The mother stated the reason for the consultation as “low milk supply – cannot pump much milk.”  Her baby was 2 oz. below birth weight at 15 days of age.  A weight check after breastfeeding from both breasts indicated an intake of approximately 2 oz (58 cc).  Pumping after breastfeeding yielded another 1 oz (28 cc).  The mother has added pumping with the hospital-grade pump but still does not have a full milk supply.  The baby is gaining weight and is more content now with supplementation of expressed breast milk and formula.

Do you think the clotting disorder could be related to her low milk production?

Deborah Ehrhardt, BA, IBCLC

Answer
Dear Deborah,

As you know, unusually shaped breasts can be a marker for abnormal development and insufficient glandular tissue (Neifert 1985 Huggins 2000).  Therefore her underlying breast development issues (now disguised by the augmentation) may explain her low milk production.  I don’t know if a history of stroke, per se, has ever been implicated in subsequent low milk production.  I hope that any of our readers with experience in this regard will comment.  We know that injury to the pituitary can affect lactation, but without evidence of brain damage in the regions that impact breastfeeding, we would only be speculating as to the relevance of her stroke history in the present situation.

Enoxaparin (Lovenox) is a low molecular weight fraction of heparin with low bioavailability and a molecular size that precludes its entry to milk in any clinically relevant levels (Hale 2006).  Both heparin and Lovenox are anticoagulants.  Hale doesn’t list any side effects beside risk of bleeding.  I doubt the drug would have a direct affect on milk production, however, I wonder if the mom (owing to the clotting disorder) lost an unusual amount of blood during delivery?  If so, perhaps she is slightly anemic and/or still recovering enough metabolic energy to support full lactation.  This phenomenon (poor milk production following greater-than-normal blood loss and anemia) is noted in the literature (Henly 1995, Willis 1995).

In cases where postpartum blood loss is an issue, the best strategy is to encourage good maternal nutrition with increased protein intake and iron supplementation.  The mother should be encouraged to rest and to augment breast stimulation.  You have taken steps (supplementation with pumped milk and formula) to stabilize the baby.  It remains to be seen whether the mom’s supply will improve.  I would ask her about the blood loss issue, because recovery from blood loss takes time.

It is interesting that the baby removed 2 oz (~60 g) directly from the breasts during the feeding you observed.  The mom then pumped an additional 1 oz (~30g), This would constitute a normal volume of intake if the milk supply was consistent at this level over the course of 24 hours.  However, the infant’s failure to recover birth weight by Day 15 suggests that something is problematical.  I know you will be reviewing management issues (number of feeds per day, etc.) and I agree that watchful waiting will bring more information.  This mother may simply have gotten off to a slow start and will increase her milk supply to normal in response to your interventions.  Whether her health history limits her to a partial supply will only become obvious over time.  I support you in what you are doing to manage the case and invite you to report back in a month to let us know whether her supply increased.

Barbara

Hale, T.  Medications and Mothers Milk, 12^th ed.  Hale Publishing, Amarillo, 2006, pp 302-3.

Henly S, Anderson C, Avery M, et al.  Anemia and insufficient milk in first-time mothers. Birth 1995; 22(2):87-92.

Huggins K, Petok E, Mireles O.  Markers of lactation insufficiency: a study of 34 mothers, in K Auerbach, (ed) Current Issues in Clinical Lactation 2000. Sudbury, MA: Jones and Bartlett, 2000, pp 25-35.

Neifert M. Seacat J. Jobe W:  Lactation failure due to insufficient glandular development of the breast, Pediatrics 1985, 76:823-28.

Willis C. Livingston V:  Infant Insufficient Milk Syndrome Associated with Maternal Postpartum Hemorrhage, J Hum Lact 1995, 11(2):123-126.

The paper by Vazirineja, et al (see abstract below) validates our observations that some breast and nipple variations negatively affect early infant weight gain. Previous research has documented that flat nipples and inverted nipples impact on breastfeeding. The new research identifies a negative effect of large nipples and large breasts upon infant weight. The difference in the average weights at 7 days was significant; 215 g (about half a pound) between the “normal” and the variations group.

It would have been helpful for the researchers to specifically describe breast and nipple sizes and to quantify what they meant by “large nipple” and “large breast.” Providing normative ranges and accurate size measurements will help clinicians identify women and infants in risk categories.

We hope these important research findings prompt earlier interventions to prevent infant weight loss. We advocate for individual assessment and active management of lactation when breast or nipple variations are observed. Appropriate interventions might include close weight monitoring, use of nipple shields, “insurance” pumping, and alternative feeding of the infant with pumped milk to prevent infant weight loss.  Creative positioning strategies, effective parental counseling, and tincture of time also support optimal breastfeeding outcomes and help prevent untimely weaning.

The article abstract appears below.  A full text of the article is available at:

http://www.internationalbreastfeedingjournal.com/content/4/1/13

The effect of maternal breast variations on neonatal weight gain in the first seven days of life

Reza Vazirinejad, Shokoofeh Darakhshan, Abbas Esmaeili

International Breastfeeding Journal 2009, 4:13doi:10.1186/1746-4358-4-13

Abstract

Background

This study aims to examine whether specific maternal breast variations (such as flat nipple, inverted nipple, large breast or/and large nipple) are barriers for weight gain in breastfed infants during the first seven days of life.

Methods

In this prospective cohort study, 100 healthy term neonates were followed from birth to day seven in two groups; Group A: fifty neonates born to mothers with specified breast variations and Group B: fifty neonates born to mothers without such breast variations (“normal breasts”). All neonates were the first child of their families and there was no sex ratio difference between the two groups. Neonates’ weight at birth and day seven were measured and the mean weight differences in the two groups were compared using paired t-test.

Results

Neonates born to mothers without the specified breast variations had a mean weight gain of (+) 53 ± 154.4 g at day seven., Not only there was no increase in the mean weight of neonates in the other group, but they had a mean decrease of weight of (-) 162 ± 125.5 g by the seventh day of their life compared to birth weight. Thus, neonates born to mothers without breast variations had significantly greater weight gain than neonates born to the mothers with the specified variations (p < 0.01).

Conclusion

Breast variation among first-time mothers acts as an important barrier to weight gain among breastfed neonates in the early days of life. Health professionals need skills in the management of breastfeeding among mothers with the specified breast variations, so that mothers are given appropriate advice on how to breastfeed and overcome these problems.

For students and clinicians interested in reviewing the literature on the subject of breast and nipple anatomy, we suggest the following

Additional References

Caglar MK, Ozer I, Altugan FS. Risk factors for excess weight loss and hypernatremia in exclusively breastfed infants. Brazilian Journal of Medical and Biological Research 2006; 39:539-544.

Cooper W, Atherton H, Kahana M, Kotagal U. Increased incidence of severe breastfeeding malnutrition and hypernatremia in a metropolitan area. Pediatrics 1995; 96(5):957-960.

Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003; 112(3):607-619.

Livingstone VH, Willis CE, Abdel-Wareth LO, Thiessen P, Lockitch G. Neonatal hypernatremic dehydration associated with breastfeeding malnutrition: a retrospective survey. Canadian Medical Assoc J 2000; 162(5):647-652.

Ramsay D, Kent J, Hartmann R, et al. Anatomy of the lactating human breast defined with ultrasound imagine. J Anatomy 2005; 206(6):525-534.

Wilson-Clay B, Maloney BM. A reporting tool to facilitate community-based follow-up for at-risk breastfeeding dyads at hospital discharge. Current Issues in Clinical Lactation, 59-67, 2002.

Yaseen H, Salem M, Darwich M. Clinical presentation of hypernatremic dehydration in exclusively breastfed neonates. Indian J Pediatr 2004; 71(12):1059-1062.

Carlotta RN,IBCLC

Answer
Some new mothers have what appears to be a build-up of very dry skin on their nipples.  Occasionally in the early days of breastfeeding the skin will flake and “pepper” the milk. Kay and I do not think this is an issue exclusive to African American women; perhaps it is merely more visible when the skin being shed is darker in color.

Sometimes the mothers we have encountered were warned to not ever put soap on their nipples.  Sometimes women interpret this advice to mean they should even guard the nipples from normal bathing activity.  Throughout the pregnancy the woman may also have been applying moisturizing creams to her nipples.  Nearer the birth, if she oozed colostrum, she may have been instructed to massage that fluid back into her nipples. Consequently, fluids and dry skin may accumulate, causing a crust to form on the nipple tips.  When the crust inevitably begins to slough off, it can appear that the woman is losing considerable amount of actual nipple.  The skin underneath has been deprived of normal air/light exposure, and it can feel tender and raw when abruptly exposed to pumping or the infant’s sucking.

Because some women experience dry skin issues, prenatal nipple care instruction should reassure women about normal bathing as a part of nipple care and address treatment for dry skin.

Postpartum women with nipple crusting can be instructed to gently and gradually remove the layers of dried skin that have formed over the nipples.  While showering, or while suspending her breasts in a clean basin of warm water to soften the skin, she should VERY GENTLY massage the nipples with a wet washcloth.  The gentle action will help remove the accumulated layers of flakey skin.  Afterwards, the mom can gently lubricate with purified lanolin or Aquaphor (an inert, mineral oil/lanolin/glycerin based lubricant dermatologists often use to help heal nipple skin fissures.)  The woman should be reassured that she does not need to protect her breasts from reasonable exposure to mild soap and water during showering or bathing.

When presenting the information, the mom should never be told to scrub the nipple vigorously. Remember:  The skin under the crust will be tender!  Respectful counseling must be employed so that caregivers simply explain how this has happened and what to do about it.  This is an issue of having received incomplete skin care information and it is not about poor hygiene.  Health care providers must also distinguish between what is merely accumulation of crusted dry skin and other conditions (e.g. staph infections which create golden, crystallized crusts, etc).

Finally, while the aesthetics of the dry skin shedding into the milk are not pleasing, we doubt the milk becomes harmful to the infant.  Surely it would not justify discarding the milk or withholding it from the infant.  Exceptions would be large chunks of shed debris that might (rarely) present a choking hazard.  It would not hurt to ask what kind of nipple cream the woman has previously used (in case there is any risk of toxic exposure).  The greatest risk in our opinion is that sucking and pumping will expose friable nipple tissue that is vulnerable to cracking, causing pain for the mother.

Could you share any information or experience with clients with the same condition and their experience with breastfeeding after radiation? I want to support her as much as I can.

Amy Shapira – Georgia

Answer
Pregnancy following breast cancer is becoming more common, and because of breast conserving therapies, women now seek information about how a previously treated breast will respond during lactation.  Some of the published articles we reviewed for the chapter on breast cancer in the 4^th edition of The Breastfeeding Atlas report that the breast is no longer capable of lactation following radiation therapy.  A few case studies, however, have described milk production in the treated breast following delivery of an infant.  In these cases, the appearance of the milk has been altered, looking thicker and somewhat discolored. Perhaps the discolored milk may result from debris in the ducts (dead cells). The reported cases uniformly describe diminished milk production.

BWC has worked with 4 women whose previously irradiated breasts became engorged following delivery.  Two opted to wean that breast immediately.  Two decided to breastfeed from the affected breast even though the milk looked different.  The infants of these 2 women preferred breastfeeding from the untreated breast, but appeared to suffer no ill effects from nursing on the affected one.  In both cases, milk flow was slow and the volume of milk was very low on the treated breast.  Pumping usually produced only drops or, at best, enough milk to cover the bottom of a bottle.  The low volume probably caused the breast preference, but perhaps the taste of the milk was altered. We know that weaning milk (milk in low volume) has increased sodium and chloride levels, and tastes salty.   Both the mothers in BWC’s practice who breastfed following radiation therapy tended to use the treated breast more for pacification and soothing, and depended on the healthy breast for feeding.

Any type of invasive breast surgery (including lumpectomy) damages the internal structure of the breast and interrupts normal drainage of milk.  Scar tissue may also create blockages. Even if radiation has not totally destroyed the lactational capacity of the breast, surgically affected breasts tend to not drain normally.  Care providers must be watchful for mastitis. The presence of any lumps in the breast is very upsetting to the mom who has had breast cancer, so she will need anticipatory guidance and education about signs and symptoms of mastitis.

This mother should, of course, be carefully monitored. The most risky time for pregnancy in women who have had breast cancer is within 2-3 years of the diagnosis.  This mother falls within that time frame, so it is prudent to be watchful and to err on the side of caution.  She will need lots of emotional support as well.  Generally, women who have had breast cancer get periodic blood work to check for tumor markers.  It will be important not to become “distracted” by the fact she is lactating or to ignore changes in skin texture or color or lumps that should be visualized to rule out recurrence of cancer.

While pregnancy itself may be somewhat of a risk factor (depending on timing), there is no evidence that it is harmful to breastfeed following treatment for breast cancer.  While it is unlikely the treated breast will produce a full supply of milk, one breast is generally capable of nourishing one baby.  Remind her that twins can thrive while feeding from only one breast. In our experience, that is typically very reassuring information for women who have only one healthy breast.  Because she will worry about whether the baby is getting enough, provide education about normal weight gain and what to expect with regard to feeding frequency.  Such information will help her distinguish between normal infant feeding behavior and signs which might reflect real problems with intake.

We have made individual chapters from The Breastfeeding Atlas, 4^th edition available for download as pdf files.  Chapter 12 reviews breast cancer.  Lawrence and Lawrence have a brief but excellent review of issues relating to breast cancer in Breastfeeding:  A guide for the medical profession, 6^th edition (pp586-588).

References:

Burns P.  Absence of lactation in a previously radiated breast.  Int J Radiation Oncology, Biology, Physics 1987, 13:1603.

Camune B, Gabzdyl E.  Breastfeeding after breast cancer in childbearing women. J Perinatal and Neonatal Nurs 2007; 21(3):225-233.

David F. Lactation following primary radiation therapy for carcinoma of the breast.  Int J Radiation Oncology, Biology, Physics 1985; 11(7):1425.

Higgins S, Huffy B.  Pregnancy and lactation after breast-conserving therapy for early stage breast cancer. Cancer 1994:73(8):2175-2180.

Answer
Here are the key details from the birth history:
Male infant born after 4 hrs pushing in an unmedicated delivery
Vacuum extractor left a giant cephalohemotoma

Baby developed jaundice (max level 17.2) that has gradually subsided

His tight frenulum was clipped on day 7

Suck evaluation last night revealed slight improvement in his ability to trough and extend             his tongue. I still feel the frenulum.

The baby has been finger feeding (FF) successfully w/ a p-syringe. Attempts to transfer directly to breast have failed.  Use of a nipple shield with tubing underneath failed as well.

I am wondering if bottle feeding would be an option at this point or if the tincture of time is still indicated.  Mom is wonderful and patient and will try anything I suggest.

Additional details:

• Mom’s milk supply is about 2/3 of what baby needs – formula supplementation by FF has been added.
• Mom is double pumping 7 – 8 times/day for 15 min w/ hospt pump getting slightly over 15             oz (425 g) each day.
• Fenugreek has been started  #3/ 3x/s / day yesterday.
• Domperidone being considered – info given.
• Skin-to-skin (s/s) is being practiced – she got a sling yesterday.

I’d love info on what to try next.

Karen Evon

Barbara’s Response:

This is a complicated case; one of those train wrecks where a difficult birth and significant birth trauma resulted in levels of jaundice.  On top of that, there is a somewhat low milk supply and a tongue tie!  All of these issues, in my experience, contribute to lethargic, ineffective feeding.

On day 8 the baby is still under birth weight.  The baby is being fed measured amounts of milk.  Either the volume being offered is insufficient, or the method of feeding is resulting in the baby not completing feeds. I suspect the baby fatigues and shuts down before taking a full feeding.  The infant’s inability to breastfeed indicates he is still recovering from the traumatic effects on motor behavior of the cephalohematoma.  I have seen such infants take weeks to recover.  Thus, time management issues related to finger feeding become an issue.  The baby’s tongue may also be sore from the frenotomy, and the tongue muscle may require strengthening before the baby can breastfeed.  Suck and the stamina to sustain effective feeding are impacted in this case by multiple physiological issues.

The law of first things first suggests that feeding the baby for recovery of weight loss has to be the big priority.  Until an infant recovers birth weight, my experience tells me he will continue to be a weak feeder.  In the case of this baby, he may continue to be a weak feeder for even longer until all the physiological issues resolve. Finger feeding carries the risk of inadequate intake and can be very time consuming for new parents, who are unfamiliar with the skill.

My advice is to help this baby get better milk volumes by switching to a bottle.  Because this is likely to be a disorganized baby, pacing techniques are critical so that the bottle flow rate dose not over-whelm him.  Explain your rationale to the mom so she views the bottle as simply one more intervention, not an abandonment of breastfeeding.  Research suggests that such counseling prevents fixation on the bottle. (Ekstrom A, Widstrom A, Nissen E.  Duration of breastfeeding in Swedish primiparous and multiparous women. J Hum Lact 2003; 19(2):172-78.)

The mother is recovering from a traumatic delivery just like the baby.  We know increased maternal stress during delivery results in delayed or depressed milk production.  If the mom is freed from time consuming (and often inadequate) finger-feeding duties, she may have more time to pump.  Given that her milk supply is below where it ought to be on day 8, this makes more sense in terms of time management. Capitalize on calibrating the milk supply with maximum pumping efforts now.  If her prolactin levels are low domperidone would help, and fenugreek is unlikely to harm her.   As they both recover, it should be possible to back away from the bottle and pumping interventions.  In the meantime, skin-to-skin care protects “breast focus” and should facilitate normal breastfeeding once everyone recovers.

As an aside, feeding tubes were invented for use in term, healthy, adopted babies.  They are not as useful for weak feeders who can’t suck normally.  If you can increase the milk supply, a shield alone would probably be less work and just as effective as a transitioning strategy.  Encourage the mom to practice breastfeeding many times every day (with and without the shield).  More than anything, this will help rehabilitate the weak tongue.  Do provide realistic expectations.  Early breastfeeding attempts may be very weak.  It often takes several weeks for full recovery in such cases.  The good news is that I have seen many similar dyads need interventions such as these.  Many of them recovered well and went on to experience happy breastfeeding experiences.

Note to Readers:  Kay had a very different response to this case.  Her comments point out that different LCs will have different approaches.

Kay’s Response:

As I read Karen’s case, I had a different take on the situation.

Most babies are back to birth weight by 5 to 10 days.  We certainly want to see the birth weight re-gained by 14 days.  This baby is 3 oz (85 g) below birth weight at 8 days.  I am not concerned by that.  If the baby is taking in appropriate amounts of milk, the baby should be back to birth weight by 11 days.  That is fine.  Since Karen has started the baby on supplements, the baby will gain appropriately if offered 20 oz (566 g) over 24 hours.  I base this on the fact that an 8 lb baby requires 20 ounces over 24 hours to gain appropriately.

This mother seems to be making ¾ of what her baby needs.  She should be able to get her milk volumes up to meet the 20 oz (566 g) target volume within the next 2 days.  Power pumping may help.  A woman in Philadelphia, whose case impressed many of us here, left her pump equipment set up and easily accessible.  Twice a day, she pumped on and off over the course of 1 hour, pumping for 10 minutes, resting, and then pumping for 10 minutes, etc.  She doubled her milk production in 2 days.

I also would encourage the woman to hold the baby skin-to-skin many hours each day.  She should massage her breasts while pumping and hand express after pumping (Morton J, Hall JY, Wong RJ, et al. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants.  J Perinatol 2009).   She needs to nap and to sleep whenever the baby sleeps.  Helpers should assist with meals, shopping, cleaning of pump parts, etc.

If finger feeding is going well, I would not discourage it.  I have found finger feeding takes no more time than bottle feeding.  Babies can take in appropriate amounts so long as appropriate amounts are offered.  However, if the mother is the only one doing the feeding, and she is trying to manage pumping, baby care, housework, etc. then she may become over-whelmed.  In my experience I have found that parents do not continue to use finger feeding for very long.  I have not worked extensively with babies with cephalohemotomas.  Therefore, if the baby’s recovery is prolonged, switching to a bottle may make feedings easier.  The baby should be carefully observed to see how he does with a bottle.

Answer:
There is one published case report in the literature describing a situation where a tight labial frenum created nipple pain.  (Wiessinger D, Miller M.  Breastfeeding difficulties as a result of tight lingual and labial frena: a case report. J Hum Lact 1995; 11(4):313-16.)  A tight upper labial (related to the lips) frenum is a known cause of malformation of the teeth. Dentists or orthodontists may sever this tissue to prevent or correct a gap formed between the upper front teeth.  We show several photos in The Breastfeeding Atlas of infants and an adult with tight upper labial frena in Chapter 18 (Orofacial Variations).

Tight Labial Frenum (click to enlarge)

Lip retraction is fairly common in newborns, and there can be other reasons for it than a tight upper labial frenum. Lip retraction is often a compensation performed by a baby who can’t keep the nipple in their mouths using normal sucking mechanics. The baby is forced to grip excessively with that rolled-in upper lip.  Weak facial tone, thin cheeks, receding chin and tongue-tie are other contributing causes for lip retraction.

In some cases, there is nothing wrong with the baby except that they are weak, not sufficiently recovered from birth and are finding their mom’s breast anatomy to be challenging.  The situation requires more observation to see which issues are coming into play before you recommend ablation of the frenum.  Of course in the meantime, you need a combination of strategies to manage the mom’s pain and protect breastfeeding until your understanding clarifies.

The reason you can’t pop the lip into a more normally flanged position is because the baby will lose the breast otherwise and resists the maneuver.  It is interesting that you can position the baby comfortably using a cigarette hold.  It suggests that when the mom or the LC holds the breast more securely, it becomes less necessary for the baby to roll in the lip. That speaks less to the frenum as the problem and makes me more curious about the other issues.

For now, make sure the nipples heal.  If the skin is broken, use mild soap and water to cleanse the wounds.  If they look inflamed, try a few days of topical antibiotic ointment to prevent infection.  If the mom can’t tolerate nursing at every feeding, alternate with a pump to make sure she brings in a robust supply and manages engorgement.  Engorgement will worsen this situation because the breast will lose more elasticity.

You might also try a nipple shield:  both to protect from pain and to give the baby more nipple to grasp.  Use a small-size shield though.  You wouldn’t want to put a large shield over such a small nipple.

Try a football position with the baby’s butt seated against the back of the chair and mom’s hand secure at the base of the baby’s head.  Lead with the chin and make sure the nose is tipped away. This will jam the chin tight against the breast.  Mom will then have a free hand to grasp the areola and push it forward.  Holding the nipple forward is what you are doing when you are helping with the latching.

Answer:
No one really knows how many mothers encounter a foul smell in their stored breast milk.  The breastfeeding literature does not provide much help because the problem has not been well studied.  Lawrence and Lawrence mention the changing flavor of stored milk in the 6^th edition of Breastfeeding:  A Guide for the Medical Professional (pg 781). They speculate that “rancid” or “soapy” smelling milk results from changes in the lipid (fat) structure of milk.  Sometimes freezer burn contributes to foul odor or taste, but there is a theory that some women have more lipase activity than others.  The enzyme lipase breaks down milk fats.  Excessive lipase activity may cause the milk of these women to smell bad after even short periods of refrigeration or freezing.  Some infants reject this milk; others do not seem bothered by the altered taste and smell.

The only solution offered is to advise these mothers to scald (not boil) the milk after pumping and before storing.  Scalding inactivates lipase and stops the process of the excessive fat breakdown.

Kim Updegrove, RN, MSN, Clinical Director of The Mothers Milk Bank at Austin, states that she and her staff occasionally encounter smell changes in some batches of donated human milk when it is thawed prior to pasteurization.  Donor milk is always bacteriologically screened.  It is reassuring that altered smell in these milk samples has not revealed contamination or “spoilage.”  Kim pointed out that the pasteurization process used in milk banks also deactivates the lipase activity in the milk.

The good news is that this milk is safe to consume.  However, foul smell and bitter taste worries mothers and care-givers alike.  It becomes a big problem if the baby rejects it.  Scalding, while effective, creates extra work, especially for employed mothers.  In our opinion, the issue of flavor and odor changes in stored milk cries out for more research.  What a study this would make!

The Conference Research Presentation Award, sponsored by Barbara Wilson-Clay and Kay Hoover, will be split between the two poster award recipients.

Congratulations for this outstanding work!

Azza Hussein Ahmed, DNS, RN, IBCLC, CPNP

Ellen Lechtenberg, BS, RD, IBCLC