Managing Lactation Problems in the Neonate Kristi Palmer, M.D. Neonatology UAMS/Arkansas Children’s Hospital

Synagis Monoclonal Antibody Given to all < 32 wk preemies Hospitalization rates for RSV fell by 47% Last winter 1200 children dosed in AR Cost $7,082 per patient Total bill = $8,498,400

Breastmilk Hospitalizations for pneumonia or bronchiolitis less than 50% that of formula-fed babies Improves immune development Decreased risk for diabetes, Crohn’s, ulcerative colitic, lymphoma, allergies, obesity Higher I.Q. 60% lower incidence of NEC Family saves $1000/year

Managing Lactation Problems in the Neonate Kristi Palmer, M.D. Neonatology UAMS/Arkansas Children’s Hospital

Benefits for mother Lower risk of postpartum bleeding Faster weight loss after delivery Fewer missed days of work Decreased risk of ovarian and breast cancer Lower risk of osteoporosis

Objectives Common myths Common lactation problems and basic management Resources for physicians/nurses

Myths A postpartum patient should not breastfeed because she is taking pain medicine or “strong” antibiotics. The baby is sick, so mom cannot breastfeed. The baby is premature and too small to nurse.

Contraindications to Breastfeeding Galactosemia Mother using illicit drugs Mother with active untreated TB HIV (in developed countries) Herpetic lesions on breast Maternal Varicella

What can the obstetrician/pediatrician do? Encourage the patient to consider breastfeeding Inform her of the real health benefits for herself and baby Provide written information

What can we do on L & D or postpartum? Encourage Breastfeeding as the norm Feed within the first hour Keep baby with mother Assess feedings regularly Knowledgeable nurses Lactation Consultant Services Limit Supplementing Encourage pumping if baby is not breastfeeding

Sleepy Baby/Problems Latching Wake the baby Correct Positioning Baby’s mouth opened widely

Assessment Prior to Discharge Trained Observer Assess Latch/Positioning/Adequacy of feed Documentation every shift Educate parents –Positioning –Feeding cues –Feeding 8-12 times/day on demand –Diary of feeds/output –Pumping –When to call physician

Signs of adequate intake Audible Swallowing Minimal Weight Loss –< 3% at 24 hours –< 7% during first week Normal Output for age –1 wet/1 stool by 24 hours –6-8 wets/4 stools at 7 days

Follow-Up AAP recommendation – Office visit within one to two days after discharge (by 2-4 days of age) For < 38 weeks, weekly weight check until 40 weeks Feeding frequency, duration, supplements, output, weight

Premature or Ill Baby Don’t forget to help mother start pumping Save all milk Label with date/time/medications Store in refrigerator or freezer

Engorgement Red Flag – Assess the baby Prevention Nurse or pump frequently, limit supplements Treatment Cold compresses between feedings Warm compresses prior to Pumping/Feeding Pain Medication

Low Milk Supply/Growth Failure Maternal issues Infrequent/timed nursing Infant issues –Difficult delivery/sedation –Jaundice –Infection

Mastitis Mother has flu-like symptoms: –Fever, chills, aches –Breast may be painful/warm/red Risk factors: –Engorgement –skin breakdown –tight clothing –poor feeding

Mastitis Nurse or pump frequently Warm compresses Acetaminophen/ibuprofen for fever/pain Antibiotics - 10 day course –Clindamycin –Cephalexin –Augmentin

Maternal Medications Mother should interrupt breastfeeding if receiving: Radioactive isotopes Antimetabolites Cancer chemotherapy agents American Academy of Pediatrics, Committee on drugs. The transfer of drugs and other chemicals into human milk. Pediatrics. 1994;93:

Medications: Principles to Consider Lipid Solubility Maternal Plasma Levels Molecular weight (< 500) Protein Binding T 1/2 Infant Dose Oral Absorption

Thomas Hale: Medications and Mothers’ Milk Information by Drug Pregnancy Risk Lactation Risk Category: L1 to L5 –L1 Safest –L2 Safer –L3 Moderately Safe –L4 Possibly Hazardous –L5 Contraindicated AAP recommendations Alternatives

Thomas Hale: Clinical Therapy in Breastfeeding Patients Drug therapy listed by maternal disease –Mastitis –Postpartum Depression –Contraception –Hypertension –Diabetes

Who can I call? Hospital Lactation Specialist/Consultant Area Health Department WIC Breastfeeding Services Arkansas Children’s Hospital Lactation Consultant

WIC Breastfeeding Services Information Hotline for parents and health professionals Provide pumps for mothers Peer counselors in some counties Educational opportunities

References for the Health Professional

Resources for the Health Professional AAP: Breastfeeding and the Use of Human Milk Pediatrics Vol. 100, No. 6, Dec AAP: The Transfer of Drugs and Other Chemicals Into Human Milk Pediatrics Vol. 108, No. 3, Sept Academy of Breastfeeding Medicine (protocols): The Breastfeeding Answer Book La Leche League International

Information Sheets for Parents Planning ahead during pregnancy Difficult Latch-On Sore Nipples Engorgement Mastitis Yeast Infection Storing Breastmilk

Written Materials: for the parents

What about formal training? Contact WIC Breastfeeding Services Arkansas Children’s Hospital/ADH –Training for the health professional –Conference Scheduled Sept