Herbpharm is one)

– 20-40 drops at one time

• Best to use when breasts are relatively empty

• Monitor for 6-8 hours to observe effect

• Use just as needed, not regularly

© IABLE 28

Peppermint

• Phytoestrogen effect

• Peppermint Tea

– 1 tbsp or a tea bag into 8 oz of water, steep for 3

min, then drink

• Peppermint lozenges with real peppermint oil

– 3-4 an hour, a few hours before going to bed

• Best to use when breasts are relatively empty

© IABLE 29

EstrogenUsually Slows

Production

• Estrogen-containing OCPS

• Start with once daily dosing for a week

• Typical drop in production by day 5-7

• If milk production begins to rise again later, can re-dose for another week, or stay on it

© IABLE 29 © IABLE 30

Bromocriptine and Cabergoline

• Strong dopamine agonists• Dopamine is the Prolactin

Inhibitory Factor

• Cabergoline has fewer side effects

• Cabergoline 0.25mg po ONCE, and observe effect over 3 days

• Dose every 3-5 days• Be careful what you ask for

• Use as VERY last resort!• Useful for fetal demise or other

reasons to abruptly wean

© IABLE 30

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Infant Gastroesophageal Reflux (GERD)

• Gastroesophageal reflux (GER) is normal in infants

• ~50% spit up at least 1x/day

• Peaks at 2-4 mo• Genetic risk

• Gastroesophageal reflux becomes GERD (a disease) with infant symptoms

• Fussiness, e.g. poor sleep, fidgety during feeding, cannot lie flat at night

• Poor feeding

• Insufficient weight gain

J Pediatr 2014;90:105-18Unsplash.com

Parental Diet and GERD

• Several well-designed studies have

demonstrated worsening of GERD due to

infant cows milk protein allergy

• Literature supports recommendation to strictly

eliminate dairy from parental diet for 2-4

weeks

– Estimated ~56% of infants with GERD will improve

• No evidence for elimination of other maternal

food proteins

• Other substances can contribute

– Caffeine

– Herbal galactogogues

J Pediatr 2014;90:105-18

Management Strategies for Infant Gastroesophageal Reflux (GERD)

• Loosen the diaper

• Burp after feeding

• Keep upright for 30-60 min after feeding

• Pace bottle feed

• Manage hyperlactation

J Pediatr 2014;90:105-18Unsplash.com

Conclusions

• Parental diet does not affect infant colic.

• The only proven effective treatment for colic is lactobacillus

reuteri.

• Infant allergic proctocolitis requires a parental elimination diet,

starting with cows milk protein.

• If allergic proctocolitis does not improve with dairy elimination,

then a step by step process of food protein elimination is

required.

• Cows milk protein allergy may present as infant fussiness,

infrequent stooling, and gastroesophageal reflux.

• Parental hyperlactation may be an underlying cause of blood

streaked stools in breastfed infants. If dietary elimination does

not help, work on decreasing maternal milk production.

• Parental hyperlactation may be an underlying cause of infant

gassiness, reflux, and frequent stools.

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Post Partum Contraception

Anne Eglash MD, IBCLC, FABM

I have no conflicts of interest regarding devices or

policies discussed in this lecture

Objectives

• Explain risks of contraception to the breastfeeding infant

• Identify the safest forms of birth control during lactation

• Define the lactation amenorrhea method

• Review WHO and CDC recommendations for immediate pp

contraception

• Recognize the existence of bias and health inequity regarding

contraception and race/ethnicity

• Discuss key points in optimizing shared decision making between

health care providers and patients regarding contraception

What % of Pregnancies in the USA are Unintended

A. 75%

B. 46%

C.39%

D.58%

MMWR July 29 2016 65 (3)

Birth 48-72 hrs pp

Estrogen

Progesterone

Prolactin

Prolactin Levels are Highest During Pregnancy and Lactation

Lactation Depends on Sustained Elevated Prolactin Over Time

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Hormonal Contraception During Breastfeeding

Placenta delivered, hormones fall

Colostrum

Gradual increase in fluid, blood flow, oxygen, etc

Early PostpartumProgesterone may inhibit

effectiveness of prolactin at the lactocyte

Prolactin

Estrogen

Barrier Methods• Condoms• Spermicide• Diaphragm• Vag Sponge

Other Nonhormonal

• Copper IUD

Sterilization• Vasectomy• Tubal ligation

What Contraceptive Methods Have Least Impact on Lactation?

Are you amenorrheic?

Is your baby < 6 moold?

You have a 1-2% change of pregnancy at this time

Lactation Amenorrhea Method

Contraception 62 (2000) 221-230Breastfeeding Med 10(1) 2015

Are you fully or nearly fully breastfeeding?

Supplementation/food no more than 1-2x/week

Behaviors that Contribute to LAM Success:• Exclusively breastfeed- avoid supplementation• Feed frequently- avoid long breaks overnight• Avoid pumping, breastfeed directly• LAM can be effective after 6 months if:

• Breastfeeding before giving solids• Continue to breastfeed every 4 hrs in day/6 hrs night

• Can consider addition of emergency contraception

*If pumping or adding supplementation, add another method of contraception

Fertility Awareness Methods

Photo by Manasvita S on Unsplash

• Can be done without return of menses• Multiple protocols

• Temperature• Cervical mucous• Hormonal monitoring

• Most methods have postpartum protocols• OM-associated pregnancy rates

• 36% risk among bfeeding women after menses started

• 13% for nonlactating women

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Cu-ID- copper IUDLNG-IUD- levonorgesterol IUD (5 yrs)Arm Implant- etonorgesterol (up to 3 years)DMPA- Depo medroxyprogesterone (3 mo)POP- Progesterone only pill CHC- combination hormone (pill, patch, ring)

(*- Please see the complete guidance for a clarification to this classification,www.cdc.gov/reproductivehealth/unintendedpregnancy/USMEC.htm)

Increased risk of expulsion

Possible effect in lactation



22

2

1

2

2

1

2

3

CDC 2016 Recommendations = red

Implants

Progest Only Pills

Progest Injectables

CHC

Progesterone IUD

Copper IUD

WHO MedicalEligibility 2015

Safety of Hormonal Contraception for Infant

• Low levels of hormones in breastmilk

• Not generally found to affect the milk composition

• No significant effect of the hormones on breastfed infant/child

The Birth Control Patch/Ring/Pill with Estrogen and Progesterone during Lactation

• Avoid estrogen in the first 3 weeks pp for ALL women, regardless of lactation due to risk of blood clots

• CDC• Level 3-avoid from 3-6 weeks pp in lactating women• level 2 > 6 weeks

• WHO• level 4-avoid from 3-6 weeks pp in lactating women• level 3 > 6 weeks to 6 months• level 2> 6 mo

Bottom Line- Estrogen always has the risk of decreasing supply, level 2 is NOT level 1!Photo by Reproductive Health Supplies Coalition on Unsplash

The Progesterone Only Birth Control Pill During Lactation

• CDC –• Level 2 until 4 week pp• Level 1> 4 weeks pp

• WHO-• Level 2 until 6 weeks pp• Level 1 > 6 weeks pp

Photo by Reproductive Health Supplies Coalition on Unsplash

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Depo Medroxyprogesterone Acetate (DMPA) During Lactation

• Product labeling recommends starting after 6 weeks• CDC- Advantages > Risks (2) until 6 weeks, no risk > 6 weeks• WHO- Risks > Advantages (3) until 6 weeks, no risk > 6 weeks

Studies found to be of low quality- Bfeeding Med 2012 7(1)• Lack of follow-up of infant weight• No exact measure of milk supply• No measure of supplement volumes

Many observations of insufficient lactation after DMPAAcademy of Breastfeeding Medicine suggests avoiding if:• Low supply or history of low supply• History of breast surgery• Multiple birth• Preterm birth• Compromised health of mother and/or infantBfeeding Med 10(1)2015

Progesterone- Only Contraceptive Use Among Breastfeeding Women: A Systematic Review (Contraception 94, 2016)

Foundation for CDC MEC


…initiation of POPs, injectables, and implants at ≤6 weeks postpartum compared with nonhormonal use had no detrimental effect on breastfeeding outcomes or infant health, growth, and development in the first year postpartum. In general, these studies are of poor quality, lack standard definitions of breastfeeding or outcome measures, and have not included premature or ill infants MMWR July 29, 2016 65(3)

CDC Medical Eligibility Criteria Update in 2016

• Comment (breastfeeding): Certain women might be at risk for

breastfeeding difficulties, such as women with previous breastfeeding

difficulties, certain medical conditions, or certain perinatal

complications and those who deliver preterm. For these women, as for

all women, discussions about contraception for breastfeeding women

should include information about risks, benefits, and alternatives.

Emergency Contraception During Lactation

Copper IUD Placement- safe and provides long term

contraception- insert within 5 days

Ella- Ulipristal (progestreceptor modulator)- Not

ready for prime time during breastfeeding, but low dose

in bmilkLevonorgestrel- generally

safe, preferred over the COC pill



Increased risk of expulsion

Possible effect in lactation

https://pcainitiative.acog.org/clinical-considerations/expulsion/

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Placement of Levonorgesterel IUD Immediately PP vs 6-8 Weeks PP

Contraception 84 (2011) 499-504

• Magee Women’s Hospital Pittsburgh PA

• Compared IUD placement immediately after vaginal delivery vs 6-8 weeks pp

• 102 women, randomized

• All women were interested in IUD pp, and all were counseled that the progestIUD would not impact bfeeding

Photo by Reproductive Health Supplies Coalition on Unsplash Contraception 84 (2011) 499-504

Immediate PP levonorgestrel IUD and BfeedingOutcomes

Am J Obstet Gynecol 2017; 217: 665

• Immediate placement (132) vs placement at 4-12 weeks pp (127)

• New Mexico and Utah

• Measurement:• Delay in lactation• Breastfeeding or not at 8 weeks• Breastfeeding or not at 6 mo Conclusion: Immediate PP LNG IUD insertion is not inferior to later insertion

Author-cited limitations:• Did not report on supplementation volumes• Did not ask about adequacy of milk supply

22

2

1

2

2

1

2

3

CDC 2016 Recommendations = red

Implants

Progest Only Pills

Progest Injectables

CHC

Progesterone IUD

Copper IUD

WHO MedicalEligibility 2015

Comparison of Bfeeding Exclusivity and Duration Rates Between Immediate PP Levonorgestrel and Etonogestrel Implant Users

Bfeeding Medicine 14 (1) 2019

• Study done in Malawi• 140 women enrolled pp. They could choose:

• Etonogestrel implant (x 3 years)= 20%• Levonorgestrel implant ( x 5 years) = 80%

• Implants placed immediately pp• Mothers interviewed every 3 mo until 24 mo pp

Nearly all mothers were marriedThose who chose Etonogestrel more likely to want more children>90% vaginal deliveries

Major limitations- no documentation on infant growthor identify women at risk for insufficient supply


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Effect of Immediate PP Levonorgestrel Contraceptive Implant Use on Bfeedingand Infant Growth, a RCT

Contraception 2019 Feb; 99(2)

• Randomized women in Uganda• Implant placed within 5 days (96) or 6-8 weeks pp (87)

• Followed for documentation of lactogenesis II by survey/call

• Assessed bfeeding concerns at 3 mo and 6 mo pp

• Infant weight checks at birth and 6 mo (low # of weight checks)• No differences in interval weight gain in the 2 groups


Author-cited limitations of this study:• Low f/u of infant weight checks• Did not assess bfeeding outcomes for women at risk for low supply, such

as prematurity• Did not measure supplementation of infants• Significant # of women were concerned re supply at 3 and 6 mo

• No comparison to the general population Contraception 2019 Feb; 99(2)

https://pcainitiative.acog.org/clinical-considerations/breastfeeding/

ABM Protocol on Contraception #13

Revised 2015

• Levonorgestrel IUD placed immediately pp may be associated with a shorter duration of bfeeding. No adverse effect on bfeeding when placed at 6 weeks or later

• Progesterone injection/oral/implant- Theoretical potential to adversely impact milk supply when started early pp, little data. If a depot shot decreases milk supply, it is irreversible

• Combined estrogen/progest options- avoid until lactation well established. Potential for adverse effect on milk supply. Risk appears more pronounced with higher estrogen levels than used in contemporary products. Begin as late as possible into well-established bfeeding

• Emergency contraceptives- progesterone only pills preferred over estrogen containing pills

In Summary- Effect of Contraception During

Lactation

• Slightly higher risk of uterine perforation due to IUD among

breastfeeding women

• LNG-IUD placed less than 10 min after delivery increase risk of

insufficient lactation, likely due to insufficient drop in progesterone pp

• Progesterone contraceptives (etonorgesterol implant, DMPA, POP)

increase risk of insufficient lactation

– According to CDC- under 30 days

– According to WHO- under 6 weeks

• The combination contraceptives (pill, ring, patch) increases risk of

insufficient lactation at any time

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Conclusions Thus Far:

• The CDC,WHO, ACOG and ABM recognize that

caution is needed when using pp LARC for

breastfeeding mothers

• The current evidence lacks strong measurements on

breastfeeding outcomes, such as infant weight

checks and documentation on volume of

supplementation

Health Care Providers Have Strong Enthusiasm for LARC

Long Acting Reversible Contraception

Bedsider.org

3-5 years

3-12 years

Equitable, Appropriate Means of Implementing Early

Postpartum LARC

Hormonal contraception, breastfeeding, and bedside

advocacy: the case for patient-centered careContraception 99 (2019) 73-76

• The following situation occurred at our institution: a 15-year-old Latina

gravida 2, para 0111 had a spontaneous vaginal delivery of an

extremely preterm infant. On her day of discharge from the hospital, a

lactation consultant entered her room just as an obstetrics and

gynecology resident was eliciting her consent for a contraceptive

implant placement. The lactation consultant asked the medical student

who was in the room with the resident whether breastfeeding had

been discussed with the patient. Once prompted, the resident advised

the patient of “a possibility” that the implant could impact her milk

supply. The patient decided not to have the implant placed at that time.

The resident texted his attending:

• I just talked to one of the lactation consultants who advises women

that immediate postpartum contraception (Nexplanon) may decrease

milk supply. I'm not aware of any literature to support this. This was in

a 15 year old on her second pregnancy who just delivered a 25

weeker. Obviously I'm all for breastfeeding but I feel like presenting her

something that is based on the LC's experience is not really neutral

and fair especially in such a high risk teen and when the literature on

PP immediate contraception is so compelling.

Discord between providers

Interest in birth spacing to reduce risk of another premie

Reduce unintended pregnancy

Emphasize lack of evidence for adverse effect on lactation

VS

Interest in lactation success

Health of the premature infant

Emphasize lack of evidence for safety of contraceptives during lactation

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Hormonal contraception, breastfeeding, and bedside

advocacy: the case for patient-centered careContraception 99 (2019) 73-76

• Most studies show little impact on breastfeeding

• Problems with studies:

– Findings may not be applicable to complex, heterogenous

postpartum populations (race, SE, etc) in the USA

– Most studies enrolled healthy women w/healthy term infants

• None with preterm or SGA infants, or twins

• None with exclusive pumpers

• None with maternal health problems such as DM, high BMI

– Very few have evaluated immediate pp contraception

Reproductive Justice Infant Mental Health J 2019;1-15

Social Injustice: Contraception and Bfeeding

• Lack of equity regarding education on contraception

• State Medicaid approval for LARC perceived as infringement of

reproductive rights without adequate implementation

• Physician enthusiasm for LARC may lead to implicit coercion

• HCPs counseling on contraception varied based on race/ethnicity

• Barriers to LARC removal

In 2011, % of Unintended Pregnancies

30% for women at or above 200%

federal poverty level

60% for women at or below 100%

federal poverty level

Low income women more likely to experience another pregnancy within 1 year pp

Unintended pregnancies assoc with:➢ Low birth weight➢ Prematurity➢ Maternal depression➢ Lifelong heath, economic, social difficulties

Womens Health Issues 28-2 (2018) 137-143

Knowledge Inequity Re Contraception Among Women in the US Military

No difference in educational level

between races

Promotion of LARC

(IUDs, Etonogesterol Implant)

• State Medicaid agencies looking to

– decrease costs of pregnancies and births

– Reduce # of unwanted pregnancies

• Considered a first-line option by many professional organizations

– High rates of effectiveness

– Lack of ‘user’ failure

– Cost- effective

– Reversible


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https://www.medicaid.gov/medicaid/quality-of-care/quality-improvement-initiatives/maternal-infant-health-care-quality/contraception-medicaid-improving-maternal-and-infant-health/index.html

How to Implement Postpartum LARC?

• Mothers receiving counseling that:• Is free of bias• Allows for autonomous decision making• Is provided during pregnancy, not just postpartum

• Physicians avoiding• Coercion• Implicit bias

Challenges of State Payment PoliciesWomens Health Issues 28-3 (2018)

Do states that cover LARC cover and pay for all necessary services and

procedures assoc with LARC?

Most states didn’t have ongoing funding for provider training on the use of LARCs

Medicaid and Immediate pp LARC

• 2012- S Carolina first state to implement immediate pp LARC

Medicaid policy to increase LARC use

– Medicaid reimbursed hospitals for pp LARC

• As of 2019, 40 states and DC have similar policies

• South Carolina Birth Outcomes Initiative developed a toolkit for best

practices on counseling and care delivery to Medicaid population

– Encouraged several prenatal conversations and pp discussion


South Carolina Study on LARC

• Interview of 25 women in S Carolina 2016-2018

– Gave birth within the last 2 years while on Medicaid

– 18 AA, 5 White, 2 Multiracial

• 23/25 received prenatal counseling on Immediate pp LARC

– Higher satisfaction rates on prenatal counseling among those attending group

prenatal classes

– Among those dissatisfied with prenatal counseling all but 1 declined immediate

pp LARC

• 9 reported no in-hospital pp contraceptive counseling

• 2 major themes

– Dissatisfaction with timing and handling of conversations in hospital

– Challenges with getting LARC removed

‘I don’t know, but I am having

contractions’

‘I just wanted to be good with side effects. After my 3rd baby, they

said they forgot to do it (tying tubes) and they offered me the

Mirena…I just don’t do)’

When they admitted me, they came in and they

said, “Hey did you talk to anybody about what

birth control you're wanting to get?” I'm like, “Not

really definite for anything.” They said, “Well,

here's the options that we can give you”... Me and

my boyfriend talked about it and [the IUD is] what

we decided to do. We signed the paper and then

they just did it right after I had [my son].

Renee decided to have the shot pp, after receiving prenatal counseling. ‘the doctor before I was checked in asked me right

before they took me back, if anything, because she was trying to talk me into getting

an IUD. I was like ‘I don’t know, we’ll talk about it later. I am in pain right now, I don’t want to talk’…I just told her I was really set on

getting the shot, and she was like, ‘Are you sure?’

Dissatisfaction With the Timing of Contraception Discussion During Labor and Early PP

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Thanks to Clay Banks

LARC Policies May Seem Unethical

Construed as limiting pregnancies of poor

women and those of color

Undermine reproductive right to

identify one’s own family planning

priorities and adopt what works for them

Shared Decision Making

Photo by Sincerely Media on Unsplash Academy of Breastfeeding Medicine Protocol #13 bfmed.org

• Healthcare providers should not ‘pre-decide’ for individuals

• Provide education during pregnancy• Include information on :

• Efficacy• Cost/affordability• Possible impact on lactation• Other side effects/complications• Removal

Effects of Patients’ Race/Ethnicity and SE Status on Recommendations for Family Planning Services

• J Womens Health Jan-Feb 2009; 18(1) National Survey of Family Growth• Among 4639 women, no difference in access to family planning services in the last 12

mo

• Hispanic women more likely to receive counseling for sterilization

• Non-whites more likely to receive counseling on birth control

• Am J Obstet Gynecol 2010 203(4)• 524 HCPs were shown videos of pts w/varying SE backgrounds

• Low SES Latinas and AA women more likely to be advised to have an IUD vs low SES white women

https://pcainitiative.acog.org/postpartum-contraception/immediate-postpartum-larc/

Association of State and Territorial Health Officials

https://www.astho.org/Maternal-and-Child-Health/Increasing-Access-to-Contraception/Guidance-for-Developing-a-Toolkit-on-Immediate-Postpartum-LARC/

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Patient Education Resources on Postpartum

Contraception

• Bedsider.org

• American College of OB/Gyn pcainitiative.acog.org

• Center for Disease Control

https://www.cdc.gov/reproductivehealth/contraception/index.htm

• Reproductive Access.org

Conclusions

• The effect of hormonal contraception on lactation is not clear,

particularly for high-risk populations.

• Current research has not used optimal measures for lactation success.

• The current CDC and WHO recommendations on medical eligibility

criteria for contraception for breastfeeding women differ.

• Both CDC and WHO acknowledge that hormonal contraception may

impact lactation.

• Patients need adequate information for fair shared decision making.

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Tongue Tie/Oral Restrictions

1



Topics

• Defining tongue tie

• The upper lip frenulum

• Parental and infant symptoms related to a problematic lingual frenulum

• Evaluating form of the frenulum and tongue function

• Evidence for frenotomy

• Post frenotomy care

• Communicating tongue tie concerns to providers

Objectives

• Define frenula- lingual, upper lip, cheek

• Describe the normal function of the tongue during breastfeeding

• Explain classification of lingual frenula and upper lip frenula

• Summarize the trend in research regarding anterior tongue ties

• Explain highlights of the American Academy of Otolaryngology’s consensus statement on tongue ties

• Describe 4 symptoms of tongue tie for mother/infant dyad

• Explain typical symptoms of posterior tongue tie

• Identify other forms of support for infants with posterior tongue ties who have had frenotomies or who have not.

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Tongue and Upper Lip Frenula

• Congenital tissue• Connecting the tongue to floor

of the mouth• Connecting upper lip to the

maxilla

• Demographics• 4-11% of newborns have an

anterior tongue frenulum• No statistics on presence of a

posterior frenulum

• Male: female = 3:1• Possibly familial

Cochrane 2018, Int J Ped Otorhinol 2013, Canadian Fam Phy 53(2007)

www.drjain.com

The Rating System Used-Upper Lip Frenula

Global Pediatric Health 4(1-6) May 2017

Type 1- Insertion near muco-gingival marginType 2- Insertion at mid attached gingivaType 3- Insertion along inferior margin at alveolar papilla and may wrap underneath

Upper Lip Frenula• 100 newborns

• Each newborn had a photograph taken of the upper lip frenula at Stanford before leaving.

• Taking a photo made them easier to see

• The frenula were evaluated by:• Newborn hospitalist

• Peds ENT attending, Peds ENT resident

• Peds dentist

• IBCLC

• Each photo was doubled, so each evaluator rated 200 photos.

• 100% of all infants have an upper lip frenulum• Only 8% of babies had the same rating from each evaluator• Only 64-68% of the time did an individual evaluator give the same

rating to the same frenulum

Global Pediatric Health 4(1-6) May 2017

6%

83%

11%

0% 20% 40% 60% 80% 100%

Type 1

Type 2

Type 3

% Frequency of Types of Lip Frenula

Systematic Review of Upper Lip Frenulum Clipping

•15 articles identified• Mainly case reports and descriptions of surgical

techniques

•No randomized controlled trials

•No good evidence for the effectiveness of routinely clipping the upper lip frenulum, in terms of improving breastfeeding problems.

Breastfeeding Med 14(2) 2019

Recommendations from theAmerican Academy of Otolaryngology Consensus Statement Feb 2020

On Upper Lip Frenula

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Clip the Upper Lip Frenulum?

•Don’t call it a tie- it is a normal part of body• If 100% of infants have one, it can’t be abnormal

•Gradually moves upward with age•No evidence that early clipping prevents wide spacing

of upper teeth•Commonly suggested reasons to clip:

• Pain where frenulum meets areola• Unchanged with positioning/latch adjustments

• Milk dripping from upper lip• Emerged teeth have early enamel changes

• Milk and solids are trapped by the frenulum against the teeth

Quintessence Int. 2013;44:177-187.

The Tongue, or Lingual Frenulum

Normal Tongue Function

• Reach out to establish contact with the nipple/areolar complex (NAC)

• Sweep the NAC to the hard-soft palate junction• Forward and backward

• Vertically to the palate

• Maintain contact with the NAC during feeding

• Provides a vacuum for milk to be sucked into the mouth

Early Human Development 89 (2013)

FauquierENT Ultrasound Video

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Types of Tongue Ties

Type 1 Type 2

Type 3 Type 4

www.drjain.com

www.drjain.com

Credit to Kristen Berning DDS

Can Have Several Insertions

Photo courtesy of James Murphy, MD

Pre and PostPosterior Tongue Tie Laser

Credit to Kristen Berning DDS

“Murphy Maneuver”

(Dr. James Murphy)

A posterior tongue tie can be

easier felt than seen

Sweep a finger under the

tongue

– If little- no resistance, normal

– If you need to move your finger

to get past it, then there is a

fibrous band considered to be a

posterior tongue tie

https://bfmed.wordpress.com/2010/11/04/clinical-pearl-the-murphy-maneuver-for-diagnosing-tongue-tie/

Parental Symptoms Possibly Due To Tongue Tie

• Parental pain with latch and throughout feeding

• Abraded/open nipples

• Persistent rubbing on nipples during feeding

• Misshapen nipples

• Decrease in milk production

• Recurrent plugged ducts/poor breast emptying

• Recurrent mastitis

www.drjain.com

7/19/2021

5

©IABLE

Infant Breastfeeding Symptoms Possibly Due to a Restrictive Frenulum

• Latch/seal difficulty:• Shallow latch

• Biting while feeding

• Clicking/snapping while feeding

• Milk dribbling/leakage

• Other:• ? Gastroesophageal reflux

• ? Air swallowing due to clicking during nursing

• Poor removal:• Frequent feeding• Sleepy at breast• Very slow/long feedings• Poor weight gain• Breast refusal• Popping on and off or fussy at the

breast

Lingual Frenula

• Its about form AND function

• Not all frenula need clipping

• High supply, no pain• Location of glandular

tissue• Easy to reach, no

symptoms

26

Key Recommendations from the American Academy of Otolaryngology About Tongue Ties Feb 2020

The Posterior TT Dilemma

• Many babies have a posterior frenulum• No statistics

• Many parental and infant symptoms may be attributed to posterior tongue tie, but clipping makes no difference

• The sleepy late preterm infant• Parental pain from subacute mastitis,

vasospasm, or nipple dermatitis• Low milk production due to insufficient

glandular tissue• Recessed chin

• Very little/no research on indications of when to clip a PTT

• Some evidence it helps nipple/breast pain

• No evidence that it improves tongue coordination

www.drjain.com

7/19/2021

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©IABLE

Other Considerations In Frenulum Evaluation?

• Infant positioning• Is it optimal for a deep latch?

• Milk production• Hyperlactation may lead to infant fussiness/GERD at the breast

• Any other causes for low milk production?

• Infant sleepiness/prematurity• Is sleepiness just at the breast or also between feeds & with a bottle?

• Oroboobular disproportion• Infant cannot reach the glandular tissue

Example of an Infant Before and After Clipping Posterior Tongue Tie

Use an Objective Measure of Tongue Function

• Hazelbaker Assessment Tool• http://www.alisonhazelbaker.com/shop/hatlff-

hazelbaker-assessment-tool-for-lingual-frenulum-function

• Bristol Tongue Assessment Tool• https://baynav.bopdhb.govt.nz/media/2345/20170816-

bristol-tongue-assessment-tool-btat.pdf

• Martinelli Assessment Tool• https://www.scielo.br/j/rcefac/a/NHtcwcYJfJ8DYjhRHwY

vwTL/?lang=en&format=pdf

Part 1 Martinelli Tool

Best = 0Worst = 12

Part 1 Martinelli Tool

Best = 0Worst = 12

Multifaceted Programme to Reduce the Rate of TT Surgery in Newborns in Canterbury NZ

• TT clippings in 2013 included 7.5% of infants, rate increased to 11.3% in 2015, but no change in breastfeeding rates at 6 weeks

• Study done at Christchurch Women’s Hospital, NZ

• Infants under 48 hrs only clipped if severe TT and feeding problems

• Infants 48 hours-8 weeks criteria for TT clipping:• Lactation consultant eval + BTAT (Bristol TT Assessment Tool) <=4

• Results-• More consistent criteria for TT assessment and management• TT clippings dropped to 6.6% in 2016, and 3.5% in 2017• Exclusive breastfeeding rates were the same for infants with a frenotomy

and those without (ie those with a BTAT score <=4, and those with 5 or greater)

Internat J Ped Otorhinolaryngology 113 (2018) 156-163

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0 1 2

Appearance of Tongue Tip

Heart-Shaped Slight cleft/notched

Rounded

Attachment of frenulum to

lower gum edge

Attached at top of gum ridge

Attached to inner gum

Attached to floor of the mouth

Lift of tongue during

crying/mouth open wide

Minimal tongue lift

Edges only to mid-mouth

Full tongue lift to mid mouth

Bristol Tongue-Tie Assessment Tool Post- Frenotomy Care

• Stretching exercises for incised region for 3 sec 4 times a day, for 10-14 days

• Controversial

• Craniosacral therapy, OMT, chiropractics, PT, PedsOT/Speech, LC

• Improve oromotor and neck mobility

• Improve tongue movement

• Reduce muscle tension

• Improve muscle strength

• Work on positioning and latch

How to Communicate to Providers About a Suspected Tongue Tie

• Describe what you feel at the base of the tongue

• Explain how the frenulum appears to be impacting feedings. For example:

• Feeding too often

• Parental pain or biting with feeding

• Nipple trauma Unable to empty the breast well

• Describe the breastfeeding modifications needed until frenotomy- usually pumping/bottle feeding to some degree

Conclusions

• The decision to clip a lingual frenulum involves several considerations.

• Tongue function should always be taken into consideration when deciding on a frenotomy.

• Use an objective tool to determine tongue function.

• Nearly 100% of infants have an upper lip frenulum that extends to the edge of the upper gum line.

• The evidence for frenotomy is stronger for anterior frenula than posterior frenula.

• Post frenotomy care ought to include evaluation and treatment for oromotor and upper body muscle tone, strength, and flexibility.

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Pre/Post Feed Weights

1© IABLE 2



Objectives

• Define a pre/post feed weight.

• Explain 3 reasons to perform a pre/post feed

weight.

• Describe how to perform a pre/post feed weights.

• Identify reasons why a pre/post feed weight could

have negative consequences.

Pre- and Post- Feed WeightsA strategy to measure intake at one feeding

Optimal Situations for

Pre-Post Feed Weights

• The baby has not been gaining well, and mom appears to have plenty of milk

• Monitoring the baby known to have low milk transfer

• The baby nurses for a long time, parent is not sure about their production, baby’s growth is marginal

• Parent is gradually building their production

• Determining if a parent with known h/o IGT needs to pump after nursing their newborn

What is the Best Proof of

Appropriate Calorie Intake?

• The proof of appropriate calorie intake is in

the daily/weekly weight gain

• Appropriate growth on the growth curve

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Risks of Pre-Post Feed

Weights

• Shake parental/family’s confidence due to

poor representation of home feedings

• Inaccuracy of the measurement

• Lack of clarity on how to use info

• Unsolicited info

– Always ask for permission, and share risks

beforehand

Performing a Pre-Post

Feed Weight

• Use a digital scale, measuring at least to 2 gram

• Weigh the baby naked for growth curve data

• Put on clean diaper and clothes that baby will wear

while nursing, and weigh the baby in grams

• Feed the baby

• Reweigh the baby in the same clothes and diaper.

• Difference in grams= amount of milk transferred

– 5400g pre-feed, 5464g post feed =64g difference, which

is 64ml transfer

Small Group Discussion

On the Use of Pre/Post Feed Weights

The Premie GraduateJS is a G1P1, healthy mother, who gave birth precipitously at 28 weeks due to incompetent cervix. Her infant Ellery is now 39 weeks corrected and just came home from the NICU nursing once a day. The rest of the time the infant is bottle fed expressed breastmilk with powdered formula as a fortifier. She expresses 900 ml a day.

She would like to gradually increase feedings at the breast, but when she tries nursing at every feeding, Ellery always needs a bottle after nursing, and she finds nursing/pumping/bottle feeding for every feeding exhausting.

How would you use pre/post feed weights to help in your assessment/management?

The Non-Gaining Term BabyA local family physician refers a dyad to you. Baby Esther was seen for her 2 month well baby visit and found to have insufficient weight gain. She was a content and smiling baby, with nl stools/voids.

.

The lactating father was understandably upset with the 2 month weight. The infant chestfeeds every 2-2.5 hours, and if he pumps in lieu of chestfeeding, he can express 4-5 oz every 3 hours. How would you use pre/post feed weights to help in your assessment/management?

Birth Weight, Term 8 lb 3 oz (3714 g)

4 days 7 lb 13 oz (3543 g)

2 weeks 8 lb 1 oz (3657 g)

2 months 8 lb 10 oz (3912g)

The Mother Who is Re-Lactating

Mom and infant Harry are seeing you at 6 weeks pp because mom had a recent drop in her milk production. Harry was born term, healthy, at 8 lb 12 oz. He was 8 lb 12 oz at 2 weeks. Mom felt that her production was well-matched at that time.

At 4 weeks postpartum, mom was hospitalized in the intensive care unit for 2 days for a kidney infection. The nurses didn’t prioritize her milk production.

Three days after admission, when mom began pumping, her production diminished to 15 ml every 3 hours. She went home on day 5, and began nursing the baby at home, as well as bottle feeding formula. You anticipate that she will rebuild her production. How would you use pre/post feed weights to help in your assessment/management?

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The Parent with a History of Low Milk Production

You are meeting with a pregnant person, who is seeking advice on their history of low milk production with their first infant.The first infant nursed well immediately after birth, but by day 3 was 12% down in weight. They were advised to start supplementing after feeding with bottles of formula. Despite nursing for every feeding, and often pumping after feeding, they needed to supplement the infant approximately 10 oz of formula a day, until weaning at 9 months.This person reports that they didn’t notice any breast growth during the first or second pregnancy. They had gestational diabetes with the first and now with the second pregnancy.You perform a breast exam, and identify changes consistent with insufficient glandular tissue.The individual would like to avoid the level of stress they had with the first infant, but would also like to provide their own milk to the infant.How would you use pre/post feed weights to help manage this individual and their infant?

Conclusions

• Pre-post feed weighing can be a useful tool for

feedback on the quality of infant feeding.

• Pre-post feed weighing does not take the place of

monitoring interval daily weights.

• Pre/post feed weighing can lead to loss of parental

confidence.

• Parents should give permission to have a pre/post

weight done.

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1

The Preterm Infant

1© IABLE 2



Topics for this Session• Definitions of prematurity

• Health risks of the premature infant

• Special considerations in the care of late

preterm and early term infants

• Counseling a parent on the decision to provide

their own milk.

• Maximizing milk production for parents of

premies.

• Optimizing contact with the NICU infant

• Growth of the NICU graduate

Objectives• Identify the different categories of prematurity

• Explain the health risks to preterm infants

• Discuss special care considerations for late preterm and early term infants

• Describe 4 reasons why parent’s own milk is vital for a premature infant, that can be shared with the family.

• Describe at least 3 best practice measures to maximizing parent’s milk production.

• Identify 3 feeding challenges for a premature infant who is leaving the NICU.

• Identify risks and benefits of using a nipple shield for a premature infant at the time of NICU discharge.

Definition of Prematurity by Weeks of Gestation

TERM- 39-40 wks

.Early Term

37-38 6/7 wks

Late Preterm34-36 6/7 wks

PretermLess than 37 wks

Early PretermLess than 34 wks

Very PretermLess than 28-32 wks

Extremely PretermLess than 28 wks

https://www.who.int/news-room/fact-sheets/detail/preterm-birth

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7 Best Practice Measures to Maximize Milk Supply

CPQCC.org Nutritional Support of the VLBW Toolkit 2018

#1 Counsel Parents on the Decision to Provide Their Own Milk

• The decision to provide one’s own milk is

based on the infant’s healthcare needs

– Lowers infant’s risks of premature-related illnesses

• If parent had no intention of feeding their

own milk, counsel on providing expressed

milk during this time for ‘medicinal’

purposes

• Health professional advice highly

influences parent’s decision

Suggested ‘Script’ for a Mother of Premie

med.stanford.edu/newborns/professional-education/breastfeeding/babies-at-risk/mothers-of-nicu-or-pscn-infants.html

Importance of Parent’s Own Milk for a Premature Infant

• Fewer GI residuals and faster

establishment of full enteral

feeds

– Fewer days of IV nutrition• Decreases risk of intravenous

total parenteral nutrition

• Lower risk of:

– Sepsis

– Necrotizing enterocolitis

– Urinary Tract Infection

– Retinopathy of Prematurity

– Chronic Lung Disease

• Improved GI function

– Stronger gut immunity

– Improved gut bacteria

– Decreased gut permeability

• Breastmilk enzymes improve

nutrient absorption

• Improved visual development

• Improved brain development


#2 Optimize Contact With the Infant

• Allows the parent to recognize the reality of the

birth and need to provide one’s own milk

• Skin to skin and early parent-infant contact

increases initiation and duration of

breast/chestfeeding.

• Provide an environment conducive to expressing

milk

– Relaxation at the bedside

– Privacy

– Nonnutritive tasting/licking the breast


#3 Secure a Breast Pump• Secure an appropriate pump for home and NICU

use

– WIC and insurances provide pumps

• Nursing staff should be trained to teach parents

appropriate pump use

• Individualize pump for each parent

– There is not one best pump

– Several factors determine the best pump options

• Double electric pump ideal

– Raises prolactin higher than sequential pumping

– Most efficient; highest yield in shortest time

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#4 Establish Milk Production Early

• Express for 15 minutes, average=8 times a day, limit night time break to 4-5 hours

• When should they start? In the first hour?

9

What Determines Timing of Secretory Activation?

• Observation that early freq feeding is associated with earlier secretory activation

• Many other factors play a role in timing of secretory activation e.g.

• Trauma during delivery• BMI• Insulin resistance• Postpartum stress/complications• Parity

• Milk production in the first few days correlates with long term production

Parker, Sullivan J Perinatology 2012 (32) 205-209

First study to investigate timing of expression on milk volume, within 1 hr

vs 1-6 hours

20 moms of VLBW Premies, Randomized, Pumping 8x/day

10 moms initiated < 60

min

10 moms initiated 1-6

hrs pp

Secretory Activation (when breasts felt full)

• Early initiation group 80.4 hours• Late initiation group 136.8 hours(timing varied greatly, 14-216 hours

in both groups)

Comparing Timing of First Milk Expression for VLBW momsBefore 6 Hours vs After 6 Hours

Parker, Sullivan Breastfeeding Med 10(2) 2015

20 initiated <6 hours pp

20 initiated >6 hours pp

Not randomized; timing of pumping was staff availability,

parent preference

Subjects randomized from

the 2012 study

All mothers encouraged to pump 8 times a day

Parker, Sullivan Breastfeeding Med 10(2) 2015

Bottom line:Pumping before or after 6 hours didn’t matter, unless pumping started within the first hour

Parker, Sullivan, et al J Perinatology 2020 40: 1236-1245

180 mothers with infants < 1500g, < 32 weeks

Previous Studies Not Adequately Powered RCTs

Timing of Milk Expression

N=58 EarlyWithin 60 Min

N=62 IntermediateWithin 61-180 Min

N=60 LateWithin 181-360 Min

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4

• Mothers who initiated at 181-360 min produced more MOM in the first 3 days and over the first 6 weeks

• Overall P values are not significant• Onset of secretory activation was earliest for the intermediate group• Mothers in the early expression group were more likely to cease lactation before discharge

What is Going On?

• 2015 study included mothers who initiated after 24 hours

• Longest time before initiation in 2020 study was 6 hours

• 2012 and 2015 studies not adequately powered to measure true differences in milk volumes and secretory activation

• During the 6 weeks of the 2020 study, the late group had more expressions on day 1 and 14% more expression sessions vs other groups.

• Higher # of expressions may be more important than exact timing

#5 Expressing Human Milk

• Most important determinant of exclusivity and duration of breastfeeding is volume of milk produced

• Maximize milk production while minimizing minutes of expression

• Optimal frequency is 8-10 expressions in 24 hours

• Customize for each individual• High storage capacity- can pump less often

• Night time expression is important to maintain prolactin level

• Duration of night time break depends on storage capacity

• Hands on pumping may improve milk production

CPQCC.org Nutritional Support of the VLBW Toolkit 2018© IABLE 22

© IABLE 23

Storage Capacity

Tolerates longer periods without

milk removal

Necessitates more frequent removal

of milk

© IABLE 24

Hands-On Pumping

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© IABLE 25

Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol 2009

Mean daily volumes (MDV) of expressed milk over the course of the 8-week study of three groups as defined by

frequency of hand expression during the first three postpartum days. Statistical comparisons using analysis of variance were performed only between Groups I, II and III. P<0.05 *vs Group I, vs Groups I and II. (Morton J, et al)

Grp 1= 2 x/day n=15Grp 2= 2-5 x/day n=18Grp 3= >5 x/day n=16

*Mean daily pumping forDay 1-14 = 6x in all groups

© IABLE 26

• Ensure proper flange fit• Too large will cause plugs/mastitis/insufficient production

• Maximize pressure to -150-200mmHg• Use a pressure gauge

• Confirm that parent has had pump education

#6 Frequently Monitor Parent’s 24 Hour Production

• Help parent with using a pumping log

• Consider using the daily 24 hour volume as a ‘vital sign’ during the NICU stay

Pumping Apps for Smart Phones

#7 Galactagogues

• Occasionally medications that increase the prolactin level are helpful

• Domperidone- not available in the USA• Has the most data to support its use for premies

• Metoclopramide- can cause neurologic side effects

• Herbal galactogogues• At least 30 different herbs can increase the supply

• Variable response to them

• Do not take the place of frequent and effective milk expression

Domperidone Use for Mothers with Premature Infants

• Randomized controlled trial- 47/166 women of premiesin a Thai NICU were unable to increase milk volume with routine management

• 24/47 in treatment group- domperidone 20mg 3x/day• 23/47 in placebo group

Breastfeeding Med J Nov 17th 2020

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Change in Prolactin Levels with Domperidone

Breastfeeding Med J Nov 17th 2020

95% of the mothers in the treatment group were providing exclusively human milk at discharge

vs52% of the mothers in the placebo group

Professional Lactation Support

• Knowledgeable health care professionals

• Board certified lactation consultants in the NICU

• Well trained NICU nurses

• NICU peer counselors

• Outpatient support• Health professionals• Support groups• Peer counselors/WIC• Lactation consultants• Public health nurses

Late Preterms(34-36 6/7 wks)

• Less stamina, less alert

• Less effective feeding at the breast

• At risk for insufficient transfer at the breast

• Higher risk of:• Jaundice

• Readmission due to poor feeding

• High sodium levels

• Dehydration

Source: US Breastfeeding Committee

Academy of Breastfeeding Med Protocol #102016 Breastfeeding Med 11(10)

Management Recommendations for Late Preterms- Day of Birth

• Skin-to-skin and early feeding

• Monitor for:• Low blood sugar

• Hypothermia

• Apnea/tachypnea

• Assume high risk of insufficient feeding• Breastfeed ad lib, and at least every 2-3 hours

• Breast compressions during feeding

• Hand express colostrum and administer by spoon in the first 24 hours


Management Recommendations for Late Preterms- In The First 48 Hours

• Avoid weight loss of > 3% by 24 hrs, 7% by 48 hrs

• Often necessary to supplement after nursing

• Supplement with expressed breastmilk or donor milk, ideally

• 5-10ml per feeding day 1• 10-30ml per feeding thereafter

• Pump after nursing if supplementing

• Supplementation can be by spoon day 1, then either cup or bottle

• Infant may be too ineffective to supplement at the breast


Management Recommendations for Late Preterms- First Few Weeks Postpartum

• Watch weights closely

• Continue to wake the infant for feeding if they don’t wake themselves up

• Consider pre-post feed weights if monitoring efficiency of feeding over time

• Stop supplementation as the infant demonstrates ability to gain well (30g day) without supplementation

• Typically the infant is waking themselves by this point


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Case- Penelope

• Penelope was born at 27 weeks gestation to a first-time mother due to premature rupture of membranes.

• She had an uncomplicated course in the NICU, and is ready to leave the hospital at 39 weeks post conception.

• Mother has been pumping regularly, and expresses 750 ml each day.

• During the week before discharge, she has been nursing twice a day with a nipple shield, transferring 25-30 ml each feeding. She then needs an additional 15-25 ml by bottle.

• She takes 45-50 ml for each feeding.

• The NICU discharge feeding plan was as follows:

‘Nurse twice a day with a nipple shield, and offer a bottle of fortified breastmilk. Every bottle of EBM should be fortified with neosure. As she nurses more at the breast, they can decrease the number of bottles of fortified expressed milk’

Case- Penelope

• Mom’s goal is to breastfeeding exclusively

• She is not happy about fortifying her breastmilk and having to pump so much, so she would like to rapidly increase the number of feedings at the breast

• She would also like to stop using the nipple shield.

How would you proceed to help her?

Points of Discussion for Case Penelope

• Understanding her social situation• Social support• ? Working• Exploring her perceived barriers

• Latching without the nipple shield• Teach signs of a nutritive feeding

• Long term risks of the nipple shield• Understanding that the shield may decrease prolactin and milk transfer over

time• Support her milk production while using a nipple shield

• Teach mom paced bottle feeding

• Monitoring growth • Strategies for determining milk transfer• Weekly weights with provider for monitoring

• Monitoring metabolic markers, to determine if she still needs fortification

© IABLE 40Breastfeeding Med 5(6)2010

Why Not a Nipple Shield?

➢An easy fix

➢Nipple shields might decrease prolactino Risk of decrease in milk supply

➢Risk of insufficient milk transfer

➢Need to pump after nursing

➢Does not teach nursingo ? Increase nursing challenges

Video

Infant Needs to Reach Past Shield Safety Measures with Nipple Shield Use

• Follow infant weights closely

• Protect milk production with frequent pumping• Watch milk production closely

• Gradually work on decreasing nipple shield use• Work on removing mid-feed

• Intermittently try latching without it

• Reduce milk supply if needed

Photo by Pop & Zebra on Unsplash

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Rapid Post-Natal Weight Gain With Excessive Fortification

• Increased risk of metabolic syndrome

• High cholesterol• High blood pressure• Cardiovascular

diseases• Type 2 diabetes• Osteoporosis in

adulthood


Decision on Fortifying HM at Discharge for Premature Infants

• Mother/infant room in together before discharge

• Assess whether infant is growing optimally• Growing well with feeding at the breast

• Growth in hospital is at target for wt, length, HC

• Biochemical measures of nutritional status are normal

• If optimal growth:• Consider changing to unfortified HM for a week before discharge,

and monitor growth

• Discharge on unfortified HM with close outpt followup

Academy of Breastfeeding Medicine Protocol #12 Breastfeeding Med 13(4) 2018

Decision on Fortifying HM at Discharge for Premature Infants

• If sub-optimal growth at time of discharge, options:• 3 feedings a day of preterm discharge formula 22 cal, and all

other feeds unfortified HM

• 1 feed of 30 cal/30g formula/day, the rest unfortified HM

• Add powdered preterm discharge formula to enrich to 22 cal/30g for each HM feeding (all are bottles)

• Breastfeed for all feedings, while giving 15 ml of 22 cal preterm formula using a supplementer for each feed

• Initiate one of the above options a week before discharge to monitor growth


Follow-Up After NICU Discharge

• See infant within 72 hours after discharge• Use the Fenton until 50 weeks or Intergrowth-21st Postnatal

Growth of Infant Chart until 64 weeks• Continue to monitor growth if doing fine, every 2-4 weeks

until 6 mo corrected age, then every 2 mo until 1 year corrected age

• Nutritional monitoring• 1 mo after discharge• 4 months corrected age

• Stop fortification if growing well for at least 2 mo after discharge

• Evidence that it is beneficial to stop fortification at 3 mo• Start complementary feeding at 6 months corrected age


Academy of Breastfeeding Medicine Protocol #12

Breastfeeding Med 13(4) 2018

Metabolic Parameters to Follow Post

Discharge

Conclusions

• Supporting parents of premature or ill infants in the NICU is vital to reduce morbidity in premature infants.

• Early milk expression within 1 hour after birth has been shown to be superior than later expression for maximizing milk production.

• Reaching an optimal milk production is associated with longer human milk feeding.

• NICU graduates need long term monitoring of metabolic parameters and growth as fortification is decreased over time.

• Late preterm and early term infants need close monitoring postpartum and often need supplementation of expressed milk.

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Induced and Re-Lactation

Anne Eglash MD, IBCLC, FABM

1

• The Planners and Instructor has no conflicts of interest to

disclose

• Nursing contact hours, continuing education recognition

points (CERPs) for IBCLE, or CPEUs for registered

dietitians, are awarded commensurate with participation

and complete/submission of the evaluation form.

Objectives

1. Describe stories on induced lactation from other cultures in the last few century.

2. Recite evidence-based reasons for relactation.

3. List 4 major topics of discussion that should be incorporated when counseling a

mother who desires induced lactation.

2. Describe 2 typical protocols for breast development.

3. Explain how to counsel on establishing a milk supply after breast preparation.

4. Identify key aspects of dyad support after the infant is born.

3

Definitions• Induced Lactation

• Initiating lactation without birthing• Adoption or surrogacy

• Desire to provide human milk for another family

• Re-lactation• Bringing back milk production after losing it or

weaning

4

1998

Conclusions:• Relactation is possible and practical for almost any woman

if she is adequately motivated and supported. Age, parity, previous breastfeeding experience, and lactation gap are less important factors

• In widely varying studies the majority of mothers produce breastmilk, usually starting within about 1 week. Roughly ½ of all mothers who relactate are able to breastfeed their infants exclusively within 1 month. Mothers relactating for infants to whom they gave birth breastfeed exclusively more often than adoptive mothers

https://apps.who.int/iris/bitstream/handle/10665/65020/WHO_CHS_CAH_98.14.pdf?sequence=1

Historical Documentation of Induced and Re-lactation

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Most Documentation of Induced and RelactationAppeared in the Early 20th Century

7

✓ Common in the Zulu culture for grandmothers to sooth their

grandchildren by suckling when mother is away

✓ Relactation among Zulu grandmothers is well documented

Int J Biomed Sci 3(4) Dec 2007

Relactation in Mothers of Children over 12 Months in Australia

• 6 case reports

• Mothers began suckling these older children• Children asked

• One mother was demonstrating supplementer tubing

• No meds or herbs used

Induced and Relactation in Papua New Guinea in 1990

• 43 women who requested a feeding bottle, ages 19-55 years old• 37 adopted, 7 fostered

• 12 never lactated previously, the others weaned - 4 months-21 years prior

J Trop Ped Vol 40 Aug 1994

89% of the mothers who completed the induction succeeded in achieving adequate lactationMost were known to nurse for at least 9 months

Image Source: Ben White

Protein Levels of Milk From Mothers who Induced Lactation

J Pediatrics Oct 97(4) 1980

5 adoptive mothers▪ 2 previous nursed an

infant▪ 3 had no biologic

children

Relactation by Mothers of Sick and Premature Infants

• 7 infants nursed with a supplementer at the breast• Used dropper or syringe until the infant would latch to the breast

11Pediatrics 67 (4) 1981

Why Induce Lactation or Relactate?

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Soc Sci Med 47(5) 1998 645-656

Breastfeeding, Weaning, and Relactation Patterns in a Shanty Town of Lima Peru 1998

• 36 mothers of toddlers interviewed about weaning and relactation

– 97% of mothers in the population bfed

– 83% of infants between 1-3 mo received non-human milks or other liquids

– Average duration of nursing was 22 mo

Survey Among 366 Women Who Relactatedin USA and Canada 1970-76

14Auerbach Pediatrics 65(2) Feb 1980

Discuss Interest and Identify Goals-

Induced Lactation

• Most often for surrogacy or adoption

• Exploring vs planning?

– Dry run or prime time?

• Review goals

– Any # of drops?

– Nursing at the breast

– Not sure, but nursing is a part of motherhood

• When mom will be with child

Discuss Interest and Identify Goals-

Relactation

• Explore with family to understand issues/goals if recently

weaned

– Maternal illness

– Back to work early

– Difficulty nursing early, now change of heart

• Maternal depression was treated

• More help at home

– Infant illness/intolerance to formula

17Typical Timeline for Induced Lactation

With child

March 1st

Coordination of care in

location where mother/child will be

together

Jan-Feb

Discuss progress with milk expression and storage

Jan 30th

Stop hormones, and start pumpingJan 15th

Pump training and

milk collection Nov 15

Decide on

intervention, discuss pump

Sept 15

Meet with family,

discuss goals, review steps/options

Sept 1

18

Inducing Lactation

Breast Development

Pump and Milk Expression

Collection and Storage of

Milk

Hospital Routine PP

Supplementation

Support Resources

Major Topics to Address

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Breast Development

19

o Most beneficial for mothers without previous pregnancy or bfeedingo Many mothers with a history of prior lactation respond without breast preparation

o Breast preparation may help

Hormonal Breast Development

• Birth control pill, patch, ring, for 1-6 months, avoid the placebo weeks

• Progesterone only pill

• Shot of Depo

Hormones thought to help growth of ducts and alveolar tissue

Breast Development

21

• Medication to increase prolactin• Metoclopramide• Domperidone

• Consider goats rue or metformin• Reduce insulin resistance

Reasons to Not Use Hormones• Medical reasons

• High blood pressure, migraines, blood clots, breast cancer, psychiatric

• Not much time available to induce lactation• Not interested in using hormones or other substances

• High likelihood of making plenty of milk• Recent history of high supply• Still can express drops of milk• Recently weaned

Anticipatory Guidance on Expectations

• Mothers with no history of lactation are expected to have

least milk volume

– Inability to take hormones for breast development adds to this

challenge

• Multiparous mothers are expected to have more milk

– Inability to take hormones may decrease volume

23

Challenges to Breast Development

• History of polycystic ovarian syndrome

• Type 2 diabetes (not using insulin)

• History of high prolactin, treated with medications

24

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Discuss Options of Meds to Increase PRL

Domperidone

• Not approved in the USA

• Cardiac considerations

• Avoid some meds/foods– Fluconazole, erythromycin,

grapefruit

• Possible GI side effects

• Underlying medical problem precluding pregnancy/breastfeeding might preclude domperidone

Metoclopramide

• Inexpensive and available in USA

• Multiple side effects– Neurologic

– Psychiatric- anxiety and/or depression

– Fatigue

– Dizziness

26

Inducing Lactation

Breast Development



Milk

Hospital Routine PP

Supplementation

Support Resources


Pumping and Milk Expression

27

• Choose a pump• During the breast development stage

• Some insurances will cover for induced lact• See back 3-4 weeks before pumping starts

• review pump use, check flanges• Review pumping details

• When to start• When hormones stop• Ideally 6 weeks before having infant

• Frequency, duration• Every 3 hours with no more than a 5 hour

break at night• Add extra nipple stim

• Teach hand expression

Addition of Other Galactogogues

• Continue domperidone or metoclopramide

• Continue goats rue or metformin

• Add galactogogues if desired. Considerations:• Moringa leaf 1000-1500mg tid

• Shatavari 800-1000mg tid

• Torbangun

• Blessed Thistle

• Milk Thistle

• Add one by one, to see effectiveness

28Angele Kamp

Beginning the Process

Expression will SLOWLY increase!

• May take 2 weeks for drops

• Explain principles of regular expression

29Photo by Neosiam 2020

Manage expectations• Expect calls/messages

of disappointment

• Lots of encouragement needed

• Check-in often

30

Inducing Lactation

Breast Development



Milk

Hospital Routine PP

Supplementation

Support Resources


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Collecting and Storing Expressed Milk

• Collect drops using a TB syringe or other w/butterfly, needle clipped off

• Place in tiny container, date, freeze• 11ml, 30ml containers

• Add cooled droplets from next expression

• Bring to the hospital for use immediately after birth

31 32

Inducing Lactation

Breast Development



Milk

Hospital Routine PP

Supplementation

Support Resources


Explore Hospital Routine

• Policies on rooming in for adoptive parents

• Communicate with adoption agency• Wishes of adoptive mother to see/nurse infant

• Will adoptive mother provide breastmilk

• Hospital protocol for surrogacy

• Will surrogate provide expressed breastmilk

For how long?

• COVID-19 rules

• Contact hospital lactation consultants• Automatic lactation consultation?

• Familiarity with surrogacy/adoption?

33

Getting Off to Great Start!

• New Parents have a lot to learn!• Skin to Skin

• Frequency of nursing/pumping

• Infant sleep cycles

• Rooming in

• Hospital routines for blood sugar testing, supplementation• Bring thawed milk

• Infant feeding cues

• Risk of NAS if adopting

• Consider a breastfeeding/ newborn care class

34

From Global Health Media

Supplementation

• Expressed breastmilk

• Donor human milk• From a close friend/relative

• May not be allowed in the hosp

• Banked donor human milk

• Formula

• Options for supplementation• Spoon for first few days• Finger feeding- for first week or so• Cup• At the breast• Bottle

• Teach paced bottle feeding

35

Typical Scenarios

• First few days

– Infant latches, and may not need supplementation

• Depends on expressed volumes already established

– Supply may markedly increase with infant at the breast

– Need to be followed carefully to determine when to supplement

36

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Hospital Lactation Consultants

• Outpatient LC or provider contact hospital LC before hospital arrival• Learn history, progress of induced or relactation

• Work with family with their goals in mind• Avoid bottle?

• Supplement at breast?

• Nurse and pc with bottle?

Photo by Erkan Utu

Outpatient Support post Discharge• Find outpatient support

– Often need to stay in the state for a few weeks

– Require very close follow up

• False sense of security– Risk of over-confidence re milk supply

• Close follow-up when back home– Stay in touch while out of town

• Milk supply may very slowly increase over time– On average over the next 4 months

38

If Adoption Falls Through

• Discuss plans for future- when to expect an infant

• Consider a holding pattern if milk supply has been established

–Decrease pumping to 3-4 times a day

39

Induction for a Transgender Female

• Increase baseline estrogen and progesterone meds (if on them)

– Start estrogen and progesterone if not on them

• Check for contraindications

• Add med (spironolactone) to block androgens

• Add domperidone or metoclopramide to increase PRL

• Consider adding goats rue

• After 2-6 months, lower estrogen and progest to baseline, and start pumping.

• Add other galactogogues

40

Reisman T, Goldstein Z (2018) Case report: induced lactation in a transgender woman, Transgender Health 3:1, 24–26

Induction for a Transgender Male

• May or may not have had top surgery

• Generally considered chest feeding, even if no

breast re-assignment

• Stop testosterone

• Induce as discussed for cisgender females

41

A G1P1 woman Jane is married to her wife Mara who is pregnant at 20 weeks gestation with her second child. Mara has a history of insufficient glandular tissue with her first child, and her maximum production was 20 ml every 3 hours.

Jane would like to relactate to help nurse their newborn. Jane describes having a high supply with her first child, who she nursed for 18 months. She weaned 2 years ago.

What advice would you give her?

How would she balance nursing/milk expression with her wife’s plans to breastfeed?

42

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Induced and Re-lactation Resources

• Book- Breastfeeding Without Birthing by Alyssa Schnell

• http://www.asklenore.-info/breastfeeding/induced_lactation/gn_protocols.shtml -protocols for inducing lactation

• WHO: Relactation: review of experience and recommendations for practice- 1998 http://www.who.int/maternal_child_adolescent/documents/who_chs_cah_98_14/en/

• Kellymom- has a list of references https://kellymom.com/ages/adopt-relactate/relactation-resources/

43

In Summary• Plan on at least 3 visits for induced lactation before birth

• First- Review of goals, expectations, and decision on breast development, educational resources, what pump to purchase.

• Second- One month before stopping hormones, review pump, proper flange fitting, collecting and storing milk

• Third- 2-4 weeks before infant is due, review supplementation strategies, and getting off to a great start

• Arrange close follow-up for dyad after birth where they will be

• Follow closely with you after they return

44

Documents

Updated July 2021 - lacted.org