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The Hows and Whys of Low Milk Supply, and the What-to-do’s

The Hows and Whys of Low Milk Supply, and the What-to-do’s. Rebecca B. Saenz, MD, IBCLC, FABM, LLLL Mississippi Breastfeeding Medicine Clinic, PLLC Madison, MS. Determine the problem. Where does the process break down? Production Transfer Utilization. Etiologies: Three-stage process.

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The Hows and Whys of Low Milk Supply, and the What-to-do’s

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  1. The Hows and Whys of Low Milk Supply,and the What-to-do’s Rebecca B. Saenz, MD, IBCLC, FABM, LLLL Mississippi Breastfeeding Medicine Clinic, PLLC Madison, MS

  2. Determine the problem Where does the process break down? • Production • Transfer • Utilization

  3. Etiologies: Three-stage process • Problems making milk (<5%)- maternal • Problems transferring milk (90+%) • Problems utilizing milk (<10%)- infant Investigate these in reverse order.

  4. Production Problems Physiologic - Interference with “supply and demand” principle (>95%) - inadequate nipple stimulation and/or breast drainage Early: • poor milk transfer • missed feedings • scheduled feedings / timed feedings • pacifier use / masked hunger cues • inappropriate nipple shield use • inappropriate supplementation

  5. Prolactin Receptor Theory There is a critical time frame after birth during which prolactin receptors must be adequately stimulated in order for full lactation to occur. Mammary tissue shows regression after the first week or so, if unstimulated.

  6. Production Problems Physiologic - Interference with “supply and demand” principle (>95%) - inadequate nipple stimulation and/or breast drainage Later: • Scheduled feedings / timed feedings • Inappropriate supplementation • Failure to recognize growth spurts • Initiation of solids • Too soon • Too much • Too fast • Before breastfeeding, rather than after

  7. Production Problems Physio-Hormonal • Retained placental fragment • Persistent theca lutein cyst of pregnancy* • Subsequent Pregnancy • Contraception • “Breast menopause” *Hoover K, et al. J Hum Lact 2002;18(3):264-8

  8. Production Problems Anatomical • Inadequate glandular tissue - congenital • 4 different sub-types described by Kathleen Huggins • augmentation is a red flag! • Inadequate glandular tissue 2o surgical reduction • Surgical denervation of nipples • Surgical interruption of ducts • Radiation therapy changes

  9. Production Problems Pathologic - Hormonal • Panhypopituitarism • Sheehan’s syndrome • Thyroid disease • Hypothyroidism = decreased supply • Hyperthyroidism = impaired MER > engorgement > decreased supply • Polycystic Ovary Syndrome (PCOS)

  10. Production Problems Pathologic – other • Interstitial edema (pathologic engorgement) • Anemia • Dehydration • Any acute or febrile illness • Mastitis • Inflammation • Plugged duct • Localized engorgement • Poorly-controlled diabetes • Obesity • Postpartum Hemorrhage (>dehydration, anemia, pituitary “shock”, Sheehan’s)

  11. Production Problems Pharmacologic - Medications Hormones: Oral contraceptives • combination • Progestin-only Injectable and implantable medroxyprogesterone • Depo-Provera • Norplant Progestin-containing IUD’s Estrogen vaginal cream, NuvaRing Progesterone lollipops

  12. Production Problems Pharmacologic - Medications • bromocriptine (Parlodel) • mebendazole (Vermox) • pseudoephedrine (Sudafed, others) • levodopa (Sinemet) • ergot alkaloids (Cafergot, Wigraine, DHE45) • ergonovine (Ergotrate) • vinca alkaloids (vincristine, vinblastine) • magnesium sulfate • antihistamines • diuretics • cabergoline (Dostinex)

  13. Production Problems Pharmacologic - other Herbal remedies • Sage* • Black Cohosh* *both are ingredients in Avlimil • Ephedra / Ma Huang high-dose vitamin B-6 Smoking - nicotine Ethanol – impairs MER Marijuana - ? high soy intake - phytoestrogens

  14. Transfer problems • poor position • poor latch • impaired milk ejection reflex • bad mechanics • “disorganized” suck • high palate • inadequate nutritive suckling

  15. If the problem is “Baby not breastfeeding well”, then Fix the breastfeeding! (The What-to-do’s)

  16. Lactation physiology (neg) FIL

  17. Transfer problems • Optimize latch • Compression • Pump and feed by alternate means if necessary • Scheduled pumping • Physiologic pumping • Using feeding tube at breast

  18. Milk Ejection Reflex Nipple stimulation causes rise in oxytocin production in anterior pituitary, which causes 1. alveolar myoepithelial cells to contract, squeezing milk down into sinuses 2. increase in prolactin level, which increases milk production

  19. Impaired Milk Ejection Reflex • Pain • Stress • Lack of Confidence • Nicotine • Ethanol • Theophylline • Hyperthyroidism • Timed / scheduled feeds

  20. Facilitating Milk Ejection Reflex • Relaxation techniques • Adequate pain control • Visual imagery • Bach’s Rescue Remedy • Homeopathic 5-flower essences • Oxytocin nasal spray 40u/ml • One spray each nostril 2-3 minutes before feeding or pumping

  21. Galactogogues-There are currently no drugs in US that are FDA approved for use to increase breast milk production.

  22. Metoclopramide (Reglan) • GI prokinetic agent • Hale = L-2 • Increases serum prolactin levels – • “off-label” use • Contraindicated with htn, pheo, sz do, GI bleed or obstruction, depression • Side effects • Dose: 10mg QID; slow taper to stop

  23. Domperidone (Motilium) • NOT FDA APPROVED in US • GI prokinetic agent • Hale = L-2; AAP approved • Increases serum prolactin levels • Contraindicated with GI bleed or obstruction • Side effects • Dose: 20mg QID; slow taper to stop

  24. Other prescription meds • Sulpiride • Chlorpromazine • Methyldopa (Aldomet) • Theophylline Investigational: • TRH • GH • Recombinant HGH

  25. Fenugreek seed • Decrease blood glucose and cholesterol, and has anti-coag effect • Hale = L-3, “GRAS” • ?blocks FIL binding site • Contraindicated in dm, asthma, peanut allergy, Coumadin or aspirin use • Side effects • Dose: 1800mg TID; slow taper to stop

  26. Blessed Thistle • Many uses • Hale = L-3 “GRAS” • ? Mechanism • No known contraindications • No known side effects • Dose ?

  27. Mother’s Milk Tea Active: Fennel fruit 560mg, Aniseed 350mg, Coriander fruit 210mg, and Fenugreek seed 35mg “Inactive”: Spearmint leaf, Lemongrass, Lemon verbena, Marshmallow root, and Blessed Thistle ?activity / efficacy Probably does no harm – “GRAS”

  28. Adjuncts for Increasing Milk Supplyin Extenuating Circumstances

  29. Metformin (Glucophage) in polycystic ovary syndrome • Type 2 diabetes, PCOS • Hale = L-3 • Contraindicated in renal failure • Decreases insulin resistance • Side effects • Dose: 500mg qd > 1000mg BID, usually in combination with metoclopramide or domperidone

  30. Methyldopa (Aldomet) in hypertension • Hypertension • Hale = L-2, AAP approved • Contraindicated with depression, hepatitis • Centrally-acting antihypertensive • 250mg BID > 500mg TID

  31. Summary • Primary insufficient milk supply is rare • Secondary insufficient milk supply is more frequent • Most causes are due to physiologic response: “If you hear hoofbeats, look for horses. If there are no horses, then look for zebras.” • Most causes can be overcome, if treated in a timely manner.

  32. Mississippi Breastfeeding Medicine Clinic, PLLC Rebecca B. Saenz, MD, IBCLC, FABM 111 Depot Drive, Suite A Madison, MS 39110 601-898-7979 Fax 601-898-7989 www.msbfmedclinic.com drbecky@msbfmedclinic.com Also on Facebook and Twitter (@litldoc)

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