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Breastfeeding Issues

Summary

  • Breastmilk is the milk of first choice in neonates, whether term or preterm
  • there are significant clinical benefits to providing breastmilk in the preterm infant
  • expressed breastmilk can be safely frozen for later use
  • human milk fortification should be considered in babies < 1500g or < 30 weeks' gestation
  • very few maternal medications contraindicate breastfeeding
  • maternal Hepatitis C does not preclude breastfeeding (unless nipples are cracked)

Introduction

The Innocenti Declaration (WHO/UNICEF, 1990) recognised that breastfeeding is a unique process that provides ideal nutrition for infants and contributes to their healthy growth and development. The Paediatrics and Child Health Division of the Royal Australasian College of Physicians encourages and supports the promotion of breastfeeding (see website).

Australia is signatory to the WHO International Code of Marketing of Breastmilk Substitutes (1981) which aims to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution (see website).

Benefits of breastmilk

The many benefits of mother's own milk are well known. Breastmilk is a unique 'living' fluid. It contains

  • anti-infective factors
  • hormones
  • enzymes
  • specialised growth factors
  • anti-inflammatory mediators
  • specific nutrients

Colostrum is a high density, low-volume feed high in immunoglobulins, which evolves into mature milk between 3 and 14 days postpartum.

Breastmilk feeding for both preterm and unwell term infants assists recovery and has major health benefits.

As the unwell or preterm infant may not be able to breastfeed mothers are encouraged to provide fresh expressed milk daily; if this is not possible breastmilk can be stored in a refrigerator or freezer.

Storage of Breastmilk for Infant Use

(see NHMRC Infant Feeding Guidelines for Health workers, Commonwealth Department of Health and Family Services, 1996)

Guidelines for collecting and storing breastmilk are more stringent for sick and preterm babies than for healthy babies at home.

  • sterilised containers are recommended
  • refrigeration at 40C for 48 hours results in minimal loss of nutrients and bacterial count is reduced
  • freshly expressed milk should be chilled in refrigerator before adding to frozen milk
  • thaw breastmilk by placing in cool or warm water
  • thawed milk should be used within 24 hours
  • never refreeze or re-warm breastmilk

Time to keep milk in various conditions

Breastmilk Room Temperature Refrigerator Freezer
Freshly expressed into closed container 6 - 8 hours (260C )
If refrigeration is available store milk there		 3 - 5 days (40C)
Store in back of refrigerator where it is coldest		 2 weeks in freezer compartment inside a refrigerator
3 months in freezer section of refrigerator with separate door
6 - 12 months in deep freeze (- 180C)
Previously frozen - thawed in refrigerator but not warmed 4 hours or less
i.e. next feeding		 Store in refrigerator 24 hours Do not refreeze
Thawed outside refrigerator in warm water For completion of feeding Hold for 4 hours or until next feeding Do not refreeze
Infant has begun feeding Only for completion of feeding then discard Discard Do not refreeze
Discard

There is controversy regarding the use of sterile vs clean washed containers for storage of expressed breastmilk (EBM) intended for preterm infants. There is limited published evidence to support the use of clean containers One Level 3 nursery in Melbourne does provide sterile containers which families re-use after washing in the dishwasher and air-drying.

Maintenance of supply of breastmilk

The long-term commitment of expressing breastmilk for a preterm infant is stressful and may result in reduced volumes of EBM. Strategies that assist in maintaining a good supply of milk include

  • the provision of a comfortable environment within the special care nursery if expression at the cotside is impractical
  • reminders that it is the regular emptying of the breasts that stimulates formation of more mature milk
  • the continuing discipline of expressing at least once overnight to ensure the longevity of supply kangaroo care (the practice of mother holding her baby skin to skin between her breasts). The close contact triggers the enteromammary pathway by which a mother produces antibodies in response to antigens in the infant's environment

If supply lags, technique and frequency of expression needs review before resorting to galactogues. Commencement of an oral contraceptive agent may also contribute to reduction in supply. In addition

Galactogues

These are substances, which stimulate the supply of breastmilk. Both pharmacological and herbal preparations are available.

  • Published evidence supportive of herbal preparations is limited. Fenugreek is the most widely recognised however there is no data regarding transmission in breastmilk or safety for preterm infants.

  • Metoclopramide (Maxalon) will stimulate breastmilk supply in the lactating mother. The safety of this medication has been established for preterm infants. Mothers should be advised about the possibility of dystonic reactions. In some women use exacerbates symptoms of depression. Controversy exists over the dosage regime and duration. A suggested regime is 10mg tds for 5 days and then tapering over the next 5 days. Some women benefit from repeated courses but little data exists on the safety of such practice. Metoclopramide often results in dramatic increase in supply, which may not be sustained once medication is withdrawn.

  • Domperidone also acts a galactogue and is safe for preterm infants. There appears to be a slower onset of action but the increase in supply is better maintained than with Metoclopramide. Unfortunately Domperidone is not approved as a galactogue on the Australian Pharmaceutical Benefits Scheme and the quantity required can prove costly. The dose required is 10 - 20 mg qid. Domperidone is better tolerated by mothers as a long term stimulant of breastmilk supply.

Developmental issues

Initiating breast-feeding in preterm infants does not require a demonstrated ability to breastfeed. Kangaroo care is a good introduction to mother's breasts for the preterm or unwell infant. Studies have shown that preterm infants show greater cardio-respiratory stability when breast feeding than bottle feeding. Infants exhibit sucking movements as early as 11 weeks gestation. By 32 weeks there is coordination of sucking and swallowing, but this is not sustained until closer to term.

Controversy exists over the issue of nipple confusion. Ultrasonography has shown that the sucking action used at the breast is different from that used for an artificial teat. A randomised controlled trial comparing artificial teats and cup feeding in preterm infants did not demonstrate any difference in time to achieve breastfeeding. (personal communication). If it is to be mentioned then the technique of cup feeding needs brief explanation

Similarly controversy exists between the advantages of indwelling naso-gastric feeding tubes and intermittent oro-gastric tube feeds.

Sandra Lang in her book "Breastfeeding Special Care Babies" addresses these issues in depth.

Prematurity and nutritional adequacy of human milk

Preterm breastmilk differs from term milk, not only in nutritional composition but also in immuno-protective factors. Preterm infants given breastmilk have significantly reduced rates of sepsis and necrotising enterocolitis compared with infants fed breastmilk substitutes. Preterm infants exclusively breastfed have been found to have an IQ several points greater than infants fed breastmilk substitutes. Is this difference real world significant? Should the degree of difference be stated?

Mother's own milk may not meet the increased nutritional demands of the preterm infant whose birthweight is below 1500g. These needs persist to term postmenstrual age. There is considerable variation in the energy content of expressed breastmilk largely due to separation of the fat whilst standing. Use of hind-milk, with a two to threefold greater fat content than foremilk will provide significantly more energy for growth. The content of protein and sodium declines throughout lactation. Calcium and phosphorous content is also insufficient for the growing preterm infant.


Human Milk Fortifier

Mother's own milk can be supplemented by combining with a commercially prepared fortifier to provide increased protein, energy and minerals.

All human milk fortifiers contain similar amounts of protein, energy, calcium and phosphorous. The differences relate to the type of protein and the amounts of lactose, sodium and vitamins. Dr K Simmer has prepared comparative tables indicating the composition of breastmilk and fortifiers available in Australia.

In general infants with a birthweight less than 1500g and less than 30 weeks gestation will benefit from addition of fortifier, which should continue to discharge, when the infant is not breastfeeding. In practice fortification of breastmilk is best delayed until the infant demonstrates tolerance of a reasonable volume of enteral feeds (150 mls/kg/day). Breastmilk fortification is often commenced at half strength for 2 days and if tolerated full strength supplementation is introduced. However, there are a number of potential complications with fortification. These include:

  • an increase in regurgitation
  • an increase in feed intolerance
  • glycosuria in extremely of preterm infants
  • hypercalcemia in extremely preterm infants

As the fortifier is usually cow's milk based there is a theoretical advantage in using a product in which the protein has been hydrolysed. Infants fed fortified human milk receive less volume, but greater intakes of protein and minerals and experience greater weight gain and incremental linear growth than infants fed unfortified milk. The growth of infants fed fortified breastmilk is still less than infants fed on preterm formula. However the quality of the milk and its many advantages far outweigh any growth disadvantage. In general, fortifier can be discontinued once the infant reaches a corrected age of term and prior to discharge from hospital.

Breastmilk substitutes

When there is insufficient breastmilk available for an infant tolerating enteral feeds parents should give consent for the use of formula. If the intention is to primarily breastfeed then use of a protein hydrolysed or semi-elemental formula may be appropriate. If the infant is not tolerating full volume feeds then the formula should be standard 67 kcal per 100 mls. Most preterm formulae are 85 kcal per 100mls and are fed once the infant is tolerating volumes of 150mls/kg/day as they provide better nutrition. Dr K Simmer has prepared comparative tables indicating the composition of preterm formulae available in Australia. Donor human milk is not an option as there are no human milk banks in Victoria.

In general, preterm formulas can be discontinued once the infant reaches a corrected age of term and prior to discharge from hospital.

Infections

  • Maternal HIV is the only infection in which breastfeeding is contra-indicated in the developed world

  • Hepatitis C has been reported to have a 5% risk of transmission. Most probably this occurs at times of active disease (PCR positive women). It is generally advised that HCV positive mothers do not breastfeed when nipples are cracked.

  • Hepatitis B is not transmitted through breastmilk

  • CMV is transmitted through breastmilk. The burden of disease acquired from breastmilk is not well established. It is presumed that preterm infants are more vulnerable and likely to exhibit more severe clinical illness, such as pneumonitis, than term infants. However women who are CMV positive are not discouraged from breastfeeding as the other benefits are thought to outweigh the risk.

  • Herpes Simplex is not transmitted through breastmilk. Should there be an open sore on the breast the mother would be advised to avoid feeding from that breast.

  • with Varicella and Herpes Zoster (shingles) maternal antibodies transmitted through breastmilk will be protective. However in the case of Varicella if the mother develops chicken pox within 5 days of birth the infant is at risk and should be protected with VZV immunoglobulin. Breast-feeding can then continue, provided there are no lesions on or near the nipple. (link)

  • bacterial infections almost never transmit disease through breastmilk

Maternal medications

  • absolutely contraindicated
    • chemotherapeutic agents
    • radioactive drugs

  • relatively contraindicated
    • lithium
    • citalopram
    • cyclosporin

Most psychoactive medications are now generally considered safe, although dosage needs to be considered. Infants should always be carefully monitored for effects of sedation when their mother's are using psychoactive drugs.

Be aware that drug companies are very cautious in their recommendation of safety for the breastfed infant. Preferably consult specific reference texts or drug advisory services experienced in lactation.

Drugs of addiction

Methadone passes in small quantities into breastmilk and generally the benefits of breastmilk overcome the disadvantages. In situations of very high maternal dosage (eg 90mg daily) the infant is at risk of sedation.

Buprenorphine is a long acting narcotic agonist and antagonist used to replace methadone in opiate addicts. Little information is available regarding the pharmacology of this drug in lactation. Sedative effects are of concern.

Marijuana passes into breastmilk and the relative dose is concentrated. Infants are at risk of sedation, feeding difficulties and poor weight gain.

Herbal preparations

Scientific data is limited. Given the variability in standards of preparation of herbal supplements it is recommended that breastfeeding mothers avoid such products.

Jaundice(see also Jaundice in the first two weeks of life)

Increased rates of initiating breastfeeding have resulted in an increased incidence of jaundice. There is an inverse correlation between the number of breastfeeds per day and level of jaundice. Increasing the number of breastfeeds per day from 6 to 12 per day for each of the first 3 days of life results in significantly lower serum bilirubin on day 3. Increased number of feeds is associated with significantly greater daily milk intake, better elimination of meconium and thereby reduced entero-hepatic circulation.

Commencement of phototherapy should be seen as an opportunity to review breastfeeding frequency and technique. It is not carte blanche to introduce supplemental formula feeds. Preferably mothers will be encouraged to express after feeding and top-up their babies with their own milk rather than formula. Excessive use of formula runs the risk of reducing milk supply, as the infant is less stimulated to empty the breast.

Drugs in pregnancy and/or lactation

ACOG Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 Use of psychiatric medications during pregnancy and lactation. Obstetrics & Gynecology. 111(4):1001-20, 2008 Apr.

Drugs in Pregnancy and Lactation. Briggs G et al. 6th edition 2002. Lippincott Williams and Wilkins.

Medications and Mother's Milk. T Hale. 10th edition, 2002. Pharmasoft publishing, Texas.

Royal Women's Drug Information. Tel. 9344 2000

Mental Health Research Institute Psychotropic Drug Information Service. Tel: 9388 1633

 

Web sites

International Code of Marketing of Breast-milk Substitutes (PDF 128KB)

Breastfeeding Online - Dr Jack Newman  Dr Jack Newman (Toronto paediatrician who established the first hospital based breastfeeding clinic in Canada) provides informative parent hand-outs in addition to practical advice for clinicians

Text: Lawrence R. Breastfeeding: a guide for the Medical Profession. 5th edition available through Breastfeeding.com - Dr Ruth Lawrence

References

J Akre. Infant Feeding: the physiological basis. WHO 1994. Bulletin (Suppl.) 67:25 J Akre.

Infant Feeding Guidelines for Health Workers. 1996. NHMRC

Sosa R, Barness L. Bacterial growth in Refrigerated Human Milk. Am J Dis Child. 1987: 141; 111-112

Whitelaw A. Kangaroo baby care: just a nice experience or an important advance for preterm infants? Pediatrics 1990; 85: 604-605

Ehrenkranz RA et al. Metoclopramide effect on faltering milk production by mothers of premature infants. Pediatrics. 1986;78:614-20.

Da Silva et al. Effect of Domperidone on milk production in mothers of premature newborns: a randomised, double-blind, placebo controlled trial. CMAJ. 2001; 164: 17-21.

Blaymore Bier JA et al. Breastfeeding infants who were extremely low birth weight. Pediatrics 1997;100:E3

Lang S. Breastfeeding Special Care Babies. 1997. Bailliere Tindall. London.

Schanler RJ, Hurst NM, Lau C. The use of human milk and breastfeeding in premature infants. Clin Perinatol. 1999;26:379 - 398

El-Mohandes AE et al. Use of human milk in the intensive care nursery decreases the incidence of nosocomial sepsis. J Perinatol. 1997;17:130 - 134

Lucas A, Cole TJ. Breast milk and necrotising enterocolitis. Lancet. 1990; 336: 1519-1523

Lucas A, Morely R, Cole TJ et al. Breastmilk and subsequent intelligence quotient in children born preterm. Lancet. 1992; 339:261-264

K Simmer. Choice of formula and human milk supplement for preterm infants in Australia. J Paediatr Child Health. 2000;36:593-595.

Ruff. Infection and breastmilk. Semin Perinatol.
Howard CR, Lawrence RA. Drugs and breastfeeding. Clin Perinatol. 1999;26: 447 - 478

Maisels MJ, Gifford K. Normal serum bilirubin levels in the newborn and the effect of breastfeeding. Pediatrics. 1986;78:837-843

De Carvalho M, et al. Frequency of breastfeeding and serum bilirubin concentration. Am Dis Child 1982;136:747-748

Clinical Aspects of Human Milk and Lactation. Clin Perinatol June 1999;26:2

Flint, A. New, K. Davies, M W. Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database of Systematic Reviews. (2):CD005092, 2007.

Moore, E R. Anderson, G C. Bergman, N. Early skin-to-skin contact for mothers and their healthy newborn infants.[update of Cochrane Database Syst Rev. 2003;(2):CD003519; PMID: 12804473].
Cochrane Database of Systematic Reviews. (3):CD003519, 2007.

Shah PS, Aliwalas LI, Shah V  Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database of Systematic Reviews. 3:CD004950, 2006.

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