Postpartum Mood & Anxiety Disorders in Breastfeeding Mothers: To Treat or Not To Treat

May 2^nd is World Maternal Mental Health Day.  Here in my home state, The Governor and General Assembly, back in 2015, declared May as Maternal Mental Health Month in the Commonwealth of Virginia.  The Blue Dot Project has defined this year’s Maternal Mental Health Week (#MMHweek) by removing the stigma of perinatal mood and anxiety disorders. Women (and men) all across the world are posting their stories (with a pastel blue dot) about the trials and tribulations of parenting, while showing the face of postpartum anxiety and depression.  #noshame #realparenting

On my iPhone early this morning, I saw a #MMHW post where a women posted a picture of her feeding her child with a bottle. She told her story about the guilt she felt (and still feels) about not being able to breastfeed her child and how that exacerbated her depression.  What followed were comments by so many other moms, how they also felt that guilt when their ‘body didn’t work’ making them unable to breastfeed their child.  Many of these women commented on how they felt shame when giving their child a bottle in public.

Mastitis Protocol Updated

In case you missed it, the Academy of Breastfeeding Medicine Protocol #4, “Mastitis“, by Dr. Lisa Amir, was published in Issue #5 (May/June) of Breastfeeding Medicine.  The good news (or the bad news, depending on how you look at it) is that not much has changed since the previous version was published in 2008.  There are slightly expanded discussions of methicillin-resistant staph aureus and secondary candidal infections, and a brief explanation of fluid mobilization for symptomatic treatment of a swollen breast.  The style has been changed to include fewer paragraphs and more bulleted lists, which makes for easier reading and reference.  And of course the references have been updated.  It is of the high caliber we expect these clinical protocols to be, and relates the state of the art as it exists for the diagnosis and management of Mastitis today.  If you haven’t had a chance to take a look at it, check it out in Breastfeeding Medicine Volume 9, Number 5, 2014 pages 239-243, or go to the Academy of Breastfeeding Medicine website, and check under the Protocols and Statements tab.

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

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

Breastfeeding in the Face of Natural Disaster and Nuclear Reactor Core Damage

It has been well over a week now that we the citizens of the world have been watching the seemingly unending horror unfold in Japan.  First they endured an earthquake of historic proportions, followed rapidly by a tsunami of untold destruction.   These unexpected natural disasters are frightening, devastating, and so very poignant and sad to comprehend. One cannot live in this age of instantaneous video reporting and see those images of death and destruction and not be affected at some deeply primal and emotional level.  Initially, the concerns for after effects in other nations around the Pacific were also frightening, but came nowhere near the complete devastation in Japan.  Totally coincidentally, I have been working on the United States Breastfeeding Committee Position Statement on Infant/Young Child Feeding in Emergencies. The images on the television brought the horrors of Hurricanes Katrina and Rita here in the US vividly back to my mind, and the words I have been typing into my computer drafting the Position Statement seem so inadequate in the face of the reality I see on the television screen.   It leaves me feeling impotent to really help, armed only with a computer and words.

And then, as if it could not have gotten any worse, one day later, an explosion occurred at the damaged Fukushima 1 nuclear power plant initiating a radiation leak, making this a catastrophe of unprecedented proportion.  By 6 days after the explosion, Japan’s nuclear safety agency raised the severity rating of the country’s nuclear crisis from Level 4 to Level 5 on a seven-level international scale, putting it on par with the Three Mile Island accident in Pennsylvania, USA in 1979.  For comparison, the Chernobyl accident of 1986, which killed at least 31 people with radiation sickness, raised long-term cancer rates, and spewed radiation for hundreds of kilometers, was ranked a Level 7.

So why am I writing this on a blog for ABM?  Besides the humanity that connects us all globally, and the immediate questions that arose in the medical and lactation communities concerning humanitarian efforts and safe infant and child feeding practices on the heels of the earthquake and tsunami, (on which there is much already written) the radiation leaks have led to many questions and some incorrect information related to breastfeeding that it is important to address, for now and should we ever need to deal with this again.

New Galactogogue Protocol–New Attitude??

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 laissez–faire 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.

Breastfeeding–Preventive Medicine for Pain?

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.

When lactation doesn’t work

As a newly-minted doctor and breastfeeding activist, I used to believe that all mothers could breastfeed. Now, after almost a decade of clinical experience, I know better. Sometimes, breastfeeding physiology just doesn’t work. And frankly, as medical professionals, we handle these situation poorly.

Is that drug safe for breastfeeding?

The answer is almost always “yes,” but that’s often not what mothers hear from doctors and pharmacists.  Early in my training, I came in on a Monday morning to round on the patients who had given birth over the weekend. One mother had had a CT scan, and she had been told that she had to pump and dump her milk for 48 hours because the IV medication given during the CT was dangerous for her baby. I clearly remember calling a medication safety information line and finding out that there was minimal risk to breastfeeding immediately after a CT scan. The mother put the baby to breast right away, but had lost 2 days of early breastfeeding. For some babies, that can completely derail the breastfeeding experience.