Managing Lactation Problems in the Neonate

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

2. 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

3. 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

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

5. 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

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

7. 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.

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

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

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

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

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

20. 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;93:137-150.

21. Medications: Principles to Consider • Lipid Solubility • Maternal Plasma Levels • Molecular weight (< 500) • Protein Binding • T1/2 • Infant Dose • Oral Absorption

22. 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

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

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

25. WIC Breastfeeding Services • Information Hotline for parents and health professionals • www.healthyarkansas.com/breastfeeding • Provide pumps for mothers • Peer counselors in some counties • Educational opportunities

26. References for the Health Professional

27. Resources for the Health Professional • AAP: Breastfeeding and the Use of Human Milk Pediatrics Vol. 100, No. 6, Dec. 1997 • AAP: The Transfer of Drugs and Other Chemicals Into Human Milk Pediatrics Vol. 108, No. 3, Sept. 2001. • Academy of Breastfeeding Medicine (protocols): www.bfmed.org • The Breastfeeding Answer Book La Leche League International

28. www.healthyarkansas.com/breastfeedingInformation Sheets for Parents • Planning ahead during pregnancy • Difficult Latch-On • Sore Nipples • Engorgement • Mastitis • Yeast Infection • Storing Breastmilk

29. Written Materials:for the parents

30. What about formal training? • Contact WIC Breastfeeding Services 501-661-2905 • Arkansas Children’s Hospital/ADH • Training for the health professional • Conference Scheduled Sept. 28-30 501-364-1576