Clinical Implications: Evidence-Based Lactation Support for Mothers Who Are Obese
Many of the midwifery support techniques described in the following sections are best practice for all lactating mothers. These techniques become especially important for obese women or those who gained weight excessively during pregnancy, as their altered hormonal milieu and physiology pose additional challenges to the initiation of lactation.
Planned midwifery support helps to assure that women who are overweight and obese are able to initiate and sustain breastfeeding. Advice on the 1990 IOM prenatal weight gain targets ( Table 1 ) to prevent excessive weight gain must begin at the first prenatal visit for maximum effectiveness.[3,5,7,9] Recommendations based on pregravid or first trimester BMI require accurate measurement of height and weight and calculation of BMI. Twenty-four to 48-hour nutrition recall can be used to identify nutrition patterns. Advice should center on the adequate caloric intake of nutritious foods with sufficient protein and iron while counseling the mother who is obese to avoid non-nutritious foods, such as soda and candy. Mothers should never be advised to lose weight during pregnancy.
Advising non-exercising mothers to "take the baby for a walk" improves their aerobic capacity for labor and prepares them for ambulation in labor and postpartum exercise. Walking 30 minutes a day can be accomplished in 10 to 15 minute increments. Mothers who are obese who have been sedentary may need to start with 10 minutes of daily walking increased gradually at weekly intervals.
Medicaid does not pay for nutrition counseling in all states. WIC nutritionists, however, can be a valuable source of educational support. Women who are obese may qualify for WIC services under medical diagnoses, such as anemia, inadequate weight gain, or excessive weight gain during pregnancy. Obesity indicates previous excess caloric intake, not necessarily adequate nutrition. Abnormal weight gain can be followed more closely with visits at 1- to 2-week intervals using the International Classification of Diseases 9 code 646.1 (maternal obesity syndrome/excessive weight gain). Preventing excessive weight gain reduces the risk of macrosomia and cesarean birth, which further complicate lactation for mothers who are obese.[5,21]
Because excessive stress during labor and surgical birth can alter the initiation of lactation and delay lactogenesis II,[21,22] intrapartum midwifery techniques, such as ambulation and frequent position changes, should be used to allow the birth to be as physiologic as possible. Pain management techniques that reduce the amount of newborn sedating medication, such as hot packs and acupressure, can increase infant alertness and enhance early sucking strength and coordination. Studies of the effect of epidural analgesia and anesthesia on lactation have conflicting results. Women who are obese are at risk for surgical birth, and therefore, exposure to epidural anesthesia. When needed, epidural analgesia with low dose fentanyl or bupivacaine instead of other anesthetics may limit problems with breastfeeding initiation and duration.
Early Feeding. Every effort should be made to keep the mother and newborn together including during postcesarean recovery periods. Newborns should be put to the mother's breast as soon as possible to facilitate early and frequent suckling. This triggers prolactin and oxytocin production, potentially negating the obesity-related blunting of the prolactin response. Oxytocin released during nipple stimulation also reduces the increased risk of postpartum hemorrhage in women who are obese, by causing uterine contractions that constrict endometrial arteries.
Skin-to-skin positioning maintains close proximity to the breasts for early, frequent feedings, which are critical to the prevention of hypoglycemia in macrosomic newborns. Skin-to-skin contact also assists with the stabilization of respirations, heart rate, thermoregulation, and the conservation of energy. Mothers who are overweight, obese, or those with excessive prenatal weight gains should breastfeed on demand, approximately 10 to 12 times in 24 hours, until the onset of lactogenesis II.
Nipple/Latch Techniques. In addition to having larger breasts, excess periareolar adipose tissue may flatten the areola and nipple in women who are overweight and obese, making the nipple more difficult for the newborn to grasp (Figure 1). The mother who is obese with flat nipples may utilize a sandwich technique to insert her breast into the baby's mouth and elicit sucking. In the sandwich technique, the mother grasps her breast by making a "C" with a thumb and index finger. The thumb stabilizes the top of the breast while the other four fingers support the breast from below. Sandwiching the breast in this manner allows it to be lifted to the newborn's mouth. A mother with flat or inverted nipples may benefit from pumping to make the nipple more erect before offering the breast to the newborn. In time, most women respond to pumping and infant sucking with increased nipple protractility. The use of a nipple shield to achieve latch may be an alternative, but this requires close follow-up to ensure adequate milk transfer. No studies have examined the use of nipple shields to assist latch on the obese breast.
Breast stabilization with towel roll. Use of a towel roll to stabilize the breast during feeding and reduce traction on Cooper's suspensory ligaments. Note the enlarged, flattened areola.
An effective latch assures that the nipple receives adequate stimulation and that the infant transfers milk effectively. The midwife may be able to evaluate latch during postpartum exams. In some settings, latch evaluation and ongoing lactation support may be provided by a lactation consultant or postpartum nurse. The critical attributes of an effective latch have been identified as positioning, latch, sucking, and milk transfer.
Assisting the mother to achieve a comfortable position is an essential first step in effective breastfeeding. A mother who is overweight or obese will need back support and sufficient space to move the infant during positioning. Large beds and wide chairs may be needed for comfortable movement and positioning. The weight of large and heavy breasts should not rest on the infant's chest. Walker suggests placing a towel roll under large breasts to assist with stabilization (Figure 1). A correctly positioned infant is held facing the mother level with the breast, has a wide open mouth, flared lips, and chin touching the breast. An effective latch is asymmetric, with more areola visible above the baby's mouth.
If engorgement of the areola is present, then reverse pressure softening (gentle inward pressure around the areola) can be utilized to soften the areola and enable the infant to achieve an effective latch. Reverse pressure softening may also stimulate the milk ejection reflex. It can be performed by a healthcare provider, the mother, or a significant other, and should be done before latching or pump use to alleviate areolar engorgement and assist with the removal of milk.
If an infant latches but does not suckle, alternate massage can be used to assist with transfer of milk. Alternate massage is done by applying pressure to the breast to assist with transfer of milk and breast emptying during pauses in infant suckling. This technique can provide encouragement for the infant to maintain an effective suckling pattern while maximizing milk transfer.
Typical breastfed infant stools and wet diapers should be reviewed with mothers so that they have appropriate output expectations. They should expect that once lactogenesis II starts, the number of stools will increase and the infant will wet at least six to eight diapers a day.
If the infant is not able to latch and feed effectively, then colostrum should be given to the infant in a manner that least compromises the transition to breastfeeding. Methods include spoon, cup, or finger feeding, and the infant should be held upright to feed with any of these methods. An amount of 0.5 mL can be easily swallowed by the infant. Providing the infant an initial snack of colostrum may boost energy so that the infant achieves a latch and initiates sucking. Hand expression of colostrum can be more effective than pumping and allows for easier collection.
Milk Pumping. If mother and infant are separated, milk production should be stimulated by emptying the breasts every 2 to 3 hours using a hospital grade pump. Double pumping, using a breast pump configured to pump both breasts simultaneously, in addition to breast massage has been shown to increase prolactin levels and produce better milk output. Additionally, double pumping halves pumping time, giving new mothers more resting time. The standard 24-mm breast pump shield may not sufficiently cover an obese breast, causing rubbing and strangulation with each pull, eventually leading to nipple damage. Ensuring that the breast shields provided are large enough will make pumping more effective and avoid nipple trauma. Figure 2 shows a standard breast shield compared to a large shield, and a nipple measurement tool to assist with shield fitting, equipment that should be available on all postpartum units. Information and support should be provided regarding breast pump use, storage and transport of breast milk, and infant feeding techniques. Mothers should be aware of community resources that provide rental or loans of breast pumps.
Breastfeeding Post-Bariatric Surgery. Bariatric surgery with gastric banding or bypass is increasingly available to women whose BMI exceeds 35, who have been unsuccessful with other weight loss methods, or who have obesity related infertility. There are case reports of vitamin B12 deficiency and failure to thrive in breastfed infants of mothers who had gastric bypass surgery, most likely because of the maternal lack of gastric intrinsic factor needed to absorb vitamin B12. These mothers will need multivitamin supplements with regular nutrition and infant growth surveillance, and may need parenteral vitamin B12 supplementation.[43,44,45]
Intertrigo. Intertrigo, the inflammation of skinfolds caused by skin-to-skin or clothing friction, is a common problem of the obese breast. Intertrigo progresses from erythema and maceration to reddened plaques that may have fissures and exudates. Women may complain of intense itching, burning, and pain as intertrigonous areas become secondarily infected with bacteria or fungi, most commonly Candida. Although the obese breast needs a bra with firm support, care must be taken that the fit is non-constricting and that the fabric is light, non-synthetic, and porous. Mothers who are obese must clean and thoroughly dry breast skin folds daily. Protective creams may be used as skin barriers or cornstarch as a drying agent. Mothers should be taught the symptoms of candidal breast infections and to recognize the cottony white oral patches or tongue plaques of infant oral thrush. Secondary infections should be treated with the appropriate antibiotic or antifungal agent.
Post-Discharge Lactation Support Plan. Completing a lactation support plan ( Table 2 ) before hospital discharge, as well as providing close follow-up, may be critical to continued breastfeeding for obese women. Discharge teaching should consist of a review of infant feeding cues, achievement of a comfortable and appropriate latch, duration and frequency of breast feedings, the identification of infant swallowing, and indicators of adequate infant intake. Giving parents a log to record daily stools and urine, breast feedings, and breast assessments may assist with the recognition of adequate output and early identification of problems. Contacts for breastfeeding assistance such as WIC offices, La Leche League, and local lactation consultants should be provided as resources upon discharge. Midwifery practices with home visit capacity are ideally organized to provide support during the first postpartum weeks when women who are obese are likely to have reduced perceptions of breast fullness and milk production. Midwives can observe lactation, assess infant hydration, and reassure the mother about infant growth and her breastfeeding capability.
Mothers who are overweight and obese should be encouraged to choose low fat foods during lactation. In the absence of chronic disease, such as heart disease or asthma, mothers may resume physical exercise gradually until they are walking at least 30 minutes per day. Exercise may be done in 15-minute increments. Physical activity helps burn excess intake if weight stabilization or loss is desired postpartum. Mothers may restrict intake no lower than 1500 calories a day to lose weight, but should wait until lactation is well established.[29,30,31,32]
J Midwifery Womens Health. 2007;52(6):606-613. © 2007 Elsevier Science, Inc.
Cite this: Lactation Complicated by Overweight and Obesity: Supporting the Mother and Newborn - Medscape - Nov 01, 2007.