Breastfeeding Basics for Primary Care

Educational Objectives

The goal of this program is to improve patient outcomes through discussion of breastfeeding basics for primary care. After hearing and assimilating this program, the clinician will be better able to:

1. List contraindications to breastfeeding.
2. Choose the optimal approach to mastitis.
3. Optimize use of analgesics in patients who are breastfeeding.

Summary

Newborn and infant feeding choices: breast milk (BM) is the gold standard, but there are different methods of obtaining it (eg, directly from the breasts, pumped BM, donor BM, and formula [an alternative, but not a gold standard])

BM handling and storage: freshly expressed or pumped BM can stay at room temperature for up to 4 hr, be refrigerated for up to 4 days, and be frozen for up to 6 to 12 mo; previously frozen BM should be used within 1 to 2 hr at room temperature or within a day if refrigerated; never refreeze thawed BM, and unfinished BM can be used within 2 hr after the baby has finished eating

Risks of BF: include a significant learning curve, breast complications, and emotionally challenging judgmental attitudes, especially if BF >6 to 12 mo; since BM is low in vitamin D, supplementation for exclusively BF infants during the first yr is needed; while BM is lower in iron, its bioavailability is higher, prompting the recommendation of iron-rich foods and supplements at 6 mo of age; an Academy of Breastfeeding Medicine (ABM) study reported a ≈9.1% prevalence of dysphoric milk ejection reflex (D-MER) among recent mothers; it involves a profound sense of unhappiness and negative feelings triggered by the milk ejection reflex during BF

Medical contraindications (CI) to BF: Center for Disease Control and Prevention (CDC) revised guidelines allow BF with antiretroviral treatment and an undetectable viral load (risk for transmission is <1%); in less developed countries, active HIV infection may not be a CI because the benefits of BF outweigh the risks; other CI include active HTLV I or II, suspected or confirmed Ebola virus infection, excessive alcohol use, and active substance use; treatment and maintenance on methadone or buprenorphine are not CI, but active substance use is; infants with galactosemia, a recessive genetic metabolic disorder, cannot digest breast milk, making it a CI; temporary CI include active Brucellosis infections, certain medications or treatment, active herpetic lesions on the nipple or breast, active, untreated tuberculosis, and active chickenpox or shingles (once healed or treated, BF can resume)

Infant benefits: reductions include necrotizing enterocolitis in preterm infants (≈58% reduction with any BF), sudden infant death syndrome (40% reduction with 2 to 4 mo BF, 60% reduction with 4 to 6 mo BF), ear infections (33% reduction with any BF, 43% with 6 mo BF), gastrointestinal (GI) infections (30% reduction in diarrheal illnesses with 6 mo BF), and severe lower respiratory disease infections (19% reduction with any BF); these reductions are more pronounced in less developed countries, making BF a global public health policy; there is a 57% reduction in type 1 diabetes with 6 mo of BF and a 33% reduction in type 2 diabetes with any BF; BF contributes to a 23% reduction in childhood and adult obesity, a 22% reduction in asthma, and an 11% reduction in the risk for leukemia with any BF, increasing to a 19% reduction with 6 mo of BF

Maternal benefits: women who breastfeed for ≥12 mo experience 26% reduction in the lifetime risk for breast cancer; there is some benefit with less BF (≈7% reduction with <6 mo of BF, 9% reduction with 6 to 12 mo of BF); risk reduction increases with longer year of BF; BF for ≥12 mo is linked to 36% reduction in risk for ovarian cancer (17% if BF <6 mo, 28% with 6 to 12 mo of BF); BF for ≥12 mo causes a 22% reduction in high blood pressure postmenopausally and a 37% reduction in type 2 diabetes; there is also a decreased risk for endometrial cancer (≈2% relative risk reduction per mo of BF)

Donor milk alternative in the United States: regulated milk banks provide a donor milk alternative; donors contribute their extra milk, which undergoes strict processing and is often given to premature babies in neonatal intensive care units (NICU); while insurance may cover this, it can be expensive for outpatient use; another alternative is personal donor milk; some individuals, often hyperproducers, may have surplus stored milk that exceeds their baby's needs; informal sharing of such milk may occur among friends, although it lacks regulation

Breast Complications

Engorgement: primary engorgement typically 3 to 5 days postpartum, signals mature milk production, causing lobule swelling, compressing vasculature and leading to painful mammary gland swelling; secondary engorgement can happen during BF because of factors such as interrupted feeding or excess pumping; it causes full milk sacs, interstitial edema, and pain; treatment includes feeding or hand expressing to physiologic need, avoiding overfeeding, and using ice; cabbage leaves are not recommended because of potential bacterial contamination; lymphatic drainage techniques and reverse pressure softening, with support from a lactation consultant, may help

Nipple pain: while common, it is not normal and often results from latch issues, positioning problems, or excessive milk production; referral to lactation consultants is crucial; for treatment, clean and moisturize the nipple with a lanolin-free organic balm or alternatives such as olive oil or Medihoney; cover the nipple with a hydrogel, nonstick pad, or parchment paper; in cases of exudative wounds, polyurethane foam like polymem can absorb moisture; patients should limit BF to physiologic needs; hand expression is preferred over pumping to avoid exacerbating trauma; avoid air drying, Epsom salts, nipple shells, and multicomponent creams such as apno

Nipple bleb or blister: small, 1 to 2 mm, inflammatory lesions on the nipple surface, often appearing white, yellow, or clear; common in hyperlactation or pumping, they can also result from localized plugging due to excessive ointments; studies suggest relief using 0.1% topical triamcinolone once a day for 1 to 2 wk; avoid unroofing as it can worsen the issue; for recurrent problems, oral sunflower lecithin (1200 mg 3 times a day) may help

Other Causes of Nipple Pain

Nipple vasospasm: causes stinging neuropathic pain that may radiate to the breast; triggered by cold, it manifests as nipple blanching after nursing; treatments include applying heat, avoiding cold triggers, and, in severe cases with debilitating neuropathic pain, considering selective serotonin reuptake inhibitors for quick desensitization; calcium channel blockers are an alternative (need monitoring for blood pressure effects)

Skin dermatitis: can cause itching, pain, cracks, and scabs on the nipple; check for use of new soaps or wipes; some women may be sensitive to lanolin-based nipple balms; consider dietary factors; nipple pain is rarely due to yeast, hence, reflex attribution to Candida should be avoided; herpetic lesions or shingles may require a culture; if issues persist, consider D-MER or screen for perinatal mood and anxiety disorders

Plugged ducts: better described as compressed ducts, not actual plugs; heating and deep massage are counterproductive; milk stasis causes compression in a specific lobule because of poor latch, supply mismatch, or physical constriction from bras; treatment involves resting the breast, feeding for physiologic needs only, and using anti-inflammatory measures such as ibuprofen and ice; therapeutic ultrasonography may reduce inflammation, and oral sunflower lecithin is considered if recurrent

Mastitis: an inflammation of the breast often preceding infection, may result from compressed ducts; symptoms include sudden onset fever, chills, and flu-like feelings; initial measures include physiologic feeding, ibuprofen, ice, acetaminophen, and therapeutic ultrasonography; antibiotics should be considered if no improvement occurs within 24 hr or in acute cases with clear cellulitic signs; first-line antibiotics include dicloxacillin or cephalexin; if no improvement occurs, a breast milk culture (body fluid, not wound) may be performed, with consideration for methicillin resistant Staphylococcus aureus coverage

Abandoning the “pump and dump” mentality: to avoid unnecessary distress, abandon the pump and dump mentality in BF; patients often face engorgement because of inaccurate advice on medication safety; instead of epocrates and Uptodate, rely on trustworthy resources such as LactMed (free, health care oriented) and Dr. Hale’s Medications and Mother's Milk (textbook with app, $60/yr)

Unsafe medications: include most maternal cancer chemotherapies, substances such as heavy alcohol or marijuana, opiates (avoid tramadol and codeine), amiodarone, most novel anticoagulants (lack data; heparin and warfarin are reasonable to prescribe), smallpox and yellow fever vaccines, and select radiologic imaging agents; if radioactive iodine 131 is used, BF should be stopped completely; for radioactive iodine 123, cessation is advised for up to 3 wk, and for technetium-based imaging, it is recommended to delay BF for 12 to 24 hr; however, BF can continue with magnetic resonance imaging, computed tomography with iodinated contrast, mammography, regular x-rays, and cardiac technetium-99m sestamibi imaging; meperidine should be avoided during breastfeeding, and while low-dose short-acting ketamine might be safe, higher doses should be avoided because of limited data

Readings

Bertino E, Giribaldi M, Baro C, et al. Effect of prolonged refrigeration on the lipid profile, lipase activity, and oxidative status of human milk. Journal of Pediatric Gastroenterology & Nutrition. 2013;56(4):390-396. doi:https://doi.org/10.1097/mpg.0b013e31827af155. View Article; Caidon Iwuagwu, Chen MJ, Hoyt-Austin A, et al. Awareness of the maternal health benefits of lactation among US pregnant women [A30]. Obstetrics & Gynecology. 2022;139(1):9S9S. doi:https://doi.org/10.1097/01.aog.0000826456.02271.f5. View Article; Cooper BB, Kowalsky D. Physical therapy intervention for treatment of blocked milk ducts in lactating women. Journal of Womenʼs Health Physical Therapy. 2015;39(3):115-126. doi:https://doi.org/10.1097/jwh.0000000000000037. View Article; Dalal PG, Bosak J, Berlin C. Safety of the breast-feeding infant after maternal anesthesia. Bosenberg A, ed. Pediatric Anesthesia. 2013;24(4):359-371. doi:https://doi.org/10.1111/pan.12331. View Article; Ito S. Opioids in breast milk: pharmacokinetic principles and clinical implications. The Journal of Clinical Pharmacology. 2018;58(S10):S151-S163. doi:https://doi.org/10.1002/jcph.1113. View Article; Louis-Jacques AF, Berwick M, Mitchell KB. Risk factors, symptoms, and treatment of lactational mastitis. JAMA. 2023;329(7):588. doi:https://doi.org/10.1001/jama.2023.0004. View Article; Mestre CT, Excellent D, Jaynes S, et al. Innovations in breastfeeding support. Clinical Obstetrics & Gynecology. 2022;65(3):648-662. doi:https://doi.org/10.1097/grf.0000000000000736. View Article; Zhao C, Tang R, Wang J, et al. Independent study module for lactation consultants. Journal of Human Lactation. 2014;30(3):371-373. doi:https://doi.org/10.1177/0890334414534918. View Article.

Disclosures

For this program, the speakers and members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Coulson was recorded exclusively for Audio Digest on January 15, 2024. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

FP721301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.