Breastfeeding Medicine

Physicians blogging about breastfeeding

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New Galactogogue Protocol–New Attitude??

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Today a new ABM protocol was published in Breastfeeding Medicine: ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting the Rate of Maternal Milk Secretion (First Revision January 2011).    I am posting today having my hat on as ABM Protocol Committee Chairperson.  When we wrote the first version of this protocol in 2004, the basic message of the document was that galactagogues were a definite second-tier therapy for increasing milk supply, after all the mechanical and physical and otherwise treatable etiologies were investigated and adequately treated. That they are second-tier has not changed in this newest version.

What has subtly shifted is the attitude toward the use of the galactogogues themselves.  In 2004 there was an almost laissezfaire attitude—if the mechanical changes and medical work-up did not yield the hoped-for increased results in milk production, then galactogogues were effective, and thus should be, and were, used.  Although one should think (briefly) about potential side-effects, they were really quite rare, and the use of galactogogues were essentially (although not definitively stated as such) standard of care.  The protocol proceeded to tell us how to use them. Read the rest of this entry »

Written by kmarinellimd

February 22, 2011 at 1:30 pm

The Surgeon General’s Call to Action to Support Breastfeeding: Reflections of an Eyewitness

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Wow! I am here in Washington DC, attending the United States Breastfeeding Committee (USBC) meeting as the representative from the Academy of Breastfeeding Medicine. I was even asked to come to town early to be a part of the USBC media team for the Surgeon General’s Call to Action to Support Breastfeeding, which occurred on Thursday, January 20 at George Washington University(GWU).  It was a monumental day in my family—my dad turned 78, and I had planned to celebrate with him on my way  from CT to DC for the meeting on the 21st.  But he understood, as great dads always do, and I witnessed history at GW! It was an absolute thrill to be there, and I can attest to the electricity in the room!  For the first time, we held the previously embargoed document in our hands.  It is an amazing document, a true gift to the breastfeeding and medical communities, and to US mothers, babies and families. Containing 20 action items with implementation suggestions, it covers virtually anything one would put on their own personal wish list of support for breastfeeding, making it our national, cultural and healthful norm.

We stood outside the auditorium of GWU for what seemed an interminable time.  When the doors finally opened, we rushed inside with the anticipation of little kids on Christmas morning. Taking our seats, the auditorium filled, the excitement palpable.  We craned our necks to see when and where she would walk in—it was real star power!

As Dr. Benjamin came into the room, we spontaneously gave her a standing ovation.  She didn’t even have to say a word—we were so thrilled with the message and the bearer of that message.  Her main message?  Pure.  Simple.

Everyone can help make breastfeeding easier.

She held our rapt attention.  20 Action Items.  Six broad categories.  Not rocket science.  Common sense. Read the rest of this entry »

Written by kmarinellimd

January 25, 2011 at 8:39 am

Is ‘breast only’ for first 6 months best?

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Boy did those headlines grab my eyes.  And my breath.   And my gut.  How could this be?  Exclusive breastfeeding for the first six months is a tenet we hold to in breastfeeding medicine.  There are loads of data to support it.  Isn’t is up there with one of the Ten Commandments?  What had I missed that changed so drastically while I was quietly celebrating Christmas and bringing in the New Year with my family and friends? Read the rest of this entry »

Written by kmarinellimd

January 22, 2011 at 10:05 am

Breastfeeding–Preventive Medicine for Pain?

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Somewhere during the excitement and preparations for all the many holidays that occur in November and December, culminating with the global ringing in of the New Year, a new issue of Breastfeeding Medicine was published, the last of 2010.  As always it contains a number of articles that are timely, interesting and on the forefront of lactation research.  It also has the newest ABM Clinical Protocol to be added to our slowly, but ever-growing list, Clinical Protocol #23: Non-Pharmacologic Management of Procedure-Related Pain in the Breastfeeding Infant.  Long title.  Important concept.

It wasn’t that long ago that the medical profession did not think babies even felt pain.  What a horribly painful thought.  Having had personal experience with chronic excruciating pain, I cannot fathom that thought.  “Minor” procedures were done with no anesthesia or analgesia—non-ritual circumcisions (we could go off on a tangent here about whether or not that even should be done, but I promise to stay on task…) being the most well-known.  But so were “major” procedures.

I am definitely not a young chickadee any longer, as my teenage daughters will readily tell you, but I am not headed for the nursing home any time soon either I don’t think.  True story—when I was a second year resident in Pediatrics, in charge and alone covering all of pediatrics one night–the floor (ward), emergency room full of asthmatics getting epi shots, theophylline drips and bronchodilator aerosols (I think that dates me) and the delivery room at an “out-lying” affiliated hospital to my Pediatric residency primary Children’s hospital (we are talking major metropolitan area in the United States, not out in the wilderness) a pediatric surgeon came barreling in the middle of the night after the unexpected delivery of a baby with a diaphragmatic hernia (yes Virginia, those things used to happen in the days before “routine” ultrasounds) and right there to my and the nurses horror, he performed an emergent  laparotomy with no anesthesia, no analgesia on the open warmer I was slaving over to stabilize the baby, to pull the intestines out of the chest before transport…. A sight I have NEVER forgotten.

So, as the saying goes, we’ve come a long way baby.  We recognize pain in even our most immature babies (I hope), and try our best to prevent or alleviate it.  Anyone who has worked in a neonatal intensive care unit has seen and heard of the use of narcotics (which will relieve pain) and sedatives and anxiolytics (which we must remember don’t relieve pain, but often settle the baby down and make it easier to control the pain with narcotics, or at least we believe so).  And that makes sense for major pain, like intubation and incisions and chest tubes and of course, surgery.

But what about the countless other things we do to babies, both sick and premature, and well and term that are noxious and painful—heel sticks for blood draws, Vitamin K injections, numerous immunizations, and yes, circumcisions being at the top of the list. We know from the literature that pain can have long-term detrimental consequences and that pain-reduction therapies are under-utilized in this age group.  We also know there is a growing body of evidence that non-pharmacological means of pain reduction not only exist, but are effective.  And guess what?  The safest, most cost-effective, natural and supportive of the breastfeeding relationship is—you guessed it—Breastfeeding!

This new ABM protocol, which can be found on our website at www.bfmed.org, under the Protocols tab, is worth taking a good look at.  It presents the data on pain relief we have now in 2011 on breastfeeding as an entire act; the various components seperately—the milk, the sugar, skin-to-skin; the use of sucrose and pacifiers; in term babies; preterm babies; and what we know of older babies.  And it points out as always where the literature is lacking, where we need further research.

This protocol, like all others before it, is a long, thoughtful, extensive review of the literature and comments by experts in the field, which undergoes multiple reviews and re-writes before publication.  It is the state of the art and the science as we know it at the time of publication.  Pain is not something I would wish on anyone.  If I was not already so immersed in lactation at the time of the accident that has caused me so many years of chronic pain, I would have put my efforts into the study of pain.  I learned quickly that the medical profession knows little about pain and its management in adults, and the consequences of that management.  The worst issues with the narcotics are not necessarily the worries about addiction, but in my view, all the other side effects associated with their use.  And in pain treatment, we have ignored our youngest even more.  The information included in this protocol is a great first step in educating us toward non-pharmacologic means of pain reduction in neonates.  We should all be familiar with it, and use it in our practices.  And we should also use it to realize how much more work there is to be done.  Pain is no fun.  It cannot have any positive outcomes past letting us know something is wrong and needs attention, even if it is the sting of an injection to a baby who cannot comprehend why those she trusts to protect her are doing this to her.  She deserves to be comforted and to have her attention brought elsewhere, so her memory is not of the pain, but of the warmth, and comfort and love.  After all, isn’t that how we are all trying to bring our babies and children into contact with our world?

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the ABM Protocol Committee.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by kmarinellimd

January 6, 2011 at 8:50 am