Catherine P. Garbin

Principles for Maintaining or Increasing Breast Milk Production

Breastfeeding rates in many developed countries remain low, and maternal perception of insufficient milk production is a major contributing factor. Mothers with a perception of insufficient milk should be advised that normal breastfeeding frequencies, suckling times, and amounts are very variable. If objective assessment confirms insufficient milk production, mothers should ensure optimal milk removal frequency and thorough breast drainage. In addition, galactogogues can be prescribed. Understanding physiological principles underlying milk production will help clinicians reassure and assist mothers.

Ultrasound Imaging of Infant Sucking Dynamics during the Establishment of Lactation

Background: Infant sucking problems are frequently implicated in early weaning during breastfeeding, yet our understanding of early sucking dynamics is limited. Objective: This study aimed to describe infant sucking patterns during breastfeeding at secretory activation and determine whether they changed by the time of established lactation. Methods: Sucking patterns and milk intake of 15 breastfeeding infants were assessed on day 3.2 ± 0.8 and later at follow-up, 16.0 (11.3-22.8) days postpartum. Nipple diameters, tongue movement, nipple position, and suck rate during nutritive sucking (NS) and non-nutritive sucking (NNS) were measured from ultrasound scans of the intra-oral cavity during breastfeeding. Milk intake and LATCH scores were also recorded. Results: As the tongue lowered during a suck cycle, the nipple increased in size (P < .001), milk flowed into the intra-oral space and the nipple moved closer to the hard-soft palate junction (P < .001). During NS, nipple diameters and the mid-tongue movement were greater than during NNS (P < .001). As the infant aged, the mid-tongue lowered further (P = .002), suck rates became faster (P < .001) and milk intake increased (P = .004), however, no differences were seen for LATCH scores (P = .34). Conclusion: Differences in tongue movement between NS and NNS suggest that there is an altered sucking action when milk flow is absent. Similar sucking patterns at day 3 and during established lactation imply that infants have a mature sucking pattern in the early postpartum period.

Longitudinal changes in suck-swallow-breathe, oxygen saturation, and heart rate patterns in term breastfeeding infants.

Background: Despite the differences in breastfeeding and bottle-feeding, our understanding of how suck-swallow-breathe (SSwB), oxygenation, and heart rate patterns change as the infant ages is based predominantly on bottle-feeding studies. Therefore, this study aimed to measure how SSwB, oxygenation, and heart rate patterns changed during the first 4 months of lactation in term breastfeeding infants. Methods: Infants less than 1 month postpartum (n = 15) were monitored early in lactation and again later in lactation (2-4 months postpartum). Simultaneous recordings of vacuum, tongue movement, respiration, swallowing, oxygen saturation, and heart rate were made during both nutritive sucking and non-nutritive sucking during breastfeeding. Results: Infants transferred a similar amount of milk (P = .15) over a shorter duration later in lactation (P = .04). Compared to early lactation, suck bursts became longer (P < .001), pauses became shorter (P < .001), vacuum levels decreased (all P < .05), oxygen saturation increased (P < .001), and heart rate decreased (P < .001) later in lactation. Conclusion: This study confirmed that term infants become more efficient at breastfeeding as they age, primarily by extending their suck bursts and pausing less. Although infants demonstrated satisfactory SSwB coordination during early lactation, they showed a level of adaption or conditioning at later lactation by applying weaker vacuum levels and demonstrating improved cardiorespiratory responses.

Nipple pain during breastfeeding with or without visible trauma.

Background: Nipple pain is a major cause of early weaning. The causes of nipple pain are diverse, and most treatments involve experience-based assessment. There is little knowledge of the intensity or variation in pain experienced by breastfeeding women. Given the high breastfeeding initiation rates, it is important to evaluate pain experienced by lactating women in detail. Objective: To investigate and compare the pain experienced by breastfeeding women using objective measures. Methods: The type, effect, and severity of pain were measured using the McGill Pain Questionnaire, Brief Pain Inventory, and Visual Analogue Scale, respectively, for 2 groups of breastfeeding women. One group were experiencing persistent nipple pain despite treatment, and the other had obvious signs of nipple trauma. Results: Pain intensity and interference scores were highly variable for both groups. Mothers with nipple trauma reported significantly higher mean pain intensity and breastfeeding interference. Higher pain intensity scores were related to higher interference scores. After accounting for pain intensity, higher interference with general activity, mood, and sleep interference was related to longer duration of pain. There was no difference in MPQ class scores. Conclusions: The ramifications of nipple pain extend far beyond the act of breastfeeding, particularly for women whose pain lasts several months. Given the lack of evidence-based treatments, it is not surprising that pain is a major contributor to premature weaning. Further research into the causes of nipple pain is necessary to enable the implementation of effective interventions, thus reducing further complications such as infection and postnatal depression. Detailed pain analysis may assist in assessing the success of these interventions.

A comparison of early sucking dynamics during breastfeeding after cesarean section and vaginal birth.

BACKGROUND The impact of cesarean section (CS) birth and pethidine for post-CS epidural analgesia on early breastfeeding behavior is unclear. This study aimed to measure infant sucking and breastfeeding behavior in infants of mothers who delivered by CS (CS group) and used pethidine patient-controlled epidural analgesia (PCEA) after CS with that of infants who were delivered by vaginal birth (V group), during secretory activation and again after the establishment of lactation. SUBJECTS AND METHODS Sucking dynamics and milk intake of breastfeeding infants were assessed on approximately 3 and 20 (follow-up) days postpartum (CS group, n=19; V group, n=15). Nipple diameters, tongue movement, and nipple position during sucking were measured from ultrasound scans of the intra-oral cavity during breastfeeding. Time of the first breastfeed and day of breast fullness were recorded, and infant neurobehavior was assessed. RESULTS CS infants displayed more anterior tongue movement on Day 3 than at follow-up compared with the V group, which showed a similar amount of movement at each assessment (p for interaction<0.001). Compared with the V group, the CS group showed faster suck rates, especially on Day 3 (p<0.001), later times to first breastfeed (p=0.01) and breast fullness (p=0.03), and lower neurobehavioral scores (p=0.047). Breastfeeding duration and milk intake were similar between groups. CONCLUSIONS Although the observed effect of CS birth followed by pethidine PCEA after CS during the period of secretory activation was small, our results indicate that successful initiation of lactation may require additional breastfeeding support and monitoring at Day 3 postpartum for mothers who undergo CS.

Sucking characteristics of successfully breastfeeding infants with ankyloglossia: a case series

Partial ankyloglossia is a congenital oral anomaly characterized by restricted movement of the tongue resulting from a lingual frenulum that is either short, inelastic, or is attached distally, too near or onto the gingival ridge (1). The prevalence of ankyloglossia is not well documented because of the lack of a standard definition or a reliable clinical method of classification (2). Studies of neonates, infants and adolescents quote the incidence of ankyloglossia to be between 0.1% and 10.7% (2,3). Recently, a resurgence of breastfeeding difficulties in infants with ankyloglossia has been reported, with a frequency ranging from 25% to 44% (3,4). Feeding difficulties associated with ankyloglossia include painful nipples (4–6), poor latch (6), reduced milk supply, neonatal dehydration (7) and decreased duration of breastfeeding (4). Controversy exists regarding the management and treatment of ankyloglossia (8), although studies show that in infants with feeding problems, frenotomy improves maternal nipple pain (5,6,9,10), latch scores (6,10), tongue action, milk transfer and milk supply (10). Fortunately, the majority of infants with ankyloglossia are able to breastfeed successfully. The controversy surrounding ankyloglossia most likely stems from the lack of knowledge of the effect the condition has on feeding, and in particular breastfeeding. Five fully breastfed infants with ankyloglossia presented for a research study designed to assess the sucking characteristics of normal breastfed infants. The study was approved by the Human Ethics Committee of The University of Western Australia. Sub-mental ultrasound scans of the infant oral cavity were made during a breastfeed to image tongue motion (Fig. 1A,B). Intra-oral vacuums were measured simultaneously via a supply line filled with sterile water connected to a pressure transducer (11). The test-weigh method was used to measure milk intakes for the monitored feed and three mothers measured every feed for a 24-h period (12). All infants recorded normal growth and the three mothers who measured every feed for a 24-h period recorded normal levels (range 478 to 1356 g per 24 h) (12). The data are shown in Table 1 (Infants 3–5). Infants 1, 2 and 3 displayed no compression of the nipple; however, weak vacuums were recorded for Infant 1 (Fig. 2A,B; Table 1). Infants 2 and 4 recorded strong maximum vacuums. Infant 4 had strong minimum vacuum and displayed compression of the base of the nipple on ultrasound (Fig. 2C,D). Infant 5 had very weak maximum vacuum and compression of the tip of the nipple (Fig. 2E,F). Mean maximum vacuums quoted in the literature range from )145 (11) to )197 mmHg (13) for breastfeeding infants. Mean minimum vacuum has been measured at )64 mmHg in one study of breastfeeding infants (11). The importance of the level of vacuum has become apparent with a recent study demonstrating an association between strong infant sucking vacuums and nipple pain (14). Conversely, similar to pumping vacuums (15), low sucking vacuums have been associated with reduced efficiency and effectiveness of feeding(16). Although these infants with ankyloglossia had intra-oral vacuums outside the normal range, they were able to obtain enough milk to grow satisfactorily and none of the mothers experienced nipple pain during feeding. It is possible that the vacuum exerted by the infant is influenced by both the restriction of tongue movement or nipple ⁄breast shape. Further research is required to investigate this. Ultrasound imaging during breastfeeding showed that two of the infants compressed the nipple. One infant compressed the base of the nipple and the other compressed the tip of the nipple. Previous ultrasound imaging of infants Acta Paediatrica ISSN 0803–5253

Simultaneous Breast Expression in Breastfeeding Women Is More Efficacious Than Sequential Breast Expression

INTRODUCTION Simultaneous (SIM) breast expression saves mothers time compared with sequential (SEQ) expression, but it remains unclear whether the two methods differ in milk output efficiency and efficacy. SUBJECTS AND METHODS The Showmilk device (Medela AG, Baar, Switzerland) was used to measure milk output and milk ejection during breast expression (electric pump) in 31 Australian breastfeeding mothers of term infants (median age, 19 weeks [interquartile range, 10-33 weeks]). The order of expression type (SIM/SEQ) and breast (left/right) was randomized. RESULTS SIM expression yielded more milk ejections (p ≤ 0.001) and greater amounts of milk at 2, 5, and 10 minutes (p ≤ 0.01) and removed a greater total amount of milk (p ≤ 0.01) and percentage of available milk (p<0.05) than SEQ expression. After SIM expression the cream content of both the overall (8.3% [p ≤ 0.05]) and postexpression (12.6% [p ≤ 0.001]) milk were greater. During SEQ expression, the breast expressed first had a shorter time to 50% and 80% of the total amount of milk than the breast expressed second (p ≤ 0.05), but, overall, a similar percentage of available milk was removed from both breasts. CONCLUSIONS SIM expression stimulated more milk ejections and was a more efficient and efficacious method of expression, yielding milk with a higher energy content.

Breastfeeding Frequency, Milk Volume, and Duration in Mother–Infant Dyads with Persistent Nipple Pain

BACKGROUND Nipple pain and insufficient milk supply are major causes of early weaning. We have found that persistent nipple pain was associated with strong infant sucking vacuums during breastfeeding. Several studies indicate that nipple pain and abnormal infant sucking have the potential to reduce milk transfer. We aimed to determine whether women with persistent nipple pain had low milk supply. SUBJECTS AND METHODS The 24-hour milk production and feeding characteristics of mothers with persistent nipple pain (n=21) were compared with those mothers without nipple pain (n=21). Milk productions were measured by test-weighing the infant before and after every feed from each breast over a 24-26-hour period. Comparisons were made using Students t tests and linear mixed models as appropriate. RESULTS Lower milk productions were associated with longer meal durations for mothers with pain. There were no significant differences in the average 24-hour milk production or any feeding characteristics between the groups. However, four women with persistent nipple pain had milk production levels below 500 mL/day. CONCLUSIONS The majority of breastfeeding women experiencing persistent nipple pain were able to achieve normal milk production levels. Feeding duration and frequency were similar to those of women not experiencing pain. However, longer meal durations in the pain group were associated with lower levels of milk production. Further investigation is necessary to identify mothers most affected by maternal nipple pain.

Evidence of Improved Milk Intake After Frenotomy: A Case Report

Ankyloglossia (tongue tie) is a well-recognized cause of breastfeeding difficulties and, if untreated, can cause maternal nipple pain and trauma, ineffective feeding, and poor infant weight gain. In some cases, this condition will result in a downregulation of the maternal milk supply. Milk-production measurements (24-hour) for a breastfeeding infant with ankyloglossia revealed the ineffective feeding of the infant (78 mL/24 hours), and a low milk supply (350 mL/24 hours) was diagnosed. Appropriate management increased milk supply (1254 mL/24 hours) but not infant milk intake (190 mL/24 hours). Test weighing convincingly revealed the efficacy of frenotomy, increasing breastfeeding milk transfer from 190 to 810 mL/24 hours. Postfrenotomy, breastfeeding almost completely replaced bottle-feeding of expressed breast milk. This case study confirms that ankyloglossia may reduce maternal milk supply and that frenotomy can improve milk removal by the infant. Milk-production measurements (24-hour) provided the evidence to confirm these findings.

Blood Flow Characteristics of the Human Lactating Breast

Background: Despite the increased metabolic activity of the lactating breast, no studies have been carried out to determine mammary blood flow (MBF) parameters or the relationship between MBF and milk production in women. The aim of this study was to measure the MBF in the internal mammary artery (IMA) and lateral thoracic artery (LTA) of lactating women and determine if these were related to milk production. Methods: Blood flow in the IMA and LTA was measured with color Doppler ultrasound in 55 lactating women. Twenty-four-hour milk production was determined with the test-weigh method. Results: IMA contributed the greater proportion of blood flow to the lactating breast (70%). MBF was highly variable between women but consistent between the left (126 L/24 h; interquartile range, 76-169) and right (110 L/24 h) breasts. No relationship between MBF and milk production was demonstrated. For 3 women, MBF was markedly reduced in 1 breast that was synthesizing almost no milk compared to the other that was producing a normal volume of milk. Discussion: Although no relationship between MBF and milk production was found, the substantial reduction in blood flow in the breasts of lactating women producing almost no milk suggests a threshold below which milk production is compromised. Conclusion: Doppler ultrasound did not demonstrate a relationship between MBF and milk production in lactating women. Further investigation is required to fully understand the role of blood flow in milk synthesis.