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The Association between Epidural Use and Breastfeeding Cessation

The Association between Epidural Use and Breastfeeding Cessation. Elizabeth Brownell, MA Breastfeeding in the Finger Lakes October 23, 2009. Preview. Description of data Background Results Conclusion Strengths Limitations Public health significance Future research Discussion.

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The Association between Epidural Use and Breastfeeding Cessation

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  1. The Association between Epidural Use and Breastfeeding Cessation Elizabeth Brownell, MA Breastfeeding in the Finger Lakes October 23, 2009

  2. Preview • Description of data • Background • Results • Conclusion • Strengths • Limitations • Public health significance • Future research • Discussion

  3. Data Sources: Feeding Your Infant Study (1) • Prospective cohort of 841 BF mothers • Recruited during postpartum hospital stay from two community hospitals in Rochester, NY • Inclusion Criteria • Initiated BF in hospital • English speaking • Healthy term births (≥37 weeks) • Singleton infants • Maternal age ≥18

  4. Data Sources: Feeding Your Infant Study (2) • In-person interview at enrollment • Mailed surveys • 2 weeks • 3 months • 6 months • Birth Certificate data • Mother medical record • Infant medical record

  5. Description of TermsExposure Epidural (EA): • Regional anesthetic injected (via catheter) between vertebrae • Numbs lower abdominal and vaginal area • EA use increasing over past two decades Devroe S, De Coster J, Van de Velde M. Breastfeeding and epidural analgesia during labour. Curr Opin Anaesthesiol 2009;22:327-9.

  6. Epidural Use in Finger Lakes Region 2008 Birth Certificate Data (n=13,776) Women receiving EA more likely to be: • Younger • Non Low Income* • > HS Education • Primiparous • Induced Labor • More forceps and vacuum deliveries *WIC or Medicaid-funded Delivery

  7. Epidural Use by County

  8. Epidural Use by Hospital

  9. County Erie Niagara % Epidural 59.3% 47.4% Epidural Use2008Western County (BC)

  10. Description of TermsOutcome(s) • Initiation: infant receives breast milk at least once • Duration: length of overall breast milk receipt • Cessation: end point • Exclusivity: infant receives only breast milk • Cessation of exclusivity: complete cessation or beginning of supplementation

  11. Progress on HP 2010 BF Objectives CDC’s 2005 National Immunization Survey (NIS) HP 2010 US NYS Initiation 75% 74%76% Duration (6 mo) 50% 43%44% Exclusivity (3 mo) 40% 32% 26% Exclusivity (6 mo)** 17% 12%8% The national immunization survey National Center for Health Statistics, Hyattsville, MD, 2009.

  12. Background (1) • Previous research indicates EA associated with elongation of first and second stages of labor and increased risk of: • maternal hypotension • maternal fever • instrumental vaginal delivery • oxytocin use • Longer labors, cesareans and instrumental deliveries are all related to poor BF outcomes. Halpern SH, Leighton BL, Ohlsson A, Barrett JF, Rice A. Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis. JAMA 1998;280:2105-10. Rajan L. The impact of obstetric procedures and analgesia/anaesthesia during labour and delivery on breast feeding. Midwifery. 1994 Jun;10(2):87-103.

  13. Background (2)Numerous Epidemiologic Studies Evaluating Association Between AE and BF Outcomes • Varying design, sample size, outcome definition, exposure definition, data available on other variables and scientific quality • Informal Conclusion: • The effect of AE on BF duration or exclusivity is inconclusive due to inconsistent results.

  14. Background (3) • Formal Conclusion: Expert opinion (ABM) acknowledges this gap in the literature • Uncertainty whether epidurals are associated with poor BF outcome • Alternatively may be a proxy for abnormal labor that contributes to shorter breastfeeding duration. Montgomery A, Hale TW. ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother. Breastfeed Med 2006;1:271-7.

  15. Background (4)Local Research • Effects on BF initiation • Mechanism = sedating effect on newborn • 181 interviews breast/bottle feeding mothers • Medical Record Review to assess epidural status • No difference between groups • Infant weight loss • Quality of feeding • Infant wakefulness • Ability to learn to feed • Multiple doses and length in system did show an effect Rosen AR, Lawrence RA. The effect of epidruaal andesthesia on infant feeding. Journal of the University of Rochester Medical Center 1994;6:3-7. Personal Communication, Ruth Lawrence

  16. Background (5)Local Research Anecdotal Evidence • Sleepy newborns • Difficulty in coordination of sucking reflex • Excessive fluid related to EA use contributes to poor latch Personal Communication, Dianne Clune Caroline Chantry, Laurie Nommsen-Rivers, Janet Peerson, Roberta Cohen. EXCESS WEIGHT LOSS IN BREASTFED NEWBORNS RELATES TO INTRAPARTUM FLUID BALANCE IN THE MOTHER. The Academy of Breastfeeding Medicine. 14th Annual International Meeting, Williamsburg, Virginia, November 5–8, 2009.

  17. Biologic Explanation of Epidurals on BF Cessation • Unknown…

  18. Research Question • Does the use of EA during labor/delivery influence BF duration or exclusivity? • Modeled analyses after existing literature Torvaldsen S, Roberts CL, Simpson JM, Thompson JF, Ellwood DA. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. Int Breastfeed J 2006;1:24.

  19. Research Objectives • Assess the effect of EA on BF cessation within 30 days • Assess the effect of EA on exclusive BF cessation within 14 days

  20. Baseline Characteristics Epidural Users: • White • > HS education • Primiparous • Community Hospital Birth (vs BFHI) • Vaginal Deliveries • Longer Labors

  21. Results: Any BF (within 30 days) (n=841) aHR p-value Epidural Yes 1.317 0.0404 Education ≤ 12 1.672 0.0019 Parity Primiparous 1.298 0.0403 Not significant in the model: age, minority status, maternal residence, birth hospital, length of labor or labor type (spontaneous, induced, elective cesarean) or delivery route (spontaneous, instrumental or cesarean)

  22. Results Exclusive BF (by 14 days) (n=717) aOR p-value Epidural 1.435 0.0445 Race 1.616 0.0372 BF Confidence < 0.0001 Middle 1.633 Low 4.362 Delivery Route 0.0471 Instrument 0.092 Cesarean 1.388 Not significant in the model: age, maternal residence, birth hospital, labor type (spontaneous, induced, elective cesarean) or BF planned milestone/goal

  23. Conclusions After accounting for relevant variables, epidural users are: • 32% more likely to cease (any) BF within 30 days relative to epidural non-users • 45% more likely to cease exclusive BF within 14 days relative to epidural non-users

  24. Strengths • Large sample size • Prospective • Clear exposure group • Data available on many other variables of interest

  25. Limitations • Secondary analysis • Self report for BF cessation • Analyses limited to primary study’s inclusion criteria; results only generalizable to similar women (no initiation) • Detailed data about intra-partum analgesia and other labor medication is lacking • Biologic effect likely occurs before 14 days • Marginal statistical significance; association may be spurious

  26. Pubic Health Significance • Increased proportion of women choosing receiving EA • Minimize maternal/infant benefits associated with BF (due to decreased duration) • Healthy People 2010 BF objectives met in NY for initiation, but not for BF duration or exclusivity; EA may hinder progress

  27. Further Research • Collect detailed pharmaceutical data • Ongoing • Collect detailed fluid intake data • Ongoing • Utilize biomarkers to document the timing of the effect of EA on delayed onset of lactation • Next step

  28. Research Team • Ann Dozier, RN, PhD (Co-PI FYI) • Cindy Howard, MD, MPH (Co-PI FYI) • Alice Brunet • Dianne Clune, IBCLC • Cynthia Childs, MFA, MPH • Joseph Duckett • Christopher Glantz, MD, MPH • Ruth Lawrence, MD • Bonnie Walden, RN, MS, IBCLC • Holly Widanka, MS

  29. Acknowledgements Data Collection: • Funded by the ATPM Cooperative agreement with Centers for Disease Control, Baby-Friendly's impact on duration and exclusivity; 2004 – 2006; T-1267 Data Analysis: • Funded by PHS Grant # RO1-HD055191, Community Partnership for Breastfeeding Promotion and Support. • The findings and conclusions are those of the authors and do not necessarily represent the views of the funders.

  30. Additional References • Baumgarder DJ, Muehl P, Fischer M, Pribbenow B. Effect of labor epidural anesthesia on breast-feeding of healthy full-term newborns delivered vaginally. J Am Board Fam Pract 2003;16:7-13. • Beilin Y, Bodian CA, Weiser J, et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study. Anesthesiology 2005;103:1211-7. • Chang ZM, Heaman MI. Epidural analgesia during labor and delivery: effects on the initiation and continuation of effective breastfeeding. J Hum Lact 2005;21:305-14; quiz 15-9, 26. • Halpern SH, Levine T, Wilson DB, MacDonell J, Katsiris SE, Leighton BL. Effect of labor analgesia on breastfeeding success. Birth 1999;26:83-8. • Henderson JJ, Dickinson JE, Evans SF, McDonald SJ, Paech MJ. Impact of intrapartum epidural analgesia on breast-feeding duration. Aust N Z J Obstet Gynaecol 2003;43:372-7. • Jordan S, Emery S, Bradshaw C, Watkins A, Friswell W. The impact of intrapartum analgesia on infant feeding. BJOG 2005;112:927-34. • Ortega D, Viviand X, Lorec AM, Gamerre M, Martin C, Bruguerolle B. Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery. Acta Anaesthesiol Scand 1999;43:394-7. • Radzyminski S. The effect of ultra low dose epidural analgesia on newborn breastfeeding behaviors. J Obstet Gynecol Neonatal Nurs 2003;32:322-31. • Ransjo-Arvidson AB, Matthiesen AS, Lilja G, Nissen E, Widstrom AM, Uvnas-Moberg K. Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying. Birth 2001;28:5-12. • Riordan J, Gross A, Angeron J, Krumwiede B, Melin J. The effect of labor pain relief medication on neonatal suckling and breastfeeding duration. J Hum Lact 2000;16:7-12. • Torvaldsen S, Roberts CL, Simpson JM, Thompson JF, Ellwood DA. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. Int Breastfeed J 2006;1:24. • Volmanen P, Valanne J, Alahuhta S. Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices. Int J Obstet Anesth 2004;13:25-9.

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