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Counting Every Drop: Navigating Low Milk Supply


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AANP 2015 presentation discussing causes, interventions, referral, and support for women who can make babies, but have difficulty producing enough milk to feed them.

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Counting Every Drop: Navigating Low Milk Supply

  1. 1. Counting Every Drop: Navigating Low Milk Supply 15.3.103 Jaclyn Engelsher DNP, APRN Family, Psych-Mental Health
  2. 2. Disclosures There are no real or potential conflicts of interest to disclose
  3. 3. Objectives O Describe production and extraction factors that contribute to low-milk supply O List allopathic and complementary interventions to improve supply O Provide referral sources for corrective interventions and psychosocial support
  4. 4. Lactogenesis Essentials O Endocrine Driven O I: Colostrum production O II: Progesterone withdrawal O III: Autocrine Driven O Feedback inhibitor of lactation O Prolactin receptors and lactocytes (Lawrence & Lawrence, 2010)
  5. 5. Transient or Perceived Supply Issues O Post-glandular O Secondary lactation failure O Perceived O Engorgement, leaking, or milk ejection reflex O Bottle preference O Slow weight gain in infant O Transient O Return of menstrual cycle O Lifestyle changes and illness O Starting solids O Frequent or cluster feedings (Lawrence & Lawrence, 2010)
  6. 6. Baby-Friendly Hospital O Skin-to-skin O Initiate breastfeeding within an hour of birth O Rooming-in O Nursing on-demand O Avoid pacifiers and artificial nipples O Exclusive breast-milk at the breast O Education, support, referral O Global initiative launched by WHO & UNICEF (Baby-Friendly USA, 2013)
  7. 7. True Low Supply O Primary lactation failure or insufficiency O Inability to meet daily need O Prevalence estimate 5-15% O Lack of acknowledgement O Pre-glandular O Glandular O Beyond “just relax,” “nurse, nurse, nurse,” and “drink more water” (Whitten, 2013)
  8. 8. Signs & Symptoms O Poor weight gain, weight loss, failure to thrive O WHO growth chart for breastfeeding infants O Regain birth weight within 2 weeks O >7% loss x 1/week O Insufficient urine output O “Marathon” nursing sessions O Falling asleep while nursing O Sucking without drinking O Etiology-specific (Whitten, 2013)
  9. 9. Risk Factors O Pre-Partum Obesity O Pre-partum or gestational diabetes O Breast surgery or structural abnormality O Congenital malformation history O Prematurity O Endocrine disorders: Thyroid, PCOS, luteal phase defect, pituitary, insulin O Hypoplasia or Insufficient Glandular Tissue (IGT) O Pesticides, dioxins, medications, smoking, ETOH, herbal preparations O Retained placenta, post-partum blood loss O Birth trauma and interventions (Dozier et al., 2013)
  10. 10. Historical Context “Suffice to say that ill health in the mother, from whatever the cause, whether functional or organic, is apt to prove a hindrance to suckling.” (Braithwaite, 1897)
  11. 11. Issues with Extraction
  12. 12. Efficient Milk Transfer O Foremilk and hindmilk sucking patterns O Weighted feeding before and after O Emptying breast fully O Positioning & latch O Bilateral & “switch nursing” O On-demand: 1.5-2-hour day intervals, 3- hour night intervals O Pumping output not a reliable indicator of intake or production (Becker, Smith, &Cooney, (2015) (Lawrence & Lawrence, 2010)
  13. 13. Tongue and Lip Tie Signs and Symptoms Mother Child O Nipple trauma – blistered, bleeding, blanched, broken O Pain or discomfort while nursing O Mastitis, thrush, plugged ducts O Sleep deprivation from “marathon” feeding O Clicking noises, chewing nipples, choking on milk, SOA, while nursing O Reflux, colic, or gassiness O Poor latch, difficulty sustaining latch O Prolonged feeding with poor weight gain (Kotlow, 2011)
  14. 14. Revision O Surgical O General or local anesthesia with incision O Insurance coverage available O Laser O In-office procedure, bloodless O Coverage varies O Aftercare O ACE for pain management O Stretching QID to prevent reattachment O Preventative O Dental decay O Orthodontics O Mobility O Speech (Kotlow, 2011)
  15. 15. Pumping for Supply O Dual-chamber and hospital grade pump O Pump after every feeding for 5-10 minutes past last drop collected O Relaxation music and breathing O Power pumping O Pump 10 minutes on/10 minutes off O Stop after 1 hours O Hand expression if non-responsive to pumps (Becker, Smith, & Cooney, 2015)
  16. 16. Stimulation to Promote Supply O Supplemental Nursing System (SNS) O Mother’s milk>donor milk>formula O Cup, syringe, finger feeding O Breast compression O Warmth and massage O On demand O Day interval: 1.5-2 hours O Night interval: 3 hours O Avoid pacifiers & artificial nipples (Becker, Smith, & Cooney, 2015) (Whitten, 2013)
  17. 17. Issues with Production
  18. 18. Hormonal O Thyroid O Regulation of prolactin for production O Regulation of oxytocin for ejection O Insulin resistance O Hypopituitarism O Prolactin deficiency O Progesterone excess O Glucocorticoid excess (Whitten, 2013)
  19. 19. Laboratory O FULL Thyroid panel: TSH, Free T3, reverse T3, Free T4, antibodies O HOMA, fasting insulin, insulin : glucose ratio, McAuley Index, lipids O Prolactin O Baseline 60-110ng/ml postpartum O Doubles 30-45 minutes after nursing O Progesterone, Testosterone, DHEA-S, Cortisol, CBC, Fe
  20. 20. Standard Interventions O Hypothyroid – replacement O Hyperthyroid – methimazole (MMI) O Insulin resistance O Diet & exercise O Metformin, myo-inositol O Postpartum hypopituitarism O Progesterone - non-hormonal birth control O Cortisol – stress reduction (Karras, Tzotzas, Kaltsas, & Krassas, G. E. 2010), (Matarrelli et al., 2013)
  21. 21. Hypoplasia/IGT O Breast asymmetry O Breasts >1.5 inches apart O Breast develop stretch marks without significant growth O Tubular or elongated breast shape O Large areolae in proportion to breast size O High mammary fold (Arbour & Kessler, 2013)
  22. 22. (Arbour & Kessler, 2013) Hypoplasia/IGT
  23. 23. Galactogogues
  24. 24. Domperidone O Dopamine antagonist, antiemetic O Second-line for gastroparesis - increases gastric emptying & peristalsis O Increases prolactin via inhibition of PIF on the pituitary gland O Hale’s lactation risk category L1 O TID dosing, total 90-120mg/day O Weight gain, h/a, menstrual irregularities O Not FDA approved, 2004 cardiac death in elderly O Approved in Canada and Europe O Compounding pharmacies (Jones & Breward, 2011) , (Phan, DeReese, Day, & Carvalho, 2014)
  25. 25. Metoclopramide O Dopamine-receptor antagonist, antiemetic O FDA approved for gastroparesis , GERD O TID dosing, total 30-45mg/day O Crosses CNS O Mood disorders, EPS, sedation O Hale’s lactation risk category L2 (Fife et al., 2011) (Shiva, Frotan, Arabipoor, & Mirzaaga, 2010)
  26. 26. Fenugreek Leguminosae Trigonella foenum-graecum O TID dosing, total of 3.5-7.3 grams/day O Simulates sweat gland O GRAS by FDA O Side Effects O GI disturbances in infant O Hypoglycemia O Maple syrup effect O Contraindicated O Thyroid disorders O Anticoagulants O MAOIs (Arbour & Kessler, 2013) (Damasceno et al., 2015)
  27. 27. Goat’s Rue Galega officinalis O TID-QID dosing, total of 1.2-2 grams/day O Tincture > powdered capsule O Increase functional breast tissue O “Herbal metformin” O Improves insulin sensitivity O Contains galegin O Side effects O Hypoglycemia O Blood-thinning O Diaphoresis (Arbour & Kessler, 2013) (Damasceno et al., 2015)
  28. 28. Adjunctive Herbals O Shatavari (Asparagus racemosus ) O “Herbal domperidone” O BID 2g/day O Estrogenic, insulin, O Production loss reported O Blessed thistle (Cnicus benedictus) O Alfalfa O Fennel (Foeniculum vulgare) O Milk thistle (Silybum marianum) (Arbour & Kessler, 2013) (Damasceno et al., 2015)
  29. 29. Food Therapy O Multi-vitamin, B-Complex, Iron O Appropriate hydration O Oats O Brewer’s yeast O Flax O Morniga oleifera O Aniseed (Pimpinella anisum) O Bitter Melon (Momordica charantia Linn) (Damasceno et al., 2015) (Whitten, 2013)
  30. 30. Resources O Mothers Overcoming Breastfeeding Issues O Closed Facebook support groups O IGT and Low Milk Supply!/groups/IGTmamas/ O Tongue Tie Babies O International Board of Lactation Consultant Examiners O Frenectomy O Hand Expression O Human Milk Banking Association of North America O Human Milk for Human Babies O La Leche League O Pinterest
  31. 31. References O Artini, P. G., DiBerardino, O. M., Papini, F., Genazzani, A. D., Simi, G., Ruggiero, M., & Cela, V. (2013). Endocrine and clinical effects of myo-inositol administration in polycystic ovary syndrome. A randomized study. Gynecological Endocrinology, 29(4), 375-309. doi: 10.3109/09513590.2012.743020. O Arbour, M. W., & Kessler, J. L. (2013). Mammary hypoplasia: Not every breast can produce sufficient milk. Journal Of Midwifery & Women's Health, 58(4), 457-461. doi:10.1111/jmwh.12070 O Becker, G. E., Smith, H. A., Cooney, F. (2015). Methods of milk expression for lactating women. Cochrane Database of Systematic Reviews, 2(CD006170). DOI: 10.1002/14651858.CD006170.pub4. O Braithwaite, J. (1897). The retrospect of practical medicine and surgery. New York, New York: G.P. Putnam’s Sons O Breastfeeding Report Card United States O Bodley,V. and Powers, D. Patient with insufficient glandular tissue experience milk supply increase attributed to progesterone treatment for luteal phase defect. Journal of Human Lactation 1999; 15(4):339-43. O Brink, C. B., Viljoen, S. L., deKock, S. E., Stein, D. J., & Harvey, B. H. (2004). Effects of myo-inositol versus fluoxetine and imipramine pretreatments on serotonin 5HT2A and muscarinic acetylcholine receptors in human neuroblastoma cells. Metabolic Brain Disease, 19(1-2), 51-70. O Dozier, A., Howard, C., Brownell, E., Wissler, R., Glantz, J., Ternullo, S., & ... Lawrence, R. (2013). Labor epidural anesthesia, obstetric factors and breastfeeding cessation. Maternal & Child Health Journal, 17(4), 689-698. doi:10.1007/s10995-012-1045-4 O Damasceno de Aguiar Brotto, L., Diniz Brusque Marinho, N., Pinheiro Miranda, I., de Fátima Almeida Lima, E., Caniçali Primo, F. L., & Caniçali Primo, C. (2015). Use of galactogogues in breastfeeding management: Integrative literature review. Revista De Pesquisa: Cuidado E Fundamental, 7(1), 2169- 2180. doi:10.9789/2175-5361.2015.v7i1.2169-2180 O Fife, S., Gill, P., Hopkins, M., Angello, C., Boswell, S., & Nelson, K. M. (2011). Metoclopramide to augment lactation, does it work? A randomized trial. Journal Of Maternal-Fetal & Neonatal Medicine, 24(11), 1317-1320. doi:10.3109/14767058.2010.549255
  32. 32. References O Huggins, K., Petok, E., Mireles, O. Markers of lactation insufficiency: a study of 34 mothers. Current Issues in Clinical Lactation 2000; 25-35 O Jones, W., & Breward, S. (2011). Use of domperidone to enhance lactation: What is the evidence?. Community Practitioner, 84(6), 35-37. Karras, S., Tzotzas, T., Kaltsas, T., & Krassas, G. E. (2010). Pharmacological treatment of hyperthyroidism during lactation: Review of the literature and novel data. Pediatric Endocrinology Reviews: PER, 8(1), 25-33. O Kotlow, L. (2011). Breastfeeding should be fun and enjoyable: Why does it hurt when I breastfeed? [PowerPoint slides]. Retrieved from O Lawrence, R. and Lawrence, R. (2010). Breastfeeding: A guide for the medical profession, seventh ed. Philadelphia, Pennsylvania: Elsevier Mosby O Matarrelli, B., Vitacolonna, E., D'angelo, M., Pavone, G., Mattei, P. A., Liberati, M., Celentano, C. (2013). Effect of dietary myo-inositol supplementation in pregnancy on the incidence of maternal gestational diabetes mellitus and fetal outcomes: A randomized controlled trial, Journal of Maternal- Fetal & Neonatal Medicine. 26(10), 967-972. 6p. DOI: 10.3109/14767058.2013.766691. O Phan, H., DeReese, A., Day, A. J., & Carvalho, M. (2014). The dual role of domperidone in gastroparesis and lactation. International Journal Of Pharmaceutical Compounding, 18(3), 203-207. O Prime, D. K., Garbin, C. P., Hartmann, P. E., & Kent, J. C. (2012). Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression. Breastfeeding Medicine, (6), 442. O Ramsay, D. T., Kent, J. C., Hartmann, R. A., and Hartmann, P. E. (2005). Anatomy of the lactating human breast redefined with ultrasound imaging. Journal of Anatomy, 206(6), 525-534. doi: 10.1111/j.1469-7580.2005.00417.x O Shiva, M., Frotan, M., Arabipoor, A., & Mirzaaga, E. (2010). A successful induction of lactation in surrogate pregnancy with metoclopramide and review of lactation induction. International Journal Of Fertility & Sterility, 3(4), 191-194. O Whitten, D. (2013). A precious opportunity: supporting women with concerns about their breastmilk supply. Australian Journal Of Herbal Medicine, 25(3), 112-126.