Chapter 17 Flashcards
Acute illness
Disease or illness that is characterized by a sudden onset and limited duration
Chronic disease
Condition or illness that is characterized by long in some cases to find as greater than six months or permanent duration
Cognitive disability
Condition that involves impairment in intellectual activities such as thinking reasoning and remembering
Nosocomial infection
An infection inquired in a hospital or other healthcare facility that is usually caused by viruses, bacteria, or fungal pathogens
Physical disability
Physical condition that impairs, interferes with, or limits of persons ability to engage in certain task or actions or to participate in typical daily activities and interactions
Physical health
Refers to the conditions of the body or body systems, a continuum of health, lack of disease, or disability to states of acute or chronic illness, disability, or disease
Sensory disability
Condition that involves sensory organs, such as eyes, ears, or skin (touch)
Headaches and migraines
Migraine headaches especially related to menstruation may have a reduction in frequency and severity during pregnancy and lactation. Some evidence of lactational headaches associated with let down an over full breath. Common drugs that are compatible with breast-feeding include propranolol and nonsteroidal anti-inflammatory drugs.
Infectious diseases
Common cold and the flu are caused by viruses. They do not affect the ability to breast-feed. Parents should beware of decongestant containing pseudoephedrine because it can reduce milk production particularly in parents with poor or marginal milk. If antibiotics are needed for bacterial infection healthcare providers should use clinical guidelines for appropriate choices, dosing and duration of treatment.
Urinary track infection is the most common problem in women
Can be treated well with sulfamethoxazole and trimethoprim
Methicillin resistant staph infections (MRSA) is an antibiotic resistant infection they can either be hospital or community acquired
If a breast-feeding parent becomes infected breast-feeding and express milk should be withheld for 24 hours while antibiotic therapy is initiated. MRSA and other nosocomial infections in the newborn can be decreased by exposure to nontoxic bacterial flora via skin to skin contact after birth.
Group B streptococci (GBS) are leading cause of neonatal sepsis, is a common cause of neonatal morbidity and mortality
Treated with antibiotics it discovered prenative or intrapartum. If present in the vagina or rectal area can colonize the nasopharynx of the newborn during birth. Where can acquire GBS from breastmilk. Milk can be cultured and parent treated and continue breast-feeding
Tuberculosis
Not common and develop countries but very prevalent and developing countries. Parents who have tuberculosis at time of birth and appropriately treated with isoniazid can breast-feed. If tuberculosis is discovered at the time of birth it is necessary to separate the parent and infant for two weeks. Parent must initiate therapy and expressed milk to protect milk production. Issiazid is secreted into milk but levels are considered safe. Breast-feeding should be withheld for two hours after drug administration to avoid peak plasma concentrations
Zika virus spread by species of mosquitoes can be transmitted to the fetus during pregnancy and can cause congenital Zika fever with defects of the skull being the most common result
Human milk spread has not been confirmed although shedding of Zika virus material may be in the milk. Mothers who have suspected, probable, or confirm secret virus infection or travel to areas where Zika virus is endemic can breast-feed their infants.
Ebola virus characterized by fever, severe headache, muscle pain, weakness, fatigue, diarrhea, vomiting, abdominal pain, and unexplained hemorrhage.
Spread by close contact. Parents who are infected should not breast-feed. Decision about feeding the infant of a parent who is infected or has been infected must be weighed carefully. If there is no safe alternative to the parents milk the parent may have to breast-feed
HIV
HIV is classified as a retrovirus. Group of RNA viruses that insert a DNA copy of their genome into the host cell in order to replicate. When left untreated HIV infection results in the distraction of T cell immunity that allows recurrent, severe, and ultimately life-threatening opportunistic infections that manifest as aids. Spread by exchange of infected blood or by mucous membrane contact with infected blood and body fluids. In infants and small children most parent to child transmissions occur either pair of Natalie or through breast-feeding. HIV infected parents in high resource countries have been encouraged to avoid breast-feeding. Resource poor countries recommend exclusive breast-feeding for six months along with antiviral therapy for the mother and the baby. Perinatal HIV infection have dropped dramatically in the United States due to routine HIV screening in the use of a RT for the control and prevention of maternal infection, elective cesarean section and HIV positive women and avoidance of breast-feeding.
Asthma
In the US the prevalence of asthma among pregnant women is 3.7 to 8.7%. Exclusive breast feeding offers protection for infants and families with a history of asthma. Lactation should not be interrupted for asthmatic parents. Corticosteroids administered through metered dose inhaler‘s avoid systemic effects by delivery medication directly to the lungs. Bronchodilation are used to manage acute exacerbation’s.
Diabetes mellitus
Impaired carbohydrate metabolism is the Hallmark. Type one diabetes can occur pre-pregnancy in which insulin is not produced by the beta cells of the pancreas. Breast-feeding should be encouraged because colostrum helps to stabilize the Newports blood glucose. Parent and infant can experience local close levels after birth and must be monitored closely. Colostrum express prenatally can later referred to the hypoglycemic infant of a diabetic parent. If infant is admitted to neonatal intensive care milk expression should begin immediately. Insulin therapy is continued after giving birth. Insert it safe during lactation because it is such a large molecule. Delayed lactogenesis about one day may occur. Supportive practices such as early and continued skin to skin contact, rooming in, and feeding on cue can offset some of the factors. Diabetic parents may be at higher risk for mastitis and candiadiasis especially if they have elevated blood glucose levels.
Type two diabetes this is when there is impaired response to insulin and beta cell dysfunction
Can be part of the metabolic syndrome characterized by hypertension, obesity, dyslipidemia and polycystic ovary syndrome. It is much more common during pregnancy today due to higher obesity rate. Patients with type two diabetes are less likely to breast-feed. Metforman is often used to treat type two diabetes during and after pregnancy. Type two diabetes is associated with postpartum low milk production. May have a shorter duration of breast-feeding.
Gestational diabetes is a glucose intolerance that occurs during pregnancy. It occurs in an estimated 9% of all pregnancies in United States
Are less likely to breast-feed the non-diabetic counterparts. Breast-feeding should be encouraged because lactation improves the maternal metabolism of glucose and may prevent type two diabetes. Delayed lactogenesis can occur in parents with gestational diabetes which may be up to 1/3. Support is essential for parents as noted with type one and type two diabetes.
Thyroid disorders - Hypothyroidism
Hypothyroidism: thyroid function is imperative to maintaining A pregnancy. Symptoms include thyroid swelling or nodules, cold intolerance, dry skin, thinning hair, poor appetite, extreme fatigue and depression. Can result in low milk production. Thyroid supplementation is safe with breast-feeding. If diagnosed postnatal he will likely experience symptom release and increase milk production. If take thyroid supplements during pregnancy should be reevaluated in the postpartum. Because medication doses could likely be reduced to the pre-pregnancy level.
Hyper thyroidism
Occurs in the first postpartum year in 9% of women. Graves disease accounts from 95% of cases of hyperthy organism during pregnancy and only zero. 2% of cases post Natalie. Lactation is not usually impacted by hyperthyroidism. Anti-thyroid medication‘s are considered safe during lactation. However doses should be low to moderate because of concerns of hepatotoxic
Postpartum thyroiditis
Most common thyroid disorder. It affects 1.1 to 16.7% of women in the first year after birth. Believed to be an auto immune disorder. Includes fatigue, depression, and anxiety. May manifest is hyper thyroidism or hypo thyroidism or I can begin as hyperthyroidism and progressed to hypothyroidism. Need radioactive iodine uptake testing to actually make diagnosis which requires temporary breast-feeding interruption.
Pituitary dysfunction
Postpartum hemorrhage and hypotension can increase the pituitary gland to cease production of gonadotrophins leading to panhyppituitarism or Sheehan syndrome. Symptoms include lactation failure, loss of pubic and axillary hair, cold intolerance, breast and vaginal tissue atrophy, low blood pressure, secondary hypothyroidism, and adrenal failure. In severe cases the symptoms can occur and progress over the years.
Cystic fibrosis
Hereditary autosomal recessive genetic disorder involving the cystic fibrosis transmembrane regulator gene on a chromosome seven. Affects the apical membrane of epithelial cell lining the airways, biliary tree, intestines, vas deferens, female reproductive tract, sweat ducts, and pancreatic ducts. Highest prevalence is in North America and lowest is in Africa and Asia. Research indicates that affected individuals may or may not have increased morbidity during pregnancy and lactation. However pregnant and lactating mothers with cystic fibrosis have increased need for pulmonary and nutritional status monitoring and treatment. Many parents with cystic fibrosis choose to breast-feed and should be supported. Human milk is not adversely affected by cystic fibrosis. Most medication’s are compatible with breast-feeding those summer contraindicated.
Polycystic ovary syndrome (PCOS)
Common endocrine disorder in women that is characterized by abnormal ovulation, clinical or laboratory indices of increased androgen levels, and polycystic ovaries. Prevalence is between four and 6%. Infertility among women with PCOS is common and breast-feeding can be challenging. Observe breast shape variations including tubular shape, large separation, and large nipples with little change in breast size during pregnancy an insufficient milk production among women with PCOS. Insulin resistance and compensatory hyperinsulinemia are hallmarks of PCOS putting women at increased risk of impaired glucose tolerance and type two diabetes. 40% of women with PCOS developed impaired glucose tolerance and 10% develop diabetes by age 40. Metformin is the drug of choice for PCOS. Metformin is safe for breast-feeding. PCOS is a complex disorder with many characteristic variations. Parents need support.
Auto immune diseases, inflammatory bowel disease
Two major forms of inflammatory bowel disease are ulcerative colitis and Crohn’s disease. Breast-feeding rates in this group are reported to be lower than the general population. Often related to concerns about safety of prescribed medications and transferred infant. Breast-feeding does not impact disease activity of either disease, breast-feeding should be encouraged. Majority of medication use particularly Biologics are considered probably compatible with breast-feeding although methotrexate is considered teratogenic and should not be used during pregnancy or lactation.
Systemic lupus erythematous
Audio immune disorder that affects multiple body systems and occurs frequently during childbearing years. Manifested diversely and can include headache, arthritis symptoms, butterfly rash on my chest and knows. Raynaud phenomenon, fatigue and myalgia. Miscarriage and prematurely rates are higher among women with lupus. About half of the women in a sample of 51 pregnancies breast-fed their infants. Low postpartum lupus activity, term delivery and a plan to breast-feed early in pregnancy where is associated with Breastfeeding. Breastfeedingg should be encouraged. Research suggests that hydroxychloroquine, azthioprine, methotrexate and prednisone have very limited transfer into milk. However some experts do not recommend methotrexate. Special considerations for joint pain and swelling and Raynaud phenomenon should be considered
Multiple sclerosis
Degenerative neurological disorder that is immune mediated, the myelin sheath covering the nerves is attacked by the immune system. Four disease courses include clinically isolated syndrome, relapsing remitting multiple sclerosis, secondary progressive multiple sclerosis, and primary progressive multiple sclerosis. Symptoms include weakness, fatigue, in coordination, paralysis, and speech and visual disturbances. More common among women and often diagnosed during reproductive years. Risk of relapse decreases during pregnancy but increases in the postpartum period as much as 70% particularly during the first 3 to 4 minutes. Now appears the breast-feeding reduces the risk of multiple sclerosis relapses. Evidence is growing for the safe use of DMARD‘s for multiple sclerosis. A pregnancy may not be powerful enough to suppress the risk of rebound relapses. Exclusive breast-feeding is an option for many women who want to do so but in cases of high disease activity and those women who do not want to breast-feed early re-introduction of MS therapies should be considered. Breast-feeding for four months or longer protects the infant against multiple sclerosis. This advantage should be discussed with parents who have multiple sclerosis and choose to breast-feed.
Rheumatoid arthritis
Chronic inflammatory disease presumably caused by a genetically influenced auto immune response the damages the synovial lining of the joints. Symptoms include pain, swelling, and stiffness of the joints, damage and deformity of the joints, fatigue, and decreased mobility. Can’t start in early childhood and last lifetime. Characterized by flares and remissions and disease activity. Women are disproportionately affected by this disease. Fertility can be diminished in women with rheumatoid arthritis. For some women when pregnant disease activity is sometimes decreased. Rheumatoid arthritis flare or more common in the postpartum. Likely due to multiple hormonal and immunologic changes during pregnancy. Some anti-rheumatic drugs are not compatible with pregnancy but can be used for lactation answered should be stopped before 32 weeks of gestational age due to risk of premature closure of ductus arteriosus in the fetus and labor impairment in the mother. And some are compatible with breast-feeding. Non-fluorinated glucocorticoid, sulfasalazine at low doses hydroxychloroquine and tumor necrosis factor inhibitors are compatible with pregnancy and breast-feeding. DMARD such as methotrexate are not recommended during pregnancy or lactation due to teratogenic status. Limited information on Biologics so not recommended in Pregnancy or Lactation. There really isn’t much evidence on support for mothers who wish to breastfeed with rheumatoid arthritis. Support to relieve fatigue in general and physical bracing to support affective joints may be particularly helpful for breast-feeding mothers.
Other muscular skeletal and neurologic injuries, disorders and diseases
Spinal cord injuries, muscular dystrophy, spinal muscular atrophy, cerebral palsy, amputation and spina bifida can affect breast-feeding. May have impact physical mobility and the ability of affected parents to hold their babies. In some cases the injury or condition may impact the parents ability to lactate and breast-feed. Spinal cord injury above cervical vertebra six or eight thoracic vertebra 4 to 6. Childbearing women with disabilities appear to have increased overtime. There are negative stereotypes of sexuality in disabled women. May have unmet needs during pregnancy and after birth. There is a need for lactation care for parents with spinal cord injuries and need for additional research on these parents breast-feeding experience.
Baby care guidelines for breast-feeding parents were physically
If confined to a wheelchair and have some upper body strength can use a harness or a white belt with a long strip of Hook and loop tape to lift and retrieve a crawling baby. One or two special breast-feeding nests that are easily accessible and comfortable can be set up. Demonstrate multiple positions for breast-feeding and help find the best position for the parents ability and comfort. A small baby can be laid diagonally across the parents knees on a pillow to breast-feed. Experiment with breast-feeding pillows to determine what works best. Elevate the parents feet on the foot rest to keep the infant secure during feeding. Parents who cannot elevate their feet and rest their forearm that is holding the infant on a pillow placed across their knees this arrangement ensures that if the infant roles the motion will be toward the parent. Changing tables and cribs can be adapted so they are accessible to a parent in a wheelchair and the room can be arranged so that moving about as minimize. The baby sling allows the parents arms to be free and ensure that the baby is safe and supported during breast-feeding. This is also helpful when parent has unilateral weakness and paralysis. A bell tied to the baby shoes helps keep track of where the mobile child is. When parent is in a wheelchair a toddler learn quickly to climb on parents knees for a ride and to sit still while the chair is moving. Baby can be given extra cuddling such as touching at night. Baby clothing overalls with cross straps can be picked up fairly easily. Breastfeeding bra that opens in front and has an easy to fasten clip can be used. Maternity clothes can be altered to incorporate hook and loop openings or large ring zippers. Parent should plan rest periods during the day and should sit to work whenever possible. If parent is deaf the sound can be transformed into flashing light signals from a baby monitor. If a parent cannot lift a baby or themselves consider caring for the baby on the floor including feeding changing and playing. This enables parent to roll the baby to the lap instead of lifting.
Epilepsy
Evidence about Pregnancy and Lactation among individuals with epilepsy often focus on the safety of epilepsy medication and preventing harm to the infant. Many epilepsy medication‘s are safe during lactation.
With all anticonvulsants regardless of the safety category parents should be educated on observing their infants for drowsiness, rash, breathing difficulties, feeding difficulties, weight gain and developmental milestones achieved. There is some medication where the relative infant dose is greater than 10% and have a long half life including various anticonvulsants. Only one drug valproate significantly reduce cognitive development in children who were exposed to antiepileptic drugs during pregnancy and breast-feeding. There are some drugs that showed an increase rate for autism. There were some drugs also that resulted in psycho motor developmental delay. Also must be safe when breast-feeding or just feeding so that their infant will not be dropped such as a padded chair or bed.
Guidelines for a breast-feeding parent with epilepsy
On each level of the house there should be a playpen in which to quickly place the baby when a seizure seems eminent. Use pillows and cushions to pad the arms of a rocker or chair where the parent usually breast-feed. Place guard rails padded with pillows around the bed if the infant is taken to bed to breast-feed. The stroller and the baby carrier should have attached a tag stating that the parent has a seizure disorder along with other pertinent information went away from home.
Vision and hearing impairment add challenges for breast-feeding
Blind parents may face stigma associated with their disability. These parents often have the same desire to breast-feed and deserve the same support. That includes prenatal education on breast-feeding baby benefits and anticipatory guidance. Seek a pediatrician who actively support the family. Should include the same skin to skin immediately after birth with continued skin to skin contact throughout the hospital staff so the parent can learn the infants feeding cues. Received all other standard breast-feeding education and support. Standard post discharge support and follow up including well baby pediatric and breast-fed infant guidelines. Refer parents to Le Leche League or other community support group.
Parents with hearing loss or deafness
May need breast-feeding assistance provided by an interpreter using sign language. Deaf parents are capable of breast-feeding and persist even with difficulties. Support and education for deaf parents come in many forms including videos graphics computer applications written materials and websites.
Dermatological disorders
Chronic or acute dermatitis may affect any area of the body including breasts and nipples. Eczema of the nipple is the most common atopic dermatitis of the breast. Presents with redness, crusting, oozing, scales, fissures, blisters, slits, and it causes itching and burning. There are three types of dermatological disorders including endogenous atopic dermatitis, irritant contact dermatitis, and allergic contact dermatitis. Management centers on cleansing, air drying after feeding and treatment with a low or medium strength Cortizone ointment twice per day for two weeks. Category V or the VI potency topical corticosteroid appointments are recommended. Category I potency topical corticosteroids should be avoided. Psoriasis is a chronic immune disease identified by well demarcated pink plaques that often appear as moist and has minimal or no scale.
Use of topical steroids to treat psoriasis follows the same guidelines as for eczema processes. Calciproteine. a topical vitamin D derivative is considered safe to use on the nipple. Systemic therapies for psoriasis include phototherapy with ultraviolet B and is considered the safest option. Biologic agents are believed to be moderately safe however the data are very limited.
Bacterial infections are often caused by S. Aureus
Parents complain of deep, dull aching breast pain during or after feedings or both. Breast tenderness especially with deep touch. Bilateral pain. Can have burning quality to the pain. Parents may have failed treatment for yeast infection. Treatment is with oral antibiotics, for at least two weeks.
Viral infection with herpes Simplex is fairly common and generally presents as miniature vesicles on an erythmatous base
Open vesicles carry the virus and the virus can be transmitted to the breast-feeding infant. It is critical to rule out herpes Simplex in infants younger than three months because they can develop a life-threatening infection involving the central nervous system. Parents with herpes Simplex virus infection should be prescribed oral ancyclovir 800 mg three times a day for 5 to 7 days. Parent should pump the breast instead of breast-feed when active lesions are present.
Raynaud phenomenon of the nipple is a vasospasm of the arterioles causing intermittent ischemia
Mothers who have experienced nipple pain for more than four weeks and had multiple failed rounds of anti-fungal or antibiotic treatment are suspected to have Raynaud phenomenon. To diagnose sensitivity to cold, manifested as classic tri phase a color change in the nipples (white, blue, and red) or biphasic color change, (white and blue) should be present. Treatment involves avoiding exposure to cold temperature using techniques to keep the breast and nipples warm, avoiding vasoconstrictive drugs that may precipitate symptoms and administer nifedipine 30 to 60 mg per day for two weeks.
Cancer
Cancers occur in 0.05 to 0.1% of all pregnancies. Breast, cervical, ovarian, and thyroid are the most frequently diagnosed during pregnancy. Breast cancer can occur at any time during gestation, during lactation or within one year after delivery. Treatment of any cancer during lactation depends on the site, stage and type. Generally chemotherapy and lactation are not compatible because all agents pass into the milk albeit in low levels and are potentially toxic to the infant. Surgical treatment of cancer during lactation is possible depending on the site, stage, and need for adjunctive therapy following surgery. Radiation of the breast may cause damage to the alveoli of the breast, although lactation with reduced volume following radiation is possible. There is no impact on the other breast.
Assistance during illnesses
Parents will need assistance when an illness leads to hospitalization or surgery. Should plan ahead and seek lactation support at the facility. Concerns will likely center around anesthesia, postoperative analgesia, access to and handling the baby for feeding, and expressing milk. Use an outpatient surgical facility rather than inpatient if possible. Arrange for breast-feeding a baby immediately before the surgery. Assess parent and breast-feeding as soon as awake from anesthesia. Make rooming in arrangements for the breast-feeding child if the parent is impatient. Express and freeze a supply of milk before surgery. Help the parent condition the baby to cup feedings if temporary supplementary feedings will be necessary. Encourage the parent to take postoperative analgesia to alleviate pain. If abdominal surgery is performed show the parent how to splint the surgical area with pillows. Cover the incision area with dressings. Emergency surgery calls for more vigilant support from the family to protect milk production in the breast-feeding child. In a critically ill parent especially one who becomes ill during pregnancy enhanced support from Lactation specialist and the healthcare team is paramount. The shock of being in critical care being a parent in critical care being transferred out of critical care and being discharged require exquisite support and patience.
Maternal mental health and breast-feeding
Should recognize the symptoms of depression and related disorders including PTSD and anxiety disorders. Understand the inflammatory response system in the ideology of depression. Understand how breast-feeding protects birth parents mental health. Breast-feeding problems can increase risk of depression and need to be addressed properly. Depression increases the risk for breast-feeding cessation. How to provide information on treatments that are compatible with breast-feeding.
Anhedonia
Inability to experience pleasure in normally pleasurable activities
Anti-natal depression
Depression during pregnancy
Anxiety disorders
Excessive worry or anxiety characterized by restlessness, hyper vigilant, irritability, sleep problems, and fears. Includes obsessive compulsive disorder, phobias, and generalized anxiety disorder
Inflammatory response system
The key part of the stress response. It is the underline physiological mechanism behind depression, anxiety, PTSD and other perinatal mood disorders
Postpartum depression (postnatal depression.
Major depressive disorder during the first year after birth. Symptoms include sadness, anhedonia, agitation, social withdrawal, sleep problems, and irritability that last more than two weeks.
Post traumatic stress disorder (PTSD)
A disorder that can occur following a traumatic event.
Traumatic event
Traumatic event according to the DSM five an event meets the exposure criteria for PTSD if it includes death or threatening death, actual or threatening physical harm, or actual or threatened sexual violation. The event can be directly experience, or can be witnessed. Additionally the event may have happened to a loved one.
Mental disorders and lactation
Postpartum mood disorders including depression anxiety disorders PTSD can lead to an early breast-feeding cessation.
Because breast-feeding down regulates the inflammatory stress responses and up regulates the oxytocin response it is important to protect this mechanism for a mothers mental health and lowers the risk of depression.
However, breast-feeding problems, particularly pain, can increase the risk of depression because these problems regulate the stress and inflammatory responses.
Exclusive breast-feeding results in a significantly lower risk of depression then does mix feeding and formula feeding.
It is estimated that 10 to 15% of birth parents will be depressed after having a baby. Recent data suggest that this is much higher in other groups besides white women. Postpartum depression is less likely to be diagnosed and treated in young women as well as African-American, Hispanic and other non-white women.
Only one treatment for depression is contraindicated for breast-feeding parents MAOI class of drugs are not recommended. All other treatments for depression are compatible with breast-feeding.
Depression may manifest as somatic complaints such as severe fatigue. Sleep difficulties can also indicate a possible depression. Those who take more than 25 minutes to fall asleep or at high risk for depression.
Incidence of depression
The highest risk of depression is during the first year of parenthood. By the time children were 12 years old 39% of mothers and 21% of fathers were depressed.
In Turkey it was found the 14 to 15% of mothers had postpartum depression.
In Australia found that 31% of mothers were depressed in the first four years of parenthood. The risk factors included young maternal age, stressful life events, adversity, intimate partner violence and low income.
In Korea one study found 49% of mothers were depressed. In the second study 41% were depressed during pregnancy and 61% were depressed at four weeks postpartum. Vietnam found 16 to 20% of new mothers were depressed.
Meta-analysis eight studies of immigrants to Canada founded up to 42% were depressed.
Causes of depression
The inflammatory response system is the physiological mechanism underlying depression. All types of physical and psychological stress increase the risk of depression in non-postpartum and also in new parents.
All the stressors do the same thing cause an up regulation of the stress response including an increase in pro-inflammatory cytokines. Pro inflammatory cytokines are messenger molecules of the immune system to increase inflammation.
During the last trimester of pregnancy is an especially vulnerable time because inflammatory levels rise significantly. Also experience of new parenthood including sleep disturbance, postpartum pain and psychological trauma also increased inflammation. Normal response to stress includes: the sympathetic nervous system response by releasing catecholamines (norepinephrine, epinephrine and dopamine). The hypothalamus – pituitary-adrenal (HPA) axis also responds with the hypothalamus releasing corticotropin releasing hormone (CRH), the pituitary releases adrenocortical tropin hormones (ACTH) and the adrenal cortex releases cortisol, a glucocorticoid. Immune system response by increasing the production of pro-inflammatory cytokines which increase systemic inflammation. Cytokines are proteins that regulate immune response and help heal wounds and fight infection by stimulating an inflammatory response.
The depressed person inflammation is increased including high levels of pro inflammatory cytokines and acute phase proteins such as C-reactive proteins (CRP) which is a physiological response to chronic distress. Inflammation levels can be 40 to 50% higher in depressed people.
The pro inflammatory cytokines that we believe has been elevated in depression or interleukin – 1B (IL-1B) interleukin-6 (IL –6) and tumor necrosis factor alpha (TNF alpha).
Breast-feeding specifically downregulates the stress response and lowers ACTH, cortisol, and inflammation. This is likely one way the breast-feeding decreases the risk for depression.
Sleep disturbance
The relationship between sleep disturbance and depression is bi directional. Even short periods of disruptive sleep can wreak havoc on physical health. Sleep disturbances increase inflammatory responses and increase the risk of chronic diseases such as heart disease and metabolic syndrome. Breast-feeding may protect mental health by improving sleep quality and quantity. Exclusively breast-feeding parents record more total sleep time and fewer minutes to get to sleep. Breast-feeding increases deep or slow wave sleep. The protective effects of exclusive breast-feeding is true even when parents have a history of sexual assault. If a breast-feeding parent is very fatigued physical causes such as anemia hypothyroidism or low-grade infection should be tested and ruled out. Parents may need help with mobilizing their support network so they can get more rest.
Pain
Postpartum pain can trigger postpartum depression and should be addressed properly. Nipple pain is one common type of postpartum pain. Pain and inflammation are mutually upregulatory, that is pain increases inflammation and inflammation increases pain. In addition pain up regulates the stress system including the sympathetic nervous system which inhibits oxytocin release and directly contributes to problems with milk ejection.
Psychological trauma
Psychological trauma increases the risk for depression and PTSD. Trauma increases inflammation. Childhood maltreatment can be shown to increase inflammation even 20 years later. Those who have experienced childhood adversities such as low socioeconomic status, male treatment, or social isolation at higher rates of major depression, systemic inflammation, and at least three metabolic risk markers.
The most common types of psychological trauma for new mothers are adverse childhood experiences and trauma related to their birth experience.
Have found that mothers who had cesarean delivery or forceps assisted births were significantly more likely to have breast-feeding difficulties at three months postpartum. An adverse childhood experience also carries increase risk. These include childhood physical and sexual abuse, emotional abuse, neglect, witnessing domestic violence, parental mental illness, substance abuse and criminal activity.
Childhood adversities are related to a number of chronic health condition in adults including cardiovascular disease, metabolic syndrome and diabetes. For patients who are abuse survivors applying trauma informed care you may need to help modify breast-feeding to make it more comfortable.
However it is also important not to disempower parents by making decisions for them. Doing so would be paternalistic and not trauma informed care. Do not assume my mother does not want to breast-feed. Some strategies may include using distraction while breast-feeding (such as reading or watching TV), avoiding nighttime feedings, reducing the amount of skin to skin contact, and feeling expressed milk from a bottle.
Negative birth experience as a form of psychological trauma
Birth intervention such as epidurals and other anesthesia decrease the risk of exclusive breast-feeding and increased depressive symptoms.
In the US 9% of mothers met full criteria for PTSD and an additional 18% scored above the cut off for PTSD symptoms following birth.
Women in countries where birth is treated as a normal event and who have continuous labor support have a lower rates of PTSD.
In Sweden they found 1.3% had birth related PTSD and 9% describe their births as traumatic.
Conversely in Iran they found that PTSD was reported by 20% of women postpartum this is in a country where women level of status is lower.
Mothers are more vulnerable to having PTSD if they had a prior episode of depression, or abuse survivors, had prior episodes of loss, or were depressed during pregnancy.
A highly stressful birth may delay lactogenesis II because high cortisol levels suppress prolactin. Infant illness, preterm birth and disability can cause depression and birth parents particularly if the babies are at high risk for severe illness or death.
However this reaction is often delayed and may not manifest until the babies are out of danger.
Treatment options
All effective treatments for depression are anti-inflammatory.
Omega three fatty acids: omega-3 fatty acids found in fatty fish may help prevent and treat depression. EPA is the omega-3 the treats depression because it specifically lowers pro inflammatory cytokines and down regulates the stress response. Even in relatively large doses EPA and DHA for safe during pregnancy and lactation and provide a number of other health benefits for breast-feeding parents including lowering the risk of heart disease and making them last vulnerable to stress.
Bright light therapy. Can be an effective treatment for depression and has been use during pregnancy and breast-feeding.
Exercise. Can be as effective as medication for even major depression. Exercise lowers inflammation. Exercise at a moderate level is safe during pregnancy and lactation but it does not decrease milk production or increase lactic acid in the milk. It is recommended for mild to moderate depression to exercise two or three times per week with moderate intensity for 20 to 30 minutes. For major depression it is recommended to exercise 3 to 5 times per week for 60 to 85% maximum capacity and then for 45 to 60 minutes.
Psychotherapy. There are two types of psychotherapy that are effective for depression cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). The premise of CBT is that depression is caused by distortions in peoples beliefs about themselves in the world. IPT specifically addresses the parents key relationships and the support they receive from those relationships. It teaches them to identify sources of support and increase the amount of support they receive.
Saint johns wort. This is an herbal anti-depressant and is the most widely used antidepressant in the world. It can be highly effective. It has an excellent safety record. It does interact with several types of medication so patient should always advise their healthcare provider if they are taking it. It should not be combined with anti-depressants, birth control pills, cyclosporine‘s, anti-neoplastic agents, HIV medication and several other classes of medication‘s.
Antidepressants. Most anti-depressants are compatible with lactation but they vary in how much exposure the infant receives. MAOIs are contraindicated during lactation.
Induce lactation and relactation
Autocrine control
The separate control of milk production and each breast in direct response to stimulation and milk removal rather than dependent on endocrine control.
Galactagogue
Pharmaceutical or herbal preparation used with the belief that it will increase milk production
Gestational surrogacy
The carrying of a pregnancy by another woman on behalf of the intended parents
Induced lactation
The purposeful stimulation of lactation when it was previously absent, usually in the absence of a pregnancy in the months immediately prior to the induction of lactation (nonouerperally). Also includes adoptive breast-feeding when a parent who is not breast-feeding induce lactation, whether or not having breast-fed in the past.
Relactation
Resumed lactation in a parent who has previously breast-fed the same baby (that is, reversing weaning). Also reestablishing Lactation for a biological child the parent has never breast-fed following the suppression of lactation postpartum. May also indicate a parent who has lactatated in the past and is inducing lactation for another child. The term is used generically for any type of reduced lactation, and sometimes includes reversing a significant decrease or lag in milk production.
Table 19.1 Patterns in human Lactation
Check out the table with all the different ways that people go from mix feeding to exclusive Breastfeeding back to mix feeding winning all the different combinations that are commonly seen
Physiological mechanism
In the absence of a pregnancy, memory stimulation triggers the release of prolactin and facilitates proliferation of secretory tissue, enabling milk secretion to occur Suckling or milk expression or other nipple and areola stimulation, stimulates both prolactin secretion and the release of oxytocin and is the most important factor in inducing lactation. Milk removal enables milk secretion to continue, through autocrine control of each breast. Confidence building it’s necessary. Oxytocin released can become a conditioned response.
Inducing Lactation or relactating
Induce lactation and relaxation are recommended to prevent or reduce infant mortality and morbidity and humanitarian emergency situations. Some are able to achieve full milk production while others are able to breast-feed with supplementation.
Induce lactation is practiced in numerous cultures. The reasons may include: to normalize the arrival of a child when adopting or fostering a baby, to simulate the experience of biological parenting and develop a close parent infant relationship, to optimize for babies health or give it debilitated infant a chance of survival, to nourish an infant if the biological parent is unable to breast-feed, to create kinship by milk for a child who is fostered or adopted in Islamic culture, when adopt a child seeks comfort at the breast where the parent or grandparent cycles to comfort a distressed child, to breast-feed a baby born to a gestational surrogate.
Inducing Lactation with an adopted child
Parents may or may not know when they will receive an adopted child. It is often difficult to predict the date. May arrive on short notice. Usually do not receive their adopt a baby‘s at or soon after birth. It is helpful to learn about the child’s feeding including the following prior to placement, the type of milk the child has been fed, and the current feeding method for example wet nurse, fair by bottle, fed by cup.
Relactation is practice for a variety of reasons
To recommence breast-feeding after weaning,
to reduce an infant health problem that occurred after early weaning such as diarrhea, malnutrition or constipation.
When the situation that lead to weaning or failure to initiate breast-feeding has been over come.
Breast or nipple conditions illness, or separation of the dyad.
Non supportive hospital practices that impacted breast-feeding initiation in the postnatal or lead to early replacement feeding.
Condition such as prematurity, oral facial anomalies, malnutrition, severe gastroenteritis and dehydration or hospitalization.
The child wishes to resume breastfeedin following weaning.
Parent expectations and support
You should ascertain a parent‘s expectation and how breast-feeding success is defined. Emphasize that it is facilitated by skin to skin contact. Success is best defined by a parent feels about the experience regardless of milk yield. There’s a lot of variation in timeframe so don’t set a specific time. You should provide counseling and support to the parents including their level of confidence. Provide regular telephone or online video contact as needed. Explore cultural factors that may be both barriers and support. Ensure that there is adequate support for the parents. Help adoptive parents find an online support group. Encourage building the trust of the baby especially an older baby before offering the breast. Optimal support includes both professional and lay input.
History and assessment
Explore the parents reproductive history. The number and duration of pregnancies and births and how long ago they occur can be a factor. History suggestive of infertility, hormonal imbalance, PCOS, assisted conception technology, thyroid or pituitary disorders or physical anomalies may impact success with achieving milk production. Provide anticipatory guidance about possible menstrual cessation or irregularities resulting from establishing Lactation.
Inquire about previous breast-feeding experience. If mother has breast-fed be aware of the following factors: any previous difficulties with breast-feeding, if weaning proceeded to wish to relactate asked what the reason for weaning was, determine length and time since previous breast-feeding occurred.
A short Lactation gap has been possibly associate with a high percentage of milk flow. Lactation gaps of 1 to 45 days reported relactation in 97.6% of the mother within 10 days. A longer lactation gap is usually associated with a longer time to achieve milk production.
Explore the infants current health status including: birth details, health history including current growth, developmental status, prematurely, tongue tie etc..
Assess the breasts and nipples that make make inducing milk production a greater challenge.
Initiating milk production
Assist with encouraging the infant to suckle at the breast. If it has been initiated by an older baby or a child who is in experience breast-feed only reassurance may be needed. Early rejection may not mean the baby will always refuse. Age can be a factor with the older the child is when introduced to the breast the greater the possibility of unwillingness to nurse unless the baby is being breast-fed by the biological mother or a foster mother at the time of adoption or as previously been breast-fed.
Newborns and babies younger than eight weeks are most likely to suck or willingly. Likely because sucking is usually reflexive. It changes to a voluntary action by about three months of age. Babies older than two months may resist or respond negatively some may need a technique similar to those that help babies who do breast refusal. Babies older than six months are likely to require patience. When babies are over nine months their personality may influence their willingness to except breast-feeding. In the case of adoption high-quality foster care prior to adoption may be an influence.
Optimize the babies willingness to go to the breast
Begin skin to skin contact when the baby is not showing hunger cues and it’s still sleepy. Put the baby to the breast while sleepy and not fully awake and use other techniques for breast refusal. Avoid all practices that limit the close body contact and very frequent suckling that support of relactation and induce lactation. This includes rigid timing of feeding attempts and separation of the parent and baby including in a baby carriage.
Encourage optimal hatch and breast-feeding technique. Discontinue the use of bottles and pacifiers so that all suckling is done at the brass. Use a feeding tube, syringe, or cup to provide supplements. Dropping milk onto the areola may encourage the baby to suck. The feeding tube can be used to provide a flow of milk when the baby suckles at the breast.
Assist with breast stimulation in preparation for breast-feeding. In the case of adoption nipple stimulation every 3 to 4 hours through gentle stroking and rolling can begin about four weeks prior to receiving the baby. Breast massage and warmth are also useful. Many parents have achieved milk production by suckling the baby intensively at the breast usually with but sometimes without manual stimulation. Some have found very little difference between mothers who used only breast and nipple hyperstimulation and those he is metoclopramide in addition to frequent suckling.
Assist with milk expression
Milk expression sessions may start with only a few minutes according to comfort and build up to a maximum 15 to 25 minutes. Express as frequently as a newborn would be breast-fit so 8 to 12 times per 24 hours with one of more expressions at night. Express at least six times per 24 hours for 15 minutes per breast.
Teach and assess the parents ability to hand express. Manual expression has been shown to extract colostrum more effectively than a Hospital grade breast pump alone.
Manual expression is appropriate for the low volume of fluid in the early stages of inducing labor. Galactagogue‘s may assist with the initiation of no production. It is often common in western counties to use hormonal medication‘s and domperidone.
It is possible though to induce lactation by manual stimulation alone.
Sometimes hormonal medication‘s are used to induce for an adopted child. Estrogen and progesterone in an oral contraceptive pill should be started as many weeks as possible before the adoption. Breast-feeding expression begins when the oral contraceptive pill is discontinued.
Caution needs to be taken particularly with older mothers about the possibility of venous thrombosis.
Synthetic oxytocin usually administered as an intro nasal spray has been used to help milk ejection. Suckling or other nipple stimulation and skin to skin contact caused the release of oxytocin without use of pharmaceuticals.
Milk composition following induce lactation and relactation
The studies have focused specifically on the nutritional and immunological composition of milk produced in induced lactation or relaxation. The little that was has been collected has shown that is similar compared to mature milk after giving birth. One case report shows a biological mother secreted colostrum for two weeks after beginning relactation at nine weeks postpartum. There are other case studies of adoptive mothers who reported the absence of colostral stage.
Feeding the baby
Supplementation is essential for the babies well-being while milk production is being established or reeestablish. A combination of supplementation methods has been used. Eliminating or decreasing the use of bottles and artificial nipples and putting the child to the breast frequently will help increase milk production. Additional nourishment can be provided with a feeding tube at the breast or with a cup or syringe after breast-feeding. Express milk can be given as a drink or mixed in other food even if the child never suckls at the breast. The baby is accustomed to being fed with a fast flow introduce bottle nipples with a slower flow. Teach the parent how to use pace feeding and pause several times. Using a supplementing feeding tube at the breast provides both stimulation and food for the baby. The baby is using only one type of oral mouth motor action so it reduces any potential confusion. A soft small feeding cup syringe or local equivalent can be used for supplements. Teach the parent to cup feed the baby in an upright position. Offer the supplement only after the baby has circled at the breast. Decreasing supplementation requires regular contact with relevant members of the healthcare team for guidance. Use the infants output and growth as guides for decreasing supplements and other foods as appropriate. Do not keep the baby hungry in an attempt to encourage suckling at the breast. Do not dilute the supplementary milk or restrict the amounts of supplements. If baby’s output decreases or if growth rate falters temporarily increase the supplement. Replace milk expression with additional breast-feeds. Gradually reduce the use of galactagogue‘s. Some infants will require supplementation throughout the duration of breast-feeding.
