EVERY CALL IS AN OPPORTUNITY

BREASTFEEDING 2001, PART II:THE MANAGEMENT OF BREASTFEEDING 0031-3955/01 $15.00 + .00

EVERY CALL IS ANOPPORTUNITY

Supporting Breastfeeding MothersOver the Telephone

Barbara L. Philipp, MD, mCLC

Health care professionals are given a golden opportunity to supportbreastfeeding families when these families solicit advice over the telephone. Foranxious mothers who call because they want to do what is best for their infants,appropriate telephone advice by knowledgeable staff can affect breastfeedingduration positively. Telephone communication may occur in various settings,including a practice's nurse-staffed telephone triage office-v 24; a breastfeedingsupport linev 21; and personal calls to a breastfeeding expert or advocate, suchas a lactation consultant or a La Leche League International leader. The advicethat health care professionals offer over the telephone should be evidence-basedand consistent.

The latest recommendations about breastfeeding are contained in the 1997policy statement of the American Academy of Pediatrics (AAP).l As an overallguideline based on extensive, evidence-based research, the AAP recommendsexclusive breastfeeding for approximately the first 6 months of life, continuingto 1 year or beyond, with the addition of complementary solid foods at aboutage 6 months. Health care professionals should use the AAP Statement on Breast-feeding as the gold standard and refer to it regularly when answering questions.

Which breastfeeding questions are asked commonly over the telephone? Inone study" of 92 calls to a breastfeeding "warmline" over a 4-month period, thecommonly asked questions involved pain or discomfort of the breasts or nipples(24%); pump or equipment questions (9%); not enough breast milk (8%); feedingschedule or solid food questions (7%); and questions about medication, sleepyinfant or infant with poor suck, fussy infant, and bottle-feeding (5% each). This

From the Department of Pediatrics, Boston University School of Medicine; the Division ofPediatric Ambulatory Services, and The Breastfeeding Center, Boston Medical Center,Boston, Massachusetts

PEDIATRIC CLINICS OF NORTH AMERICA

VOLUME 48 • NUMBER 2 • APRIL 2001 525

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article reviews the most common questions asked over the telephone and sug-gests appropriate responses to aid health care professionals in offering the bestbreastfeeding telephone advice possible.

NIPPLE PAIN

Question. I have been breastfeeding for a week. I am in a lot of pain. Myleft nipple is cracked and bleeding. What can I do?

Discussion and Advice. Successful breastfeeding hinges on the latch: theway the infant attaches to the breast. Poor latch is a common cause of sorenipples in the early days of breastfeeding. If a mother has received poor orinadequate teaching about the latch and, as a result, the infant's latch is incorrect,the infant may gum or chew the nipple, leading to painful, cracked, and some-times bleeding nipples. The pain may be sufficiently severe to inhibit the let-down reflex. Working with the latch over the telephone is difficult, but thefollowing suggestions may helpv ":

1. Hold the breast using a C hold, with the thumb on top of the breast andfour fingers underneath. The C hold is recommended over the scissorshold because the fingers are placed further back on the breast and thereis less compression of breast tissue and more support for the breast.

2. When using the cradle-hold position, hold the infant on his or her side,"tummy to tummy and nipple to nose."

3. The infant should be brought to the mother, rather than the motherbending over to reach the infant.

4. Gently touch the infant's lips with the nipple to elicit the rooting reflex.When the infant's mouth gapes open at its widest point, pull the infantquickly to the breast.

5. Encourage the infant to take a large mouthful of the areola and breast,with as much of the breast as possible going into the mouth. (Offer theimage to the mother of how someone would need to open their mouthto get it around a "Big Mac" sandwich.) When the infant is latchedcorrectly, the nipple is protected in the back of the infant's mouth.

6. With proper latch, less of the lower portion of the areola is seen comparedwith the upper areola, the infant's lips are flanged out, the cheeks puffout as they fill with breast milk, and the jaws move rhythmically as theinfant sucks and swallows.

7. If the infant causes pain with each suck, detach the infant from the breastby gently inserting a finger into the corner of the infant's mouth andbreaking the suction. Then start over; otherwise, the infant will damagethe nipple again.

To heal the damaged nipple, the mother also can expose it to air, applysmall amounts of expressed breast milk and purified lanolin cream, and limitbreastfeeding on the sore side. Because of the difficulty of assessing or correctingthe latch over the phone, the mother should be seen in person if the pain doesnot improve within 24 hours.

PAINFUL BREASTS

Question. I just arrived home with my 3-day-old infant. My breasts are fulland painful. The infant can't even find the nipple and he is crying all the time.What should I do?

EVERY CALL IS AN OPPORTUNITY 527

Discussion and Advice. It is ironic that, while in the hospital, mothers haveplenty of help and little milk. When they arrive home, most have plenty of milkand little help. Some engorgement is part of the normal process of lactogenesis,when the milk starts to be produced in an ample supply. The body needs a fewdays to learn exactly how much milk to make. The key to relieving engorgementis to express the overabundant supply of milk and allow the areola to soften sothat the infant can properly latch on. To help soften her breasts, the mother canmanually express milk by massaging her breasts while standing under warmwater in a shower or she can immerse her breasts in a basin of tepid water.After the areola softens, it may be easier for the infant to latch on; frequent feedsby the infant are the best source of relief for the engorgement. After each feed,the mother can apply cool compresses (e.g., an ice pack or a bag of frozen peas)to her breasts, and, for those suffering severe discomfort, take a pain medication,such as acetaminophen or ibuprofen. A breast pump can be used to help softenbreasts in extreme cases. The mother should pump only for relief, until theareola is sufficiently soft for the infant to latch on.

BREAST PUMPS

Question. I am going back to work, and I want to continue breastfeedingmy daughter. I think I need a breast pump, but I tried the one my sister gaveme at my baby shower, and it hurt. Do you have any suggestions?

Discussion and Advice. Before deciding how to advise this mother, clini-cians should find out how old the infant is and whether the mother is returningto work full-time or part-time. Other considerations are the mother's workplaceenvironment, her financial situation regarding the cost of pump rental, and herhealth insurance. Although hand expression is one alternative for mothers whocannot afford an electric pump, this method of expression is time consumingand rarely used in the US workplace.

The ideal option for employed, breastfeeding mothers is to obtain a high-quality, electric breast pump that they can use at work. Some workplaces providebreastfeeding rooms equipped with an electric pump. The woman can thenpump her milk at work, store it, and have the milk fed to her infant at a latertime. If the infant is young «6 mo), the scenario is different from that of olderinfants, who take some solids and are not exclusively dependent on humanmilk. The length of the workday also is important. A mother returning to workpart-time can pump less frequently and use a smaller pump than, for example,a mother who works full-time or long shifts. Women often inquire about whethertheir health insurance will cover the cost of a breast pump.

The retail cost of top-grade electric pumps is approximately $750, so mostwomen choose to rent. Rental fees vary from $30 to $70 per month, dependingon the length of the rental. (A prepaid, 6-month rental may work out to be $30per month, but a 'l-month rental may cost as much as $70.) Rental pumps areconsidered the "Cadillac models" and should be recommended for women whohave a long workday, such as a nurse working a 12-hour shift. After the rentalmodels, Medela's Pump in Style (Medela, Inc., McHenry, IL), which retails forapproximately $275, and Ameda's Purely Yours (Hollister, Inc., Libertyville, IL),which retails for approximately $199, are realistic options. These "personal-use" pumps are easy to carry, electric, fully automatic, and pump both breastssimultaneously; however, they are less powerful than are the bigger rentalmodels. In most cases, they are adequate for women who do not have anunusually long workday or a history of poor milk supply. A woman who workspart-time might want to use a small, single breast pump, such as Medela's

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Mini Electric, which retails for approximately $100. Ameda, Medela, and Avent(Bensenville, IL) also make high-quality hand pumps for women who only willbe separated from their infants for short periods of time.

If an infant is exclusively breastfeeding, his or her mother should pumpapproximately every 3 or 4 hours at work. A mother who works an 8-hour daymight be able to pump only once at work if she breastfeeds the infant immedi-ately before leaving for work and as soon as she arrives home.

Question. I am returning to work in 1 week. I have been pumping breastmilk, but my 3-month-old infant is refusing to drink it from a bottle. He onlywants me! Is there anything I can do?

Advice. Unfortunately, this is a common and a difficult problem becauseexclusively breastfed infants may develop a strong preference for the breast andrefuse other forms of feeding. A solution that might work for one infant maynot work for another, so several ideas should be suggested to the caller. Someoneother than the mother can attempt to feed the infant breast milk from a bottle.Suggest trying this when the infant is sleepy and with the mother out of theinfant's sight. Alternatively, breast milk can be offered in other containers besidesa bottle, depending on the age of the infant. An infant 4 months of age or oldercan be offered breast milk in a "sippy cup"; a younger infant can be offeredbreast milk in a small medicine cup or given the breast milk in drops from asyringe. In some situations, the infant could be brought to the mother's work-place. This option may not always be realistic, but it is worth suggesting.

Health care professionals can take steps to prevent this problem by routinelydiscussing return-to-work issues with the parents at the I-month visit. If themother is returning to work, she will need to decide on whether she will behand-expressing milk or using a breast pump. If she decides on a pump, shecan be given information about which type of pump will be best for her worksituation. She should start to offer one bottle a day of breast milk after her milksupply is fully established (usually at approximately 1 mo post partum). Usuallyan infant at this young age will drink from the breast and a bottle.

MEDICATIONS AND BREASTFEEDING

Question. I have a sinus infection and have been given a prescription foramoxicillin. Can I take this drug and continue to breastfeed?

Discussion and Advice. Three facts about drugs and human milk havebeen described:

1. Most drugs pass into breast milk.2. Almost all medication appears in only small amounts in human milk,

usually less than 1% of the maternal dosage.3. Few drugs are contraindicated for women who are breastfeeding their

infants." 14,22

It is helpful to have at least one reference book or resource on hand (seeAppendix B, page 539 of this issue).

To answer this question, the penicillin-like antibiotic amoxicillin is compati-ble with breastfeeding.

A few categories of drugs are not compatible with breastfeeding: cancerchemotherapy agents, radioactive isotopes, antimetabolites, and drugs of abuse("street drugs"). Other medications may fall into a not recommended categoryif they have not been tested for compatibility with breastfeeding. In such cases,


the mother should be encouraged to ask her doctor about a substitute medicationthat is compatible with breastfeeding. Most medications can be changed andmothers should be encouraged to pursue this solution. Another tip to consideris to have the mother take a medication immediately after the baby feeds. Oncean infant has stopped breastfeeding, it may be difficult to restart, especially ifthe infant is young. If breastfeeding must be stopped, the mother should begiven instructions on how to obtain and use a quality electric breast pump sothat her milk supply can be maintained until she can resume breastfeeding(pump-and-dump technique).

AM I MAKING ENOUGH MILK FOR MY 1-DAY-OLD INFANT?

Question. I am worried that I won't be able to make enough milk for myinfant. How will I know if I am making enough milk when I am in the hospital?

Discussion and Advice. Offering breastfeeding anticipatory guidance, par-ticularly at prenatal visits, to expectant parents about what to expect duringtheir 2- to 4-day hospital stay is a wonderful way to help parents to be successfulat breastfeeding. Winikoff et aF7 found that the most common reason thatmothers stop breastfeeding in the hospital setting is because they think they arenot making enough breast milk. Information and the knowledge that help is atelephone call away may be all that a hesitant or nervous mother needs to be asuccessful breastfeeder.

Breastfeeding anticipatory guidance starts with the fact that all infants,whether breastfed or formula-fed, lose weight during the first few days becausehealthy infants are born with extra fluid. This occurrence especially is true forinfants born to mothers who receive an epidural before delivery because anepidural is accompanied by a fluid bolus. A weight loss of as much as 8% ofbirth weight in the first 2 days of life is expected."

Information about normal milk production is helpful. Colostrum is the firstmilk produced by the breasts before the full milk supply arrives. Colostrummay be clear to yellow in color and may be sticky to touch. Little colostrum isproduced in the first few days, but that which is made is exactly the rightamount for the infant's small stomach (approximately the size of the infant'sfist). Three tablespoons (approximately 50 mL) are produced on day 1 of life,increasing to 13 tablespoons (approximately 200 mL) on day 2 of life." Colos-trum, which is high in protein (secretory IgA), calories (17 calloz), and livingcells, offers newborn infants nutrition and protection. It provides infants' firstimmunization and has a natural laxative effect to help pass the bilirubin-ladenedmeconium." Colostrum lives up to its nickname of "liquid gold." In the firstfew days, mothers commonly comment that they feel like they are failing toproduce much milk; this information may alleviate fears they have and encour-age them to put the infant to breast as often as possible and avoid formulasupplements. Abundant milk production typically occurs on days 2 to 4 of life.

Parents can be given information about Baby-Friendly Hospital Initiativepolicies, such as placing the infant to breast within 1 hour of birth, rooming-in,discouraging the use of pacifiers and bottles of formula, and putting the infantto breast on feeding cues. Infant feeding cues include hand-to-mouth activity, lipsmacking, rooting, movement of extremities, and eye movement in light sleep.

Finally, information about healthy newborn infants' stooling pattern givesnew parents something to watch for. Specifically, they can watch for the stoolsto progress from meconium (sticky, tarry, and black) to transitional stools(muddy and dark green) to milk stools (loose, seedy, and yellow). As the family

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heads home, they should expect their infant to breastfeed at least 8 to 12 timesin 24 hours and pass at least six urinations and three or more stools per daywhen the infant is 5 to 7 days of age.'

SLEEPY INFANT

Question. My infant has a check-up in 3 days, but she seems sleepy. I haveto wake her up every 4 hours to feed her. Is this normal for a 4-day old?

Discussion and Advice. Many parents assume a newborn infant who ishungry will scream and demand to be fed; however, with the exclusivelybreastfed infant, beware the sleepy infant! Some breastfed infants in the first fewweeks of life are "content to starve," and, instead of signaling hunger, theysleep. Parents often are fooled into thinking that these are "good infants." Thefollowing clinical presentations are concerning!":

1. A weight loss of more than 8% birth weight in first 3 or 4 days of life2. No signs of an abundant milk supply by day 3 or 4 of life3. A sleepy, undemanding infant (an infant sleeping >3-4 h consistently

between feeds or sucking on a pacifier a lot, causing less eating and moresleeping)

4. Fewer than 8 feeds in 24 hours5. Fewer than 3 bowel movements (milk stools) in 24 hours6. A weight gain of less than 15 to 30 g per day7. Infant is not back to birth weight within 10 to 14 days of life8. A mother who does not show signs of adequate milk supply (no letdown

sensation or leaking or infant pulls off breast and seems unhappy afterfeeds)

More information obtained from the mother over the telephone about thissleepy infant included only six feeds per 24 hours, two brownish stools per day,a history of an early discharge, and the mother without a sensation of milkletting down. Based on several concerning parameters, this mother should betold to bring her infant in for a medical examination on the day of the call.

BREAST IMPLANTS

Question. I had silicone breast implants in 1990 for cosmetic reasons. Can Isafely breastfeed?

Discussion and Advice. Silicone breast implants have been available for 30years and have been used by approximately 1 million women." Numerousarticles have been written addressing concerns about possible pathologic re-sponses in infants and silicone leakage and autoimmune issues in mothers.v- 26

The first report of issues in the children of mothers with silicone implants waspublished in 1994 and generated a great deal of attention. This report linkedsilicone breast implants and a scleroderma-like esophageal disease in eightchildren." Subsequent reports found no evidence of esophageal or other diseasein children.lv !S Regarding mothers, no clear relationship has been found betweensilicone breast implants and connective tissue disease or neurologic disease?Another study found no significant difference in silicone levels in breast milk orblood samples among women with silicone implants compared with womenwithout implants. Interestingly, silicone levels have been shown to be 10-fold


higher in cow's milk and even higher in infant formula than in human milk":however, since 1992, silicone implants are available only as part of controlledclinical trials,' and saline-filled implants are now used.

Women who have undergone breast-augmentation surgery are, in general,successful at breastfeeding, although the level of success of lactation may varyaccording to the type of incision used, specifically if there was any damage tonerve or ductal tissue." More problems with breastfeeding are seen after breast-reduction surgery;'? 19 In his commentary in Pediatrics, Berlin" finds no absolutecontraindication to breastfeeding by women with silicone breast implants. Ac-cording to the US Food and Drug Administration, it is not necessary for amother who wishes to breastfeed to have intact implants removed or to havebreast milk silicone levels checked."

This caller can be encouraged to breastfeed. The infant should be followedup closely for adequate weight gain.

SUMMARY

Breastfeeding generates numerous questions. Every call about breastfeedingreceived over the telephone is an opportunity for health care professionals tolisten and support the caller and offer factual information and advice to helpthe family to have an enjoyable breastfeeding experience.

References

1. Amercian Academy of Pediatrics, Work Group on Breastfeeding: Breastfeeding andthe Use of Human Milk. Pediatrics 100:1035, 1997

2. American Academy of Pediatrics, Committee on Drugs: The transfer of drugs andother chemicals into human milk. Pediatrics 93:137, 1994

3. Berlin CM: Silicone breast implants and breastfeeding [commentary]. Pediatrics94:547, 1994

4. Cotterman KJ: Consultants' Corner, Always Handy. Journal of Human Lactation15:45,1999

5. American Medical Association, Council on Scientific Affairs: Silicone gel breast im-plants. JAMA 270:2602, 1993

6. DeMarzo S, Seacat J, Neifert M: Initial weight loss and return to birthweight criteriafor breast-fed infants: Challenging the "rules of thumb." Am J Dis Child 145:402, 1991

7. Ferguson JH: Silicone breast implants and neurological disorders. Neurology 48:150,1997

8. Gilhooly J, Hellings P: Breastfeeding problems and telephone consultation. J PediatrHealth Care 6:343, 1992

9. Hale T: Medications and Mothers' Milk 2000. Amarillo, Pharmasoft Medical Publish-ing,2000

10. Harris L, Morris SF, Freiberg A: Is breastfeeding possible after reduction mam-moplasty? Plast Reconstr Surg 89:836, 1992

11. Hurst N: Lactation after augmentation mammoplasty. Obstet Gynecol 87:30, 199612. Kessler DA: The basis of the FDA's decision on breast implants. N Engl J Med

326:1713, 199213. Kjoller K, McLaughlin JK, Friis S, et al: Health outcomes in offspring of mothers with

breast implants. Pediatrics 102:1112, 199814. Lawrence RA, Lawrence RM: Breastfeeding: A Guide for the Medical Profession, ed 5.

St. Louis, Mosby, 199915. Levine n, Lin H, Rowley M: Lack of autoantibody expression in children born to

mothers with silicone breast implants. Pediatrics 97:243, 1996

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16. Levine JJ, Ilowite NT: Sclerodermalike esophageal disease in children breastfed bymothers with silicone breast implants. JAMA 271:213, 1994

17. Mohrbacher N, Stock J: Positioning, latch-on, and the baby's suck. In The BreastfeedingAnswer Book, revised. Schaumburg, IL, La Leche League International, 1997

18. Neifert M: Early assessment of the breastfeeding infant. Contemporary Pediatrics13:142, 1996

19. Neifert M, DeMarzo S, Seacat J, et al: The influence of breast surgery, breast appearanceand pregnancy-induced breast changes on lactation sufficiency as measured by infantweight gain. Birth 17:31,1990

20. Philipp BL, Cadwell K: Calls to a breastfeeding warmline: Using the data to shapeteaching curriculum. Presented at the 3'" Annual Meeting of the Academy ofBreastfeeding Medicine. Kansas City, November 1998

21. Philipp BL, Cadwell K: Fielding questions about breastfeeding. Contemporary Pediat-rics 16:149, 1999

22. Riordan J, Auerbach KG: Drugs and breastfeeding. In Breastfeeding and HumanLactation, ed 2. Boston, Jones & Bartlett, 1999

23. Schmitt BD: Calls about sick children: Launching your own triage system. Contempo-rary Pediatrics 15:49, 1998

24. Schmitt BD: Calls about sick children: A triage system for the office. ContemporaryPediatrics 15:138, 1998

25. Semple JL, Lugowski SJ, Baines CJ, et al: Breast milk contamination and siliconeimplants: Preliminary results using silicone as a proxy measure for silicone. PlastReconstr Surg 1102:528, 1998

26. Teuber SS, Gershwin ME: Autoantibodies and clinical rheumatic complaints in twochildren of women with silicone gel breast implants. Int Arch Allergy Immunol103:105, 1994

27. Winikoff B, Myers D, Laukaran VH, et al: Overcoming obstacles to breast-feeding in alarge municipal hospital: Applications of lessons learned. Pediatrics 80:423, 1987

28. Zinaman MJ, Hughes V, Queenan JT et al: Acute prolactin, oxytocin responses andmilk yield to infant suckling and artificial methods of expression in lactating women.Pediatrics 89:437, 1992

Address reprint requests to

Barbara L. Philipp, MD, IBCLCDivision of Pediatric Ambulatory Services

ACC5Boston Medical Center

850 Harrison AvenueBoston, MA 02118

e-mail: [email protected]

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EVERY CALL IS AN OPPORTUNITY