Milk Supply: Building Confidence in Mother's & Providers Nan Dahlquist, MD, IBCLC, FAAP, FABM

Reasons for Earlier than Desired Cessation of Breastfeeding Reasons for Earlier than Desired Cessation of Breastfeeding. By Edom, Li, Scanlon, Perrine, Grummer-Strawn. 2/18/13 Pediatrics.

Reasons for Earlier than Desired Cessation of Breastfeeding Reasons for Earlier than Desired Cessation of Breastfeeding. By Edom, Li, Scanlon, Perrine, Grummer-Strawn.Pediatrics 2/18/13 A study of 1177 mothers who completed monthly surveys found that 60% of the moms stopped breastfeeding before they had originally planned. Prenatally, both groups planned to breastfeed around 8 mo.. Moms who reported meeting their goals, nursed around the 8 mo. and those reporting they did not reported 3.8 mo. breastfeeding on average.

Reasons for stopping significantly associated with mother's breastfeeding intention. adjusted for age, parity, household poverty level, race, marital status, education, WIC participation, and prenatal months of breastfeeding intention (N = 1177). Reasons for stopping significantly associated with mother's breastfeeding intention. adjusted for age, parity, household poverty level, race, marital status, education, WIC participation, and prenatal months of breastfeeding intention (N = 1177). Odom E C et al. Pediatrics 2013;131:e726-e732 ©2013 by American Academy of Pediatrics

Reasons for stopping significantly associated with mother's breastfeeding intention. adjusted for age, parity, household poverty level, race, marital status, education, WIC participation, and prenatal months of breastfeeding intention (N = 1177). Reasons for stopping significantly associated with mother's breastfeeding intention. adjusted for age, parity, household poverty level, race, marital status, education, WIC participation, and prenatal months of breastfeeding intention (N = 1177). Odom E C et al. Pediatrics 2013;131:e726-e732 ©2013 by American Academy of Pediatrics

Most common reasons for early cessation were in 4 categories. Lactation Infant nutrition and weight Need to take meds or illness. Milk pumping, improper latch.

Lactation

Overproduction Underproduction Lactation Maternal complications Infant complications Underproduction Maternal contributions Infant contributions

Overproduction Maternal Complications Incomplete emptying Pain plugged ducts or pores Infection Mastitis, abscess Engorgement Latch complications

Overproduction Infant Complications Transfer mismatch Poor weight gain Foremilk/hind milk imbalance Difficult latch Overfed Reflux Fussiness

Underproduction Maternal contributions Medical, Glandular deficiencies Less than 5% of women Breast surgery. Delay in lactogenesis Surgery Delivery complications Medical

Underproduction Mental Health Depression Edinburgh Depression Screen Dependencies Nicotine Drugs, prescription vs. illicit.

Underproduction Social Lack of support Lack of knowledge base Doubts and undermining Lack of knowledge base Perceptions Supplementation Which came first?

Underproduction Infant contributions Sleepy baby Fussy baby Social Jaundice Late preterm Fussy baby Hungry Gassy Social Schedules Work Supplementation

Underproduction Management Evaluation Support History Latch Expectations Support Reevaluate latch Review milk transfer

Underproduction Treatments Review supplementation. Stimulation General health support Galactagoges Herbs Domperidone Reglan Review supplementation.

Perceptions Insufficient or lost milk soft breasts short feedings pumped volume Baby not satisfied with breast milk. gassiness maternal diet quiet after formula maternal stress

Infant nutrition & weight

Infant nutrition and weight Insufficient milk transfer Immaturity Developmental problems Medical issues Slow weight gain ½ to 1 oz.. a day. Test weight caution Familial growth patterns Perceptions, growth curves Who vs. CDC growth curves. Perceived Insufficient milk transfer

Infant nutrition and weight Insufficient milk transfer Immaturity Late Preterm 36-37 wks. Preterm Developmental problems Low tone/high tone infant Chromosomal anomalies, e.g. Downs Drug affected infants Medical issues Reflux Intake good, cannot maintain calories. Physical cardiac, renal, endocrine, etc.

Infant nutrition and weight Slow weight gain Intake vs. expenditure. Look for ½ to 1 oz. gain per day. Preterm infant growth and expectations. Test weight caution Milk transfer difficult to quantify in first week of life in single test weight. Familial growth patterns Sibling growth patterns. Parental size.

Perceptions Perceived Insufficient milk transfer Shorter feedings, improved efficiency Frequency (growth spurt vs. cluster feeding) Expectations of growth (preterm, term) Night wakening Long feedings (nutrition vs. pacification) shorter feeds, improved efficiency frequency (growth spurt vs. cluster feeding) Expectations of growth (preterm, term) Night wakening Long feedings (nutrition vs. pacification)

Infant nutrition and weight Perceptions Slow gain based on growth curve Who vs. CDC growth curves. Measurement errors

Comparison of the WHO and CDC weight-for-age Z-score curves for boys. de Onis M et al. J. Nutr. 2007;137:144-148 ©2007 by American Society for Nutrition

Illness or Medications.

Need to take meds or illness. Maternal illness Mastitis or abscess Medication compatibility with breastfeeding Most antibiotics are safe. Milk cultures recommended. Systemic illness Acute-cold management, hydration Chronic-medication management Medications and breastfeeding Thomas Hale, PhD Mediations & Mothers Milk Lactinet on Toxnet

Need to take meds or illness. Infant Illness Acute Respiratory RSV URI Gastric GI Antibody support factors Chronic Excess energy expenditure Poor absorption/utilization

Milk pumping, improper latch.

Milk pumping, improper latch. Abandoned direct feeding Pump and bottle feed complications Sore cracked bleeding nipples Shallow latch Tongue tie Mouth-nipple mismatch Too painful Breast pains Nipple pain nipple blebs Engorgement Day 3-5. After 1st month

Milk pumping, improper latch. Abandoned direct feeding Pump and bottle feed complications Milk removal limitations Bottles and nipples Mechanics of suck Overfeeding/underfeeding

Milk pumping, improper latch. Sore cracked bleeding nipples Shallow latch Should be reversible with support Tongue tie Clip Mouth-nipple mismatch Large nipple, small mouth. Shield Temporary pump while baby grows.

Milk pumping, improper latch. Too painful Breast pain Tissue fullness inflammation is temporary Let down tenderness Dysphoric milk letdown syndrome Nipple pain Good latch should not hurt! Teething Nipple blebs Lecthitin Olive Oil massage Instrumentation

Milk pumping, improper latch Engorgement Day 3-5. Lactogenesis Inflammatory process Supplementation After 1st month Growth spurts Change feeding frequency

Reasons for Earlier than Desired Cessation of Breastfeeding Reasons for Earlier than Desired Cessation of Breastfeeding. By Edom, Li, Scanlon, Perrine, Grummer-Strawn.Pediatrics 2/18/13 CONCLUSIONS: Our findings indicate that the major reasons why mothers stop breastfeeding before they desire include concerns about maternal or child health (infant nutrition, maternal illness or the need for medicine, and infant illness) and processes associated with breastfeeding (lactation and milk-pumping problems).

CONCLUSIONS: Continued professional support may be necessary to address these challenges and help mothers meet their desired breastfeeding duration. Question: Are Goals Reasonable? Expectations vs. Reality.

Ideals

Reality

Summary Rarely is the problem true loss of milk production. More often decreased milk supply secondary to lack of emptying related to poor removal or on occasion poor letdown. Pain can be the start of the long term supply problems. Support can help resolve pain. Mom’s need to understand pain is NOT a part of breastfeeding. If there is a concern about infant intake, feeding needs to be evaluated and supported by a trained provider.

Questions?