Breastmilk as Epigenetic Medium NPO Conference, Portland Oct 2018 - - PowerPoint PPT Presentation

Breastmilk as Epigenetic Medium

NPO Conference, Portland Oct 2018

Sylvia Metzger

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Objectives

1. Introduce the concept of epigenetics

• 2. Discuss epigenetic effects of breastmilk and lactation programming on

infant health outcomes

• 3. Compare and contrast modes of feeding and its impact on

microbiome and infant health outcomes

• 4. Discuss common breastfeeding challenges and strategies to support

mother-baby breastfeeding dyads in clinical practice

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Baby’s menu impacts DNA

Globally, only 38% of infants are exclusively breastfed US: only 13-14% are exclusively breastfed for 6 months Nutritional epigenetics – the diet changes the gene expression

• modulates gene expression –turns genes on/off
• later effects on health.

Verduci et al. ( 2014). Epigenetic effects of human breast milk. Nutrients, 6 : 1711-1724

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Epigenetics

Modification of gene expression without changes in DNA (the genetic code itself)

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Basic epigenetic mechanisms

1. DNA methylation 2. Histone modification 3. miRNA

https://en.wikipedia.org/wiki/File:Epigenetic_mechanisms.jpg

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• 1. DNA methylation – genome guardian
• A chemical cap (CH3-) binds to or near a gene
• Gene is silenced or turned off

e.g. Breastfeeding – baby LEPTIN “ I am full” The longer she BF, the less chance that the gene will be methylated (silenced), which sends signals of satiety

Obermann-Borst, S.A. et al (2013). Duration of breastfeeding and gender are associated with methylation of the LEPTIN gene in very young children. Pediatric Research, 74(3):344-349.

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• 2. Histone modification- access to info
• DNA hugged tightly: the info CANNOT be “read”  NO PROTEIN
• Histones “loosen”, information is ACCESSED & “READ” - PROTEIN is made

e.g. DM Type 1: Altered histone methylation induced by hyperglycemia

Picascia et al. (2015). Epigenetic control of autoimmune diseases: from bench to bedside. Clinical Immunology, 157(1):1-15.

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• 3. miRNAs – key regulators in maternal-fetal crosstalk

Do not code, but regulate gene expression

• Key in fetal metabolic & immune programming
• Promote infant’s growth
• Deficient in infant formula
• Most human and bovine milk miRNAs sequences are

identical

• Raw farm milk (miRNA-148s)- atopy preventive effect
• Persistent consumption of pasteurized milk – increased risk
• f obesity and hyperphagia

Melnik, B.C., & Schmitz, G. (2017). MicroRNAs: Milk’s epigenetic regulators. Best Practice & Research Clinical Endocrinology & Metabolism, 31:427-442.

miRNA

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Breast Milk Microbiota

• Modulates the immunologic development via personalied microbial and

immune factors

• Breastfed baby ingests up to 800,000 bacteria daily (BM 1,000 CFUs/ml)
• Seeding the infant’s gut: transfer from breastmilk to baby
• Different composition in formula fed infants
• Maternal health also alters milk microbiota (delivery mode, stress etc)
• Better Th1 responses in breastfed infants compared to formula

Le Doare, K.L., Holder, B., Bassett, A, & Pannaraj, P.S. (2018). Mothers’s Milk : A purposeful contribution to the development of the infant microbiota and immunity. Frontiers in Immunology,9(361):1-10. Pannaraj, P.S., Rollie, A. & Bailey, A. (2017). Association between breast milk bacterial communities and establishment and development of the infant gut microbiome. JAMA Pediatrics, 17(7):647-654.

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Be Benefits nefits fo for r BA BABY BY

Condition % Lower risk Breastfeeding comment Otitis media Recurrent OM 23% 50% 77% Any BF compared to formula >3 or 6 mon of EBF (exclusive) > 6 mon EBF compared to 4-6 BF Upper respiratory tract infection (serious colds, ear and throat infections) 63% >6 mon (EBF) Lower respiratory tract infection – risk of hospitalization in 1st yr of life 72% 77% >4 mon EBF > 6 mon EBF compared to BF 4-6 mon Asthma 40% 26% >3 mon (if atopic family history) >3 mon (if no atopic family history) RSV bronchiolitis – severity (duration of hospitalization / O2 requirements) 74% > 4 mon EBF NEC (1 case could be prevented if 10 babies EBF) 77% NICU, preterm – exclusive human milk Atopic dermatitis 27% 42% > 3 mon (EBF negative family history) > 3mon (EBF positive family history)

American Academy of Pediatrics (2012). Breastfeeding and the Use of Human Milk, 129(3)”827-841 http://pediatrics.aappublications.org/content/129/3/e827/T2.expansion.html

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Condition % Lower risk Breastfeeding comment Gastroenteritis (effect lasts for 2 m after BF is stopped) 64% Any BF SIDS 36% Any BF > 1 mon Inflammatory bowel disease (intestinal colonization is different in BF babies) 31 % Any BF Obesity 24% Any BF Celiac disease (if BF when exposed to gluten) 52% > 2mo Type 1 DM 30% >3 mon EBF Type 2 DM 40% Any BF Leukemia (ALL) Leukemia (AML) 20% 15% > 6 mon > 6 mon

American Academy of Pediatrics (2012). Breastfeeding and the Use of Human Milk, 129(3)”827-841 http://pediatrics.aappublications.org/content/129/3/e827/T2.expansion.html

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Autoimmunity

American Academy of Pediatrics (2012). Breastfeeding and the Use of Human Milk. Pediatrics 129(3): e827-e841 Lund-Blix et al. (2017). Infant feeding and risk of type 1 diabetes in two large Scandinavian Birth Cohorts. Diabetes Care, 40(7): 921-927

• Diabetes Type I – by 30% if exclusively BF at least 3 months
• Celiac disease – by 52% in infants breastfed when exposed to gluten
• Rheumatoid arthritis (cumulative BF > 12 m, RR 0.8, if > 24 m, RR 0.5)
• Childhood inflammatory bowel disease – by 31% (Crohn’s , Ulcerative

colitis)

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Maternal Benefits

Decreased risk of

• Breast, ovarian, & endometrial cancer
• Obesity
• Diabetes mellitus II
• Hyperlipidemia
• Hypertension
• Myocardial infarction
• Rheumatoid arthritis
• Decreased postpartum blood loss
• Postpartum depression

Schwarz, E.B., & Nothnagle, M. (2015). The Maternal Health Benefits of Breastfeeding. Am Fam Physician, 91 (9):604-4 American Academy of Pediatrics (2012). Breastfeeding and the Use of Human Milk, 129(3):827-841 http://pediatrics.aappublications.org/content/129/3/e827/T

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Lactation as critical window of opportunity

• The First 1000 days – breastmilk as a

significant early life programming medium

Cunha, A.J., Leite, A.J., & Almeida, I.S. (2015). The pediatrician’s role in the first thousand days of the child: the pursuit of healthy nutrition and development. J Pediatri (Rio J), 91(6 Suppl 1): S44-51

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Lactational programming

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• 1. IMMUNE programming
• miRNAs in breastmilk – key players in immunity
• Milk – body fluid richest in miRNA
• More in colostrum > mature milk
• Modify gene expression of distant cells
• ~60% of all human genes
• Decrease inflammation (↓NEC)
• This mom-baby signaling is absent in formula

Alsaweed, M., Hartmann, P.E., Geddes, D.T., & Kakulas, F. (2015). MicroRNAs in Breastmilk and the Lactating Breast: potential immunoprotectors and developmental regulators for the infant and the mother. International Journal of Environmental Research and Public Health, 12(11):13981-14020. Melnik, B.C., & Schmitz. G. (2017). MicroRNAs: Milk’s epigenetic regulators. Best Practice and Research. Clinical Endocrinology and Metabolism, 31(4):427-442.

miRNA

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Breastfeeding & Childhood Asthma

Canadian longitudinal birth cohort (N=3296)

• Mode of feeding ~ asthma diagnosis at 3 yrs

Results

• Modes of infant feeding are associated with asthma development
• Direct BF (most protective) > expressed breastmilk> formula
• Bottled fed with BM or formula – increased risk of

coughing/wheezing episodes by 1 yr compared to babies directly BF

Klopp et al. (201 7). Modes of Infant Feeding and the Risk of Childhood Asthma: A Prospective Birth Cohort Study. The Journal of Pediatrics, 190:192-199.

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• 2. METABOLIC programming
• Lactation period- a critical window of susceptibility to insults due

to continued organ differentiation and growth

• Transient insults can have lasting effects
• Metabolic tissues – sensitive to developmental stressors
• Increased risk of Obesity, insulin resistance, abnormal glucose

levels, DM in offspring

Ellsworth, L., Harman, E., Padmanabhan, V., & Gregg, B. (2018). Lactational programming of glucose homeostasis: a window of opportunity. Reproduction, 156(2):R23-R42

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Breastmilk ↓ the risk of pediatric obesity

Mischke & Plösch (2013). More than just a gut instinct- the potential interplay between a baby’s nutrition, its gut microbiome, and the epigenome.

American Journal of Physiology. Regulatory, Integrative, and Comparative Physiology, 304(12):R1065-9.

Authors propose that:

• Early nutrition influences the baby epigenome via microbial

metabolites

• ↑ adult obesity
• The type of feeding
• Affects the composition of the early gut microbiota
• Formula feeding
• different metabolites impact the epigenome of intestinal cells,

hepatocytes, and adipocytes- predisposes to obesity

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Metabolic programming & obesity

Australian peri/post epigenetic twin study

• EBF for 4-6 m as compared to 1-3 m ↓ BMI
• Infants BF less than 4m: ↑BMI, arm and abdominal circumference at 18 m
• The Early Protein Hypothesis & obesity
• 55-80% higher protein in infant formulas ~ rapid weight gain in the first few months

 obesity

• Leptin deficiency theory & obesity
• The hormone leptin “Mom, I am full” via neurological pathways -
• verweight/obesity risk ↓
• Hypomethylation of the Leptin gene with longer duration of BF (hypomethylation

= Leptin is awake and working) – Obermann-Borst,2013

• Leptin is absent in formula

Temples et al (2016). Breastfeeding and Growth of Children in the Peri/Postnatal Epigenetic Twins Study (PETS): Theoretical Epigenetic Mechanisms. Journal of Human Lactation, 32(3):481-488 Obermann-Borst, S.A. et al (2013). Duration of breastfeeding and gender are associated with methylation of the LEPTIN gene in very young children. Pediatric Research, 74(3):344-349.

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• 3. REPRODUCTIVE programming

Signals from mother to offspring continues during postnatal period (pig studies)

• Lactocrine signals 12-48 hrs from birth and colostrum are

essential to support healthy uterine development of

• ffspring
• Limited colostrum consumption or replacer feeding –

alters neonatal pig uterine development via uterine gene expression & negatively impacts healthy uterine development in adult pigs

• 800 expressed, lactocrine-sensitive genes

Bartol, et al. (2017). Physiology and endocrinology symposium: Postnatal reproductive development and the lactocrine hypothesis. Journal of Animal Science, 95(5):2200-2210.

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• 4. NEUROLOGIC programming
• Both mammary gland & nervous system – same origin
• Breastmilk-derived stem cells
• Affect infant brain development
• Can differentiate into neuron-like cells
• Gene expression of stem cell markers ↓ in
• Prematurity
• ↑ Mom’ BMI

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So, why do women stop breastfeeding?

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Why do women stop breastfeeding?

• Formula supplementation before 72 hr
• Early postpartum - I don’t have enough milk
• Perceived or real low milk supply
• Satiety - Baby is crying a lot – must be hungry and is not satisfied
• Breast / Nipple pain
• Mastitis/plugged ducts
• Return to work/father’s attitude
• Concerns about medications

Ruowei, L, et al. (2008). Why mothers stop breastfeeding: mother’s self-reported reasons for stopping during the first yet. Pediatrics, 122;S69 Newby, R.M. & Davies, P.S. (2016). Why do women stop breast-feeding? Results from a contemporary prospective study in a cohort of Australian women. European Journal of Clinical Nutrition, . 70(12):1428-1432

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How can we best support those who choose to breastfeed?

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Keys to success

• Skin to skin after birth?
• Infant state optimal?
• Feeds on cue?
• Position optimal?
• Latch painless?
• Milk being transferred?

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Skin to Skin Benefits

For babies:

• Decreased crying (x12)
• More effective suckling
• HR, T, RR stable
• Increase in blood sugar

For mothers

• Less anxiety 3 days after birth
• Less breast pain at 3 days

Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.pub3

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Expected weight loss/gain in EBF infants

Flaherman et al. (2015). Early weight loss nomograms for exclusively breastfed newborns. Pediatrics, 135(1) Tawia, S. & McGuire, L. (2014). Early weight loss and weight gain in healthy, full-term, exclusively-breastfed infants. Breastfeeding Review, 22(1):32-42

Newborn weight loss nomogram https://www.newbornweight.org

• Loss 7-10% of birth weight is

normal in the first few days of life

• Weight gain 20-20 g per day or

150-200 g per week once milk is in but this can vary

• Regain birth weight by 10-14 d

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If medically indicated, what & how much to supplement?

Volume of Supplement Average intake of colostrum per feeding Birth to 24 hr 2-10 mL 24-48 hr 5-15 mL 48-72 hr 15-30 mL 72-96 hr 30-60 mL

• At 1 week – 300-450 ml of breastmilk /day
• At 1 month – 750-1050 ml of breastmilk/day

Academy of Breastfeeding Medicine Protocol #4, 2017

Choice of Supplement Expressed BM Donor Milk in the hospital Protein hydrolysate formulas

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Possible indications for supplementation (term baby)

Maternal Indications

• Milk not in between days 3-5
• Primary glandular insufficiency
• Breast pathology, surgery with

poor milk production

• Temporary cessation of BF

(e.g.chemotx) or separation without expressed BM

• Intolerable & unrelieved pain

ABM Clinical Protocol #3. Supplementary Feedings in the Healthy Term Breastfed Neonate. Breastfeeding Medicine, 12 (3)

Infant Indications

• Asymptomatic hypoglycemia

unresponsive to frequent BFs

• Inborn errors of metabolism
• Inadequate milk intake
• Evidence of dehydration
• Weight loss + or > 8-10% day 5 or later or > 75th

percentile for age

• Delayed bowel movement, < 4 stools on day 4,
• r meconium still on day 5
• Hyperbilirubinemia
• Breast milk jaundice

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Safe Formula preparation

• Powdered formula is NOT sterile
• Risk of contamination with C sakazakii – NEC, sepsis, meningitis
• FAO/WHO guidelines (2007) : Boil water to 158 F = 70 C to kill the bacteria
• Important especially in premature babies, babies < 28 d, LBW
• Use liquid formula if needed
• controversies exist – too strict vs temperature not high enough for some

pathogens?

FAO/WHO. Enterobacter sakazakii and Salmonella in powdered infant formula; meeting report. Microbiological Risk Assessment Series 2006:10 Losio, M.N., et al. (2018). Preparation of Powdered infant formula: could product’s safety be improved? J Pediatr Gastroengerol Nutr, 67(4):543-546

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Common Breastfeeding Challenges

1. Nipple pain

• 2. Engorgement
• 3. Mastitis
• 4. Low milk supply

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• 1. Nipple Pain
• Incidence of persistent nipple pain - 9.6% by day 7
• Predisposing factors:
• primipara
• inappropriate positioning and latch (72.3%)
• tongue-tied (23.2%)
• oversupply (4.4%)
• Active management helps the mothers recover in 2 weeks

Puapompong, P et al. (2017). Nipple Pain Incidence, the Predisposing Factors, the Recovery Period After Care Management, and the Exclusive Breastfeeding

• Outcome. Breastfeeding Medicine, 12:169-173.

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NIPPLE PAIN – focus on the latch & positioning

For persistent pain with BF – see ABM Clinical Protocol #26

https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/26-persistent-pain-protocol-english.pdf

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Treatment of sore nipples

• Positioning
• Expressed breast milk
• Lanolin (??)
• Proper suction set up on a pump
• Breastmilk + breast shells > lanolin
• Moist wound healing
• Saqez ointment (Pistacia) > breastmilk

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Could it be yeast?

• Deep breast pain is anecdotaly linked to Candida albicans

Swedish case-control study

• Neither clinical symptoms nor microbial cultivation was reliable for

making a diagnosis of C.albicans

• Refer to LC for support, focus on positioning

Kaski, K. & Kvist, L. J. (2018). Deep breast pain during lactation: a case-control study in Sweden investigating the role of Candida albicans . International Breastfeeding Journal, 13:21.

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Berens, P., Brodribb, W., & The ABM. (2016). ABM Clinical Protocol #20: Engorgement, Revised 2016. Breastfeeding Medicine, 11 (4): 159- 163 Wong, B.B., et al (2017). Application of cabbage leaves compared to gel packs for mothers with breast engorgement: Randomized controlled trial. International Journal of Nursing Studies, 76:92-99 Cotterman KJ. Reverse pressure softening: A simple tool to prepare areola for easier latching during engorgement. J Hum Lact 2004;20:227–237 Khosravan S. et al. The effect of Hollyhock (Althaea officinalis L) leaf compresses combined with warm and cold compress on breast engorgement in lactating women: A randomized clinical trial. J Evid Based Complementary Altern Med 2015;pii: 2156587215617106.

• Frequent breastfeeding
• Hand expression
• Reverse pressure softening
• TBML towards the axilla
• Cabbage leaves?
• Hollylock?
• 2. Engorgement

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• 3. MASTITIS
• Inflammation of the breast, may or may not involve a bacterial infection

Risk factors

• nipple damage, infrequent, scheduled or missed feeding, poor latch,
• versupply, blocked ducts, maternal stress and fatigue, oversupply, rapid

feeding, illness in mom or baby Management:

• Effective milk removal – responsive feedings, latch, positioning
• Comfort measures- rest, fluids, nutrition, heat prior to feeds, cold compress

after feeds

Amir, L. H. & The Academy of Breastfeeding Medicine Protocol Committee. (2014). ABM Clinical Protocol #4. Mastitis. Breastfeeding Medicine, 9(5):239-243

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MASTITIS - Pharmacologic management

Analgesics

• Ibuprofen not detected in BM in doses up to 1.6 g/day

Antibiotics

• Mild symptoms, < 24 hr – effective milk removal/comfort measures
• No improvement within 12-24 hr- ABX 10-14 days (?)
• Dicloxacillin 500 mg PO QID for 10-14 d
• Cephalexin 500 mg PO QID for 10-14 d if suspected penicillin allergy
• Clindamycin 300 mg PO TID for 10-14 d if severe penicillin hypersensitivity
• r CA-MRSA

Amir, L. H. & The Academy of Breastfeeding Medicine Protocol Committee. (2014). ABM Clinical Protocol #4. Mastitis. Breastfeeding Medicine, 9(5):239-243

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When milk needs to get out - TBM

• Engorgement, plugged ducts, mastitis
• Acute breast pain ~ Milk stasis
• Breast emptying is the key intervention
• In-office Therapeutic breast massage ~ 30 min

Witt, A.M., Bolman, M., Kredit, Sh., & Vanic, A. (2016). Therapeutic breast massage in lactation for the management of engorgmenet, plugged ducts, and

• mastitis. Journal of Human Lactation, 32 (1): 123-131.

VIDEO http://bfmedneo.com/our-services/breast-massage/ Or https://vimeo.com/65196007

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• 4. Low milk supply – support is critical!
• SUPPLY/DEMAND principle
• Ensure baby gets enough calories
• Frequent and thorough breast emptying
• On cue feeding
• Hand expression to stimulate milk flow
• Hands-on pumping
• Insufficient evidence to recommend increased maternal fluid intake

Ndikom, C.M., Fawole, B., & Illesanmi, R.E. (2014). Extra fluids for breastfeeding mothers for increasing milk production. Cochrane Databased of Systematic Reviews, 6:CD008758. Riddle, S.W., Nommsen-Rivers, L.A. (2017). Low milk supply and the pediatrician. Current Opionion in Pediatrics, 29:249--256

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Low milk supply- evaluate the mom

• Obesity
• Hypothyroidism
• Labor complications – C/S? Hemorrhage?
• Insufficient glandular tissue – breast changes in pregnancy?
• PCOS?
• Breast surgery
• Medications? E.g. Decongestants/estrogen?
• Is there pain with feedings?
• What pump is she using?
• Postpartum depression

Riddle, S.W., Nommsen-Rivers, L.A. (2017). Low milk supply and the pediatrician. Current Opionion in Pediatrics, 29:249—256

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Low milk supply – evaluate the baby

• Skin to skin?
• Does the baby feed on cue?
• Unrestricted feedings? (timing, just one breast?)
• Poor transfer?
• Latch? Positioning?
• Baby’s oral anatomy?
• Is baby feeding with a nipple shield?
• Gestational age?

Riddle, S.W., Nommsen-Rivers, L.A. (2017). Low milk supply and the pediatrician. Current Opionion in Pediatrics, 29:249—256

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Low milk supply

• If supplementation needed - BF first
• Use a hospital-grade pump & “hands-on” pumping to drain the

breasts more fully after breastfeeding if baby is not draining well

• If baby is draining well, don’t add pumping – discouraging
• BF-bottle feed-pump is exhausting- refer to LC
• Abnormalities in glucose metabolism may play a role
• Delayed lactogenesis ~ maternal obesity
• Galactogogues ?
• Metoclopramide – jitteriness, fatigue, EPS, depression

Lemay, D.G., et al. (2013). RNA sequencing of the human milk fat layer transcriptome reveals distinct gene expression profiles at three stages of lactation. PLoS One, 8:e67531 Nommsen-Rivers, L., Riddle, S., et al. (2016). Milk production in mothers with and without signs of insulin resistance. Breastfeeding Medicine, 11 ( Supplement 1, S3-S4) Pinheiro, T.V., Goldani, M.Z, & IVAPSA group. (2018). Maternal pre-pregnancy overweight/obesity and gestational diabetes interaction on delayed breastfeeding initiation. PLoS One, 13(6):e0194879

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What else to consider?

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My baby is fussy, he must be hungry?

Do I have enough milk?

http://purplecrying.info

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Medications & Breastfeeding

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MEDICATIONS while breastfeeding

• Blood levels attained in mom’s circulation
• Protein binding – choose drugs with high protein binding
• Lipid solubility – choose lower lipid soluble = less milk & CNS penetration
• Molecular weight < 300 enters milk easier; > 600 unlikely to enter milk in high conc.
• Oral bioavailability : typically < 1 % of maternal dose gets into the milk and baby
• Half-life in plasma – drugs with long half lives build up in baby’s plasma over time –

choose drugs with shorter half-life

• pKa- choose drugs with a lower pKa
• Milk level is directly proportional to the maternal plasma level

Hale, T. (2018). Drug entry into human milk . Retrieved from https://www.infantrisk.com/content/drug-entry-human-milk

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General rules when prescribing

• Is the drug absorbed from the GI tract? 3rd gen Cephalosporins (Rocephin),

morphin Epsomn salts, magnesium salts, aminoglycosides, vancomycin – poorly absorbed – very little gets to the baby

• Shorter half-life drugs: wait 2-3 hr minimum after dosing before BF
• Prolonged released forms: assume the drug has a long half-life (12-24hr)
• Radioactive or dangerous drugs: after 5 half-lives 98% of a drug or

radioisotope is eliminated. Wait 4-5 half lives!

• Topical medication on the nipple will likely be absorbed
• Infants of drug abusing moms may test + for 2-4 weeks to months after

maternal exposure

• Forewarn the mother - Diarrhea, constipation, sedation, weakness may

indicate neonatal absorption

Hale, T. (2018). Drug entry into human milk . Retrieved from https://www.infantrisk.com/content/drug-entry-human-milk

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Contraception & Breastfeeding

Controversies in research!

• IUD- progestin – 6 wks pp or later
• Immediate postpartum placement may lead to shorter duration of BF
• Nexplanon
• Depo-Provera
• Progestine-only pill
• Emergency contraception – postcoital copper IUD

Berens, P., & Labbok, M. &, The ABM. (2015). ABM Clinical Protocol #13: Contraception during breastfee3ding, revised 2015. Breastfeeding Medicine, 10(1): 1-10.

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Is this medication safe while BF?

• Hale’s Medications & Mother’s Milk
• The Infant Risk Center Texas Tech University Health Sciences Center www.infantrisk.com

Helpline (806)352-2519 (M-F 8-5pm, CT)

• LactMed (A TOXNET database)

https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm

• Academy of Breastfeeding Medicine - protocols
• UK : The Breastfeeding Network – Drugs in Breastmilk Information

(factsheets or inquiries via email)

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Lactation support

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RESOURCES for Breastfeeding Support

• IBCLC / CLC consultants
• Hospital/community support groups
• WIC – breastfeeding as a priority
• Breastfeeding peer counselors
• Breastfeeding Clinics
• Breastfeeding Management Clinic at Children's Hospital

Colorado, please call 720-777-3605.

• Fathers support breastfeeding
• Colorado State Law
• Employer – time to express milk up to 2 yrs
• Home visiting programs
• Nurse Family Partnership-1st time moms
• New Parent Support Program – military