Maternal Conditions and Breastfeeding

This presentation will discuss some maternal condition that effect bresatfeeding and contribute to the delay/failed lactogenesis II.

1. Maternal Conditions and Breastfeeding dr. Muhammad Ilham Aldika Akbar SpOG Maternal Fetal Medicine Division Dept Obgyn RSUA-RSUD Dr. Soetomo Faculty of Medicine Universitas Airlangga Surabaya

2. Lactogenesis The changes that occur between pregnancy and lactation Two stages: Lactogenesis I : during pregnancy, initiation of the synthetic capacity of the mammary glands Lactogenesis II : after delivery, initiation of plentiful milk secretion dr. M. Ilham Aldika A, SpOG - FK UNAIR

3. Lactation Physical and mental health Past experiences Intention related to breastfeeding Body image Socioeconomic factors General p hysical environment Family support Hospital and clinician support Maternal conditions Internal Environment External Environment dr. M. Ilham Aldika A, SpOG - FK UNAIR

4. Lactogenesis II Changes in milk constituents Feeling of breast fullness 30-40 hours following birth Influenced by complex hormonal milieu Reproductive hormones (E, P, HPL, Prolactin, Oxytocin ) Metabolic hormones (glucocorticoid, growth, insulin, thyroid)

5. Problems in Lactogenesis II DELAYED FAILED Longer than usual interval between the colostrum phase and copious milk production The mothers able to achieve full lactation but an extrinsic factor has interfered with the process One or more factors result in failure to attain adequate milk production dr. M. Ilham Aldika A, SpOG - FK UNAIR Primary Secondary

6. Delayed or failed achievement of Lactogenesis 2 is a result of various maternal and infant factors Early recognition of these factors is critical for clinician dr. M. Ilham Aldika A, SpOG - FK UNAIR

7. Risk Factor for Delayed or Failed Lactogenesis II dr. M. Ilham Aldika A, SpOG - FK UNAIR

8. Hormonal and metabolic problems Diabetes, Hypothyroidism, Obesity, PCOS, SLE Delay breastfeeding initiation Preterm labor, CS Complication pregnancy Gestational DM, preeclampsia Problem related to labor and delivery Post partum haemorrhage , Hysterectomy, Sheehan Anatomic breast abnormalities Post breast surgery, breast implants, reduction mammoplasty Maternal medication Pseudoephedrine, birth control Maternal Condition causing Delay/Failed Lactogenesis II dr. M. Ilham Aldika A, SpOG - FK UNAIR

9. BREASTFEEDING AFTER A CESAREAN DELIVERY

10. CS rate is dramatically increasing in recent years CS is strongly associated with delayed lactogenesis , delayed in early breastfeeding, decrease in success of breastfeeding, poorer infant suck, more suplementation , and shorter duration breastfeeding ( Dewey et al, 2002; Smith, 2010) Different breastfeeding experience with vaginal delivery dr. M. Ilham Aldika A, SpOG - FK UNAIR

11. Caesarean Section Delay/Failure Lactogenesis Post operative pain Pain R elief drugs Supress Breastfeeding Stress/ Fatique Decreased milk supply Blood loss Anemia Stress Hormone Infant Problems RDS  NICU Admission Separation from mother IMD  BF difficulties dr. M. Ilham Aldika A, SpOG - FK UNAIR Inhibit oxytocin

12. Benefits of Breastfeeding after Caesarean Faster uterine involution Endogenous oxytocin release by breast stimulation Less postpartum bleeding Weight loss more quickly Risk of immobility after caesarean Decreases incidence of infant infection Risk of infection from longer hospitalisation Prevent hypoglycemia, jaundice Bonding dr. M. Ilham Aldika A, SpOG - FK UNAIR

13. Breastfeeding After CS Epidural or spinal anesthesia is ideal (pain free post operative) Need extra support by hospital staff and family Common position: cradle hold, football hold and side-lying position IMD Rooming in dr. M. Ilham Aldika A, SpOG - FK UNAIR

14. BREASTFEEDING IN WOMEN AFTER POST PARTUM HAEMORRHAGE dr. M. Ilham Aldika A, SpOG - FK UNAIR

15. Many Factors Contributed to Breastfeeding Failure in Women with PPH Maternal condition ( unconsious , fatique , severe anemia) ICU Admission (mother baby separation) Traumatic maternal stress Severe blood loss/hypotension Ischemia/infarct pituitary glands Altered prolactin level Sheehan Syndrome

16. Management of Breastfeeding in Women After PPH Collaboration care by lactation consultant, obgyn , pediatrician, nurse, patient and family M aternal condition stabilisation Educate mothers about potential problems Stimulate maternal lactation potential Carefull infant feeding plan, supplementation needed P artial BF  complete BF dr. M. Ilham Aldika A, SpOG - FK UNAIR

17. dr. M. Ilham Aldika A, SpOG - FK UNAIR

18. BREASTFEEDING IN WOMEN WITH PREECLAMPSIA dr. M. Ilham Aldika A, SpOG - FK UNAIR

19. PREECLAMPSIA 2 nd leading cause direct maternal mortality 70 -80.000 maternal and 500.000 perinatal death annually > 99% South Asia & Sub Saharan Africa Incidence 29.7% (RSUD DR. Soetomo ) dr. M. Ilham Aldika A, SpOG - FK UNAIR

20. Breastfeeding in Women with Severe Preeclampsia Maternal Condition Magnesium Sulphate administrassion Prematurity ICU admission NICU admission Early Separation Obesity Delay initiation of Breastfeeding dr. M. Ilham Aldika A, SpOG - FK UNAIR

21. Study of Breastfeeding in women with PE, Cordero L et al, Breastfeeding Medicine vol 7, number 6, 2012 2007-2010, USA 281 women with Severe Preeclampsia 81 term and 200 late preterm infants All mothers and infants survive 54% infants were admitted to NICU 51% sucessfully initiated breastfeeding Factors associated with Breastfeeding initiation failure: African american race Young age Lower education Multiparity Smoking Obesity dr. M. Ilham Aldika A, SpOG - FK UNAIR

22. Magnesium Sulphate Prevent Eclampsia Fetal neuroprotectant No effect on Apgar Score Transfer trans placentally Risk neonatal hypermagnesemia ? Decrease in sucking rate? Decrease breast stimulation? Benefit Risk Breastfeeding

23. Is not expected to affect breastfeed (not increasing magnesium level significantly in milk ) Decrease in sucking rates  decrease in breast stimulation Need to feed more frequently , need more stimulation to suckling Manual expression or breast pumping Magnesium S ulphate on Breastfeeding dr. M. Ilham Aldika A, SpOG - FK UNAIR

24. Retained Placental F ragments dr. M. Ilham Aldika A, SpOG - FK UNAIR

25. RETAINED PLACENTAL FRAGMENTS DELAY/FAILED LACTOGENESIS II Causing haemorrhagic post partum  Sheehan Syndrome Inhibit decrease of progesterone level  inhibit action of prolactin to stimulate milk production Management: removing placental fragments dr. M. Ilham Aldika A, SpOG - FK UNAIR

26. DELAYED LACTOGENESIS RELATED TO GESTATIONAL DIABETES dr. M. Ilham Aldika A, SpOG - FK UNAIR

27. GESTATIONAL DIABETES High blood glucose level in pregnant women who have never had diabetes 9.2% (CDC) 7x more likely to develop permanent Diabetes type 2 dr. M. Ilham Aldika A, SpOG - FK UNAIR

28. BREASTFEEDING IN GESTATIONAL DIABETES WOMEN Delay onset of lactation by 15-28 h Decrease milk volume over 3 first days Hypoglycemia may reduce glucose availability to lactocytes  reduce lactose synthesis & ability to initiate lactation Women with GDM are less likely to breastfeed (cross sectional study, 2038 women, 2005-2007) dr. M. Ilham Aldika A, SpOG - FK UNAIR

29. L onger duration of breastfeeding showed a correlation with reduction in risk of developing type 2 diabetes Kaiser prospective cohort study, 1010 women who breastfeed 2 month vs several month. RESULT: After 2 years, 11.8% women developed DM 35% to 57% reduction in two years diabetes incidence associated with longer duration of breastfeeding (< 2 vs > 10 month) Why Mothers with GDM should Breastfeed?

30. Another Benefit of Breastfeeding in Gestational Diabetes Mothers Better overall health Less insulin need during lactation Infant Help adjust glucose level Protection against malnutrition during early childhood Lower risk of developing obesity, diabetes, hypertension and cardiovascular disease later in life dr. M. Ilham Aldika A, SpOG - FK UNAIR

31. Study of womens experience with early breastfeeding after gestational diabetes Barriers to breastfeeding: BF challenges and support Milk supply challenges Concern for infant health A need for consistent breastfeeding education as well as strategies for addressing BF challenges and milk supply issues dr. M. Ilham Aldika A, SpOG - FK UNAIR

32. MATERNAL OBESITY dr. M. Ilham Aldika A, SpOG - FK UNAIR

33. MATERNAL OBESITY Delay increase prolactin after breastfeeding > 2 days Low milk transfer at 60 hours post birth High Leptin  inhibit milk ejection 1 unit increase in BMI ~ 0.5 hour delay in lactogenesis Maternal BMI ~ shorten BF duration dr. M. Ilham Aldika A, SpOG - FK UNAIR

34. Developmental Origins of Health and Disease Warner MJ, Ozzane SE, 2010 Fetal Programming

35. DELAY LACTOGENESIS RELATED TO POLYCYSTIC OVARIAN SYNDROME dr. M. Ilham Aldika A, SpOG - FK UNAIR

36. High Androgen down regulate prolactin receptor Insulin resistance Low progresterone  poor breast tissue development dr. M. Ilham Aldika A, SpOG - FK UNAIR

37. MANAGEMENT OF DELAY/FAILURE OF LACTOGENESIS II dr. M. Ilham Aldika A, SpOG - FK UNAIR

38. MANAGEMENT PLAN for DELAY-FAILURE LACTOGENESIS II dr. M. Ilham Aldika A, SpOG - FK UNAIR

39. PROVIDE ADEQUATE INFANT NUTRITION An infant who is malnourished will not have energy to BF effectively Recommending the mother simply increase frequency BF will not improve this situation when failed lactogenesis II is suspected dr. M. Ilham Aldika A, SpOG - FK UNAIR

40. Determining the need for supplementation is essential in provide adequate infant nutrition Expressed breast milk/formula should be given as a complement (immediately following BF session) rather than full suplement (replace BF) To maximize maternal breast stimulation and maintain infant BF ability dr. M. Ilham Aldika A, SpOG - FK UNAIR

41. Determining suplementation feeding methods need carefull consideration Bottle, cup, syringe, or feeding tube device dr. M. Ilham Aldika A, SpOG - FK UNAIR

42. MAXIMIZE BREAST STIMULATION AND COMPLETE BREAST EMPTYING Any potential infant sucking problems should be corrected Breast problem should be corrected Breast pumping following each BF should be initiated Galactagogues dr. M. Ilham Aldika A, SpOG - FK UNAIR

43. OBJECTIVE MEASUREMENT OF MILK INTAKE DURING BREASTFEEDING Subjective estimation is inaccurate Test weighing procedure are important diagnostic tool for delayed/failed lactogenesis II  1 g ~ 1ml milk intake Weekly provider visit to asses BF paterns , vol of supplement, and post feeding pumping vol dr. M. Ilham Aldika A, SpOG - FK UNAIR

44. MAINTAINING FEEDING or PUMPING RECORD Having mothers maintain a simple record of daily feeding, pumping and infant stooling and urinary patterns is useful to monitor progress Guide plan of care for modification as BF improves or not dr. M. Ilham Aldika A, SpOG - FK UNAIR

45. RECOGNIZING When MATERNAL LACTATION POTENTIAL Has Been Reached This is a challenge! Asses proportion of daily BF, supplements, and expressed breast milk volume  information to determine lactation potential has been reached dr. M. Ilham Aldika A, SpOG - FK UNAIR

46. Refference Anderson AM, 2001. Case Report: Disruption of Lactogenesis by Retained Placental Fragments. J Hum Lact . 17(2), 2001. Chapman DJ, 2014. Risk Factors for Delayed Lactogenesis among Women with Gestational Diabetes Mellitus. Journal of Human Lactation 2014, Vol. 30(2) 134-135. Cordero L, Valentine CJ, Samuels P, Giannone PJ, Nankervis CA, 2012. Breastfeeding in Women with Severe Preeclampsia. Breastfeeding Medicine Vol 7, Number 6, 2012. Hurst NM, 2007. Recognizing and Treating Delayed or Failed Lactogenesis II. Journal of Midwifery & Women's Health. Kair LR, Colaizy TT, 2015. When Breast Milk Alone is Not Enough: Barriers to Breastfeeding Continuation among Overweight and Obese Mothers. Journal of Human Lactation 1-8, 2015. Sema Kuguoglu , Hatice Yildiz , Meltem Kurtuncu Tanir and Birsel Canan Demirbag (2012). Breastfeeding After a Cesarean Delivery, Cesarean Delivery, Dr. Raed Salim (Ed.), ISBN: 978-953-51-0638-8, InTech , Available from: http:// www.intechopen.com /books/cesarean-delivery/breastfeeding-after-a-cesarean-delivery Marasco L, Marmet C, Shell E, 2000. Polycystic Ovary Syndrome: A Connection to Insuficient Milk Supply? J Hum Lct 2000;16(2):143-148. Neville MC, Morton J, 2001. Physiology and Endocrine Changes Underlying Human Lactogenesis II. J Nutr . 131: 3005S-3008S, 2001. Riordan J, Hoople KG, Angeron J, 2005. Indicators of Effective Breastfeeding and Estimates of Breast Milk Intake. J Hum Lact . 21(4):406-412, 2005.

47. dr. M. Ilham Aldika A, SpOG - FK UNAIR Thank You!