Misconceptions Disrupt Breast-Feeding Mothers

Tara Haelle

April 28, 2018

AUSTIN, Texas — As breast-feeding rates rise in the United States, physicians can actively support mothers and correct the many misconceptions about breast-feeding, according to Susan Crowe, MD, from Stanford University in California.

About one third of women (34%) in the United States now breast-feed for at least 1 year, she said, compared with 22% in 2007. The number of those who have ever breast-fed or breast-fed to 6 months have increased by similarly substantial margins, and rates of exclusive breast-feeding to 3 months and 6 months are also inching up.

Yet many myths about breast-feeding persist and run the risk of disrupting the relationship, Crowe told delegates here at the American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting.

"One of the most damaging things we do from a medical perspective is interrupt breast-feeding without evidence-based justification," Crowe told Medscape Medical News. "It undermines women's confidence, and that can sabotage breast-feeding, when women aren't confident and trusting their bodies to do what they can do."

One of the most damaging things we do from a medical perspective is interrupt breast-feeding without evidence-based justification. Dr Susan Crowe

Significant health disparities already exist among different demographic groups, and not giving patients accurate information when they may not have sufficient access to such information can exacerbate those disparities, she added.

One of the biggest misconceptions about breast-feeding is that women should breast-feed every 3 to 4 hours to establish an adequate milk supply at the start, Crowe said. In reality, mothers should breast-feed their babies on demand, based on the infant's feeding cues, which should end up being about at least 8 times in a 24-hour period.

"There are some women with the ability to feed at long intervals and can develop a full milk supply," Dr Crowe told Medscape Medical News. "However, most women will need to breast-feed much more frequently than that to establish a milk supply."

This might not work for women with multiples, Crowe acknowledged in response to an attendee's comment that feeding on demand might not be feasible for more than one baby. Women with multiples will need to find an appropriate rhythm that works for them, such as feeding on demand with the first hungry twin and then waking the other to feed.

Crowe also reminded attendees that it's not "normal" for breast-feeding to hurt. It may cause tenderness as the nipples adjust to nursing, but intense pain indicates a problem with the baby's latch or some other issue that requires evaluation by the physician or a lactation consultant.

"A proper latch has more than the nipple in the baby's mouth," Crowe explained. "The baby's mouth will be open wide and the lips will be 'fish lips.' "

Women receiving medication or undergoing medical procedures may be encouraged to stop breast-feeding in case it might not be safe, but this could have other negative effects, Crowe cautioned.

"What that may do is completely sabotage breast-feeding for some women," Dr Crowe told Medscape Medical News.

Don't Stop Breast-Feeding

Women do not need to stop or even temporarily pause breast-feeding after a computed tomography or magnetic resonance imaging scan with contrast agents, while taking antibiotics, while fighting a mastitis infection, or after surgery that requires sedation. The only exception after surgery is receiving codeine or tramadol if mothers have the gene that affects metabolism of these opioids, which could put their infants at risk for overdose.

Crowe recommends resources for knowing which drugs are safe for breast-feeding:

  • LactMed smartphone app from the National Institutes of Health;

  • InfantRisk app (costs $9.99);

  • Book of Medications and Mothers' Milk, by Thomas Hale;

  • American Academy of Pediatrics Statement on Drugs and Breastmilk;

  • Academy of Breastfeeding Medicine; and

  • ACOG Breastfeeding Toolkit

She also recommended physicians join the Dr. MILK peer network online, available only to medical students, residents, and working physicians.

Even for women who want to drink alcoholic beverages, pumping and dumping is not usually necessary. Women who limit themselves to about two standard drinks early in the evening can safely breast-feed when they return home, Crowe said.

Don't Pump and Dump

"Ingestion of alcoholic beverages should be minimized or limited to no more than 0.5 g alcohol per kilogram of body weight, which, for a 60-kg mother, is approximately 2 oz liquor, 8 oz wine, or 2 beers," Crowe explained. Ideally, nursing should take place at least 2 hours after drinking the alcohol so its concentration in breastmilk is lowest, she said. And women should be aware that alcohol may blunt the prolactin response to suckling, potentially negatively affecting infants' motor development.

The evidence on marijuana use during breast-feeding, however, is murkier, primarily because insufficient data exist. Researchers know that tetrahydrocannabinol, the active ingredient in marijuana, becomes concentrated in breastmilk up to 8 times greater than plasma levels. It is also stored in body fat with a half-life ranging from 20 hours to 5 days.

ACOG currently discourages marijuana use during breast-feeding and recommends its use as a medical agent be replaced with something with better, longer-term safety data during pregnancy and lactation.

Myths About Milk Supply

Crowe also addressed myths about how to improve milk supply, pointing out that blue Gatorade will not increase supply. Further, herbs such as Fenugreek or those found in Mother's Milk teas or lactation cookies are not needed to help with lactation.

Mothers of preterm infants can optimize their initial milk supply by hand-expressing breastmilk within the first hour after delivery, which has far better results than pumping with a hospital-grade pump within 6 hours of birth.

In fact, Crowe showed data from one study revealing that women expressed 4.19 mL breastmilk if they hand-expressed within an hour postpartum compared with just 0.1 mL if they pumped between 1 and 6 hours after giving birth.

Women returning to work while breast-feeding should not aim to fill their freezers with pumped milk while at work, Crowe said. They should feed babies what they pumped that day instead. Giving babies more milk than was pumped in a day, or additional pumped milk after they breast-feed, is unwise because it can overfeed their baby and risk breast refusal.

"If supply is truly low, it won't come up by using frozen stash," Crowe said.

Rebecca Hunt, MD, an obstetrician/gynecologist at Maine Medical Center in Portland, said Crowe's presentation was excellent and addressed many of the misconceptions she hears in her practice.

"It helps to learn what the myths [are] and hear what some good responses are," Hunt told Medscape Medical News. "The bottom line take-home is that by far the most common response to any breast-feeding problem is to breast-feed rather than avoid it."

Nicholas Zarilla, MD, a retired obstetrician/gynecologist and former professor of medicine at Marshall University in Huntington, West Virginia, was also impressed with the quality of information and with Crowe herself, whom he said is one of the country's best advocates for breast-feeding.

"The presentation was insightful and informative, in terms of dispelling [myths] and presenting facts," he told Medscape Medical News. He attended the lecture "to see what the current data showed, both clinically and in terms of mythology," and it fulfilled his expectations.

In fact, as a father of three children who were breast-fed, in addition to his career in obstetrics, Zarilla said he has encountered nearly all the misconceptions or difficulties that Crowe addressed, and he always encouraged his patients to breast-feed if they were physically and mentally capable of doing so.

"As providers of women's healthcare, this is really about supporting women and the choices they make regarding the reproductive spectrum, and breast-feeding is part of that reproductive health spectrum," Crowe said. "More women today are choosing to breast-feed, and we need to help them to achieve their own breast-feeding goals."

Crowe, Hunt, and Zarilla have no financial disclosures. No external funding was used for the presentation.

American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting. Presented April 27, 2018.

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