The Motherwear Breastfeeding Blog

Study: Common antidepressants can delay milk coming in

A new study has found an association between the use of some common antidepressant medications and delayed of milk "coming in."  An article on the study reports:

"The breasts are serotonin-regulated glands, meaning the breasts' ability to secrete milk at the right time is closely related to the body's production and regulation of the hormone serotonin," said Nelson Horseman, PhD, of the University of Cincinnati and co-author of the study. "Common antidepressant drugs like fluoxetine, sertraline and paroxetine are known as selective serotonin reuptake inhibitor (SSRI) drugs and while they can affect mood, emotion and sleep they may also impact serotonin regulation in the breast, placing new mothers at greater risk of a delay in the establishment of a full milk supply."

In this study, researchers examined the effects of SSRI drugs on lactation using laboratory studies of human and animal cell lines and genetically modified mice. Furthermore, an observational study evaluated the impact of SSRI drugs on the onset of milk production in postpartum women. In this study of 431 postpartum women, median onset of lactation was 85.8 hours postpartum for the SSRI-treated mothers and 69.1 hours for mothers not treated with SSRI drugs. Researchers commonly define delayed secretory activation as occurring later than 72 hours postpartum.

Note that this study concerns mothers who were taking antidepressants at the time of their babies' births.  I don't think any claims are being made about the use of antidepressants after the onset of full milk production.

As I'm sure you know, delayed milk "coming in" can have some serious consequences, especially if it isn't managed well.  The drill goes something like this:  delayed onset of mature milk leads to higher than normal weight loss in the baby, which leads to supplementation, which can lead to compromising of the milk supply and/or nipple preferencing if the supplementation isn't done carefully.  It can also increase the risk of jaundice.

I checked my handy copy of Medications and Mothers' Milk, and there is no mention of this effect in the write ups for fluoxetine (Prozac), sertraline (Paxil), paroxetine (Zoloft).

Obviously, mothers aren't usually on antidepressants in pregnancy unless there is a very good reason for it, so in most cases this probably can't be avoided.  But this new evidence makes me wonder if we shouldn't consider telling mothers (as we should - but usually don't - for other things that can cause a delay, like diabetes), that it might take a little longer for their mature milk to come in.

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The top ten breastfeeding stories of 2009

Here's my summary of the year's most significant stories related to breastfeeding.  If you're feeling nostalgic you can see my 2008, 2007, and 2006 summaries, too.

The Case Against Breastfeeding.  Probably the biggest ruckus in the breastfeeding world was caused by an article in the Atlantic Monthly, titled "The Case Against Breastfeeding," which essentially made the arguments that a) there is scant evidence for the superiority of breastfeeding over formula feeding, and b) breastfeeding "keeps women down."  You can read my response here if you like, as well as other reactions, from groups as influential as the American Academy of Pediatrics.  This article was followed by a similar one in the Times of London.

Far fewer people than those who read The Case Against Breastfeeding saw this article about Dr. Michael Kramer, one of the researchers whose work was cited in the article.  Described as "spitting tacks" over how his work was characterized, he says that his findings were "grossly misinterpreted," and that "there really isn't any controversy about which mode of feeding is more beneficial for the baby and the mother."  He called the articles "sensationalist" and accused the journalists of misquoting him in order to support their opinions.

Salma Hayek and "the latch heard round the world."  Salma Hayek turned even more heads than usual when she nursed a baby (not her own) while on a goodwill mission to Sierra Leone.  This ignited a debate about cross nursing, particularly of babies in need. For more of the year's celebrity breastfeeding stories, see this week's celebrity round-up guest post.

New HIV recommendations should reduce transmission through breastmilk in developing world.  In what may lead to a major advance in the prevention of mother-to-child transmission of HIV through breastfeeding, the World Health Organization is now recommending that mothers take antiretroviral drug therapy during the course of breastfeeding.  For a more thorough description of this policy change and its implications, see this post.  

Formula marketing issue heats up; plastics industry plots campaign to make us want to ingest BPA.  An eagle-eyed reader of this blog was the first to point out that a formula company website was using a page header calling their product "the breastmilk formula," and one formula company revealed a new "nightime formula" which is actually exactly the same as their "reflux formula" (added rice starch).  And notes from an industry meeting of plastic executives revealed that they considered launching a campaign to promote BPA, using a pregnant mother as their 'holy grail' spokesperson.

Recession hits breastfeeding support programs.  Around the country, breastfeeding support programs, became victims of the economic downturn.  One of the premier lactation programs on a university campus, UC Davis, wasn't immune, losing its breastpumps and lactation specialist support.

Breastfeeding and the law in the spotlight.  New laws were enacted, most notably for my state (Massachusetts).  And in some of the first judicial tests of lactation laws, an Ohio court case dodged the issue of whether pumping at work is protected under the state's pregnancy discrimination law, and a California employment commission found that it was illegal to fire a mother for breastfeeding on the job. 

Countries inch closer to using breastfed growth as the norm.  In the biggest practical endorsement yet of the World Health Organization's new growth charts which use the breastfed baby as the normative growth pattern, the U.K. largely adopted the charts for use in the National Health Service.  Next up, the American Academy of Pediatrics?  A girl can hope.

WIC changes food package to push exclusive breastfeeding.  I'll be publishing a guest post explaining this in more detail soon, but the news is that this year WIC began distributing an enhanced food package for mothers who breastfeed exclusively.  Exclusive breastfeeding moms now get the largest and most varied food package of all, and get the largest quantities and most varied baby foods once their babies turn 6 months old.  The hope is that these incentives will significantly improve the rate of exclusive breastfeeding among moms enrolled in WIC.

Best for Babes Foundation launches new ad campaign.  The Best for Babes Foundation created an attractive and persuasive new ad campaign, and the ads have appeared in national pregnancy magazines.  Best for Babes' advocates to eliminate the "booby traps" that stand in the way of breastfeeding success.

Toxins in breastmilk and formula in the news again.  Several studies were released on toxins in breastmilk and toxins in formula, and the blogosphere briefly became fixated on the question of whether toxins in breastmilk cause autism.  Want the facts?  See this post. 

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2009 brings yet more reasons to breastfeed

Every year brings more and more studies showing the power of breastfeeding to protect infant and maternal health, and 2009 is no exception.  Below is a summary of some of the more publicized research.  You can read my summaries of 2006, 2007, and 2008, too.

Child health:

• Infants who are breastfed are less likely to be abused
• Breastfeeding protects infants against Sudden Infant Death Syndrome (SIDS)
• Breastfeeding is associated with higher academic achievement
• Breastfeeding reduces risk of childhood obesity and metabolic syndrome in children
• Breastfeeding is effective in providing pain relief in newborns

Maternal health:

• Mothers who breastfeed, and particularly those who have gestational diabetes during pregnancy, have a lower risk of developing metabolic syndrome
• Breastfeeding provides protection against premenopausal breast cancer for women with a family history
• Mothers who breastfeed have a lower risk of coronary disease
• Mothers with multiple sclerosis have a lower risk of relapse within a year after their babies' births if they breastfeed
• Women who breastfed were less likely when they were older to have developed high blood pressure, diabetes, high cholesterol and cardiovascular disease

Other studies of interest:

• Using antiretroviral drugs during breastfeeding is now recommended for mothers with HIV
• There are several types of stem cells in breastmilk
• Nipple piercings may impact breastfeeding after all
• Weaning to start multiple sclerosis medications may actually increase the risk of relapse
• Environmental toxins in breastmilk not shown to have an impact on infants.  A study also found perchlorate in infant formula
• Maternal smoking is associated with lower rates of breastfeeding initiation, and earlier weaning

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Did you have gestational diabetes? Breastfeeding may give you extra protection against metabolic syndrome.

In the first study of its kind, researchers at Kaiser Permanente have found that breastfeeding offers protection against metabolic syndrome among women who have had gestational diabetes. 

What's metabolic syndrome?  According the American Heart Association, it's a combination of factors including abdominal obesity, high cholesterol, elevated blood pressure, insulin resistance, high inflammatory state.  These factors significantly increase the risk of heart attack and Type II diabetes.

Recent research has shown a protective effect against metabolic syndrome for all women, but the effect appears to be even stronger for women who have had gestional diabetes.  And that's important, because women who have gestational diabetes are 2½ times more likely to develop metabolic syndrome after pregnancy.

USA Today reports:

In women who didn't have gestational diabetes, breast-feeding cut metabolic syndrome risk 39%-56%. In those who did, it cut the risk 44%-86%. In both, the authors write in Diabetes: The Journal of the American Diabetes Association, the longer women breast-fed, the lower their risk.

Breast-feeding is associated with a quicker loss of pregnancy weight, but that's only "a little bit of the explanation," Gunderson says. Another possibility, she says: Breast-feeding might minimize the accumulation of belly fat, fat linked to type 2 diabetes risk.

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WHO announces a big change in breastfeeding recommendation for HIV positive mothers.

On the eve of World AIDS Day, the World Health Organization has released updated recommendations on preventing mother-to-child transmission of HIV.  And the news for breastfeeding is really big.

You may recall that HIV can be transmitted from mother to child during pregnancy, childbirth, and breastfeeding.  In the developing world this has been a major source of new infections. 

For this reason, it's been the recommendation that women who are HIV positive not breastfeed, as long as formula feeding is "acceptable, feasible, affordable, sustainable and safe."

Many women in developing countries don't have access to clean water, much less the resources to purchase formula, and not breastfeeding puts their infants at a high risk of death and disease.  In one recent study of 14 developing countries, not breastfeeding resulted in over 325 deaths per 1,000 births compared to 35 deaths per 1,000 births among breastfed babies. 

That's why breastfeeding, even though it may mean that a child becomes infected with HIV, is considered safer than not breastfeeding in much of the developing world.  Both feeding options carry significant risks, but a child is far likelier to die early in life if he is not breastfed. 

So, until today, the recommendation has been that women in developing countries feed their babies breastmilk substitutes only if it is "acceptable, feasible, affordable, sustainable and safe."  Otherwise, exclusive breastfeeding is recommended during the first six months of life, to be discontinued as soon as is feasible thereafter.

This has been a really difficult recommendation to follow, for several reasons.  Exclusive breastfeeding (considered the safest method) is relatively rare.  Weaning from exclusive breastfeeding to no breastfeeding at six months, as you can imagine, is extremely difficult.  And women face significant stigma when not breastfeeding.  Unlike in the U.S., many developing countries never lost the "breastfeeding culture," and not breastfeeding is considered a give away that a woman is HIV positive.

But recent research has shown that when HIV positive mothers take antiretroviral drugs while breastfeeding, it reduces the risk of transmission dramatically.  Access to ARVs has increased significantly in recent years.  Accordingly, the WHO has changed its recommendation:

WHO now recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV-positive mother or baby is taking ARVs during that period. This will reduce the risk of HIV transmission and improve the infant's chance of survival.

"In the new recommendations, we are sending a clear message that breastfeeding is a good option for every baby, even those with HIV-positive mothers, when they have access to ARVs," said Daisy Mafubelu, WHO's Assistant Director General for Family and Community Health.

National health authorities are encouraged by WHO to identify the most appropriate infant feeding practice (either breastfeeding with ARVs or the use of infant formula) for their communities. The selected practice should then be promoted as the single standard of care.

I think that this is really good news for mothers, babies, and the tradition of breastfeeding.

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Stem cells in breastmilk may help a child "fulfill its genetic destiny"

It's been known for some time that breastmilk contains stem cells, but new research suggests that there are three types of stem cells present in breastmilk, and hints at a role they may play in the development of muscle and bone tissue.

The Independent reports:

Dr Mark Cregan, medical director at the Swiss healthcare and baby equipment company Medela, believes the existence of stem cells means breast milk could help a child "fulfil its genetic destiny", with a mother's mammary glands taking over from her placenta to guide infant development once her child is born.

Breast milk is the only adult tissue where more than one type of stem cell has been discovered. That is very unique and implies a lot about the impressive bioactivity of breast milk and the consequential benefits to the breastfed infant," said Dr Cregan, who is speaking at Unicef's Baby Friendly Initiative conference this week. His research has isolated adult stem cells of epithelial (mammary) and immune origin, with "very preliminary evidence" that breast milk also contains stem cells that promotes the growth of muscle and bone tissue.

Dr Cregan said the discovery of immune stem cells was the "most exciting development", adding, "It's quite possible that immune cells in breast milk can survive digestion and end up in the infant's circulation. This has been shown to be occurring in animals, and so it would be unsurprising if this was also occurring in human infants.

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What should our national breastfeeding goals be? Time to comment on the Healthy People 2020 goals.

Every ten years since 1979, the U.S. Department of Health and Human Services has set "Healthy People" objectives.  These objectives for a kind of public health agenda for the country, and are used to assess the progress of some government sponsored public health programs.

Healthy People 2010 set goals of 75% breastfeeding in the early postpartum period, 50% at six months, and 25% at one year.  There are other goals for exclusive breastfeeding, too.

I explored the Healthy People website, looking for information on how far we've progressed toward these goals.  The 2008 data on "any breastfeeding" show us falling short of the 75% goal by 4 percentage points.  Not too bad, and maybe by 2010 we'll actually make it. 

It gets more interesting when you look at breastfeeding rates by ethnicity.  Some ethnic groups are surpassing the goal significantly.   Specifically, Asian/Pacific Islander, Latina, and American Indian/Alaska Native moms are exceeding the targets (with rates of 86%, 79% and 80%, respectively).  White mothers may meet the target by 2010, since their breastfeeding rate in 2008 was 74%.  The breastfeeding rate of African American moms has increased significantly in recent years, but is still lower, at 51%. (See my podcast interview for a discussion of African American moms and breastfeeding).  And disparities by education persist. 

While we're making progress, we have a lot further to go when it comes to exclusive breastfeeding.  The goal for exclusive breastfeeding to six months was 17%, but the actual rate in 2008 was 10%. 

The Healthy People 2020 goals are now in development, and the draft objectives have been opened up to public comment.  I'm planning to comment on the need for a focus on disparities between different demographic groups, based on income, age, and race, for example.  A few years ago I wrote about some of these stark disparities here. 

You can comment here.  The public comment period is open until December 31st.

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New York Times: "Breastfeed the Baby, Love the Calorie Burn"

I'm always surprised to find articles about breastfeeding in the New York Times, but I was shocked when I realized that I know the mother and baby whose picture is prominently displayed at the top!  We met a little while back at a breastfeeding group I run, and I think she had some of the most sensible comments in the piece.

The article states:

That breast-feeding gives mothers an edge shedding baby weight has long been suspected. But lately, a parade of celebrities has attributed their postpartum slimming to nursing, bringing this age-old topic back into the spotlight. Adding to the conversation is a large study that suggests that weight loss through breast-feeding is not a myth.

...Is it any wonder that some new mothers are quietly thrilled at the calorie cushion that breast-feeding provides? “Nobody wants to admit they are doing it for themselves, or ‘I’m doing it to help myself look hot again,’ ” said Jesse Comer, from Portland, Ore., [not the mother I met] whose main motivation to breast-feed was her baby’s health. “It’s tough to admit to other people that everything isn’t about the baby.” But Ms. Comer, like many mothers interviewed for this article, “felt like until the weight was off, I wouldn’t feel myself.”

For those incredibly shrinking women, the time they nurse is precious not only for its skin-on-skin cuddling, but also for the Get Out of Dieting Jail Free card that comes with it.

But does breast-feeding actually speed weight loss in postpartum women? It depends.

Last year, and epidemiological study of 36,000 Danish women found that the more a mother breast-feeds, the less weight she retains six months after birth. A few factors determined how much she lost: whether a woman was overweight before pregnancy, what she gained while expecting and duration of nursing, said Kathleen M. Rasmussen, an author of the study and a nutrition professor at Cornell.

So here's the thing about the guilt some of us feel when we experience weight loss with breastfeeding:  It may feel like it's about vanity, but it's actually about your health.  Numerous studies have shown that breastfeeding protects mothers against weight and metabolism related health problems, including diabetes, heart attack, coronary artery disease, obesity, and the high blood pressure, high cholesterol, and insulin resistance associated with metabolic syndrome.  Researchers attribute this to the weight loss and metabolism shifts that occur during breastfeeding.  Not burning off the weight - which your body added during pregnancy as a fuel source for breastfeeding whether you intended to breastfeed or not - puts you at a higher risk for these and other health problems.  So it's not just about fitting into your old clothes.  It's about your health.

Still feeling selfish for loving, as one of the stars of Ugly Betty put it, "nature's lipo?"  Just keep in mind this quote in the article from breastfeeding advocate Marsha Walker:  “We deserve it.  She ought to get into those skinny jeans after 9 months of pregnancy and 20 hours of labor. That’s what I tell mothers. Go for it.”

I know it doesn't work for everyone, and the article points that out.  My own observations:  Some women appear at a month as if they've never been pregnant, while others seem to have a huge appetite during breastfeeding and hold onto some of the weight until they wean.  Some mothers lose it gradually at first but lose more rapidly after the 6 month mark.  And some women struggle with the last few pounds until they wean, while others go well under their pre-pregnancy weight.  (This happened to me, and it wasn't pretty.  Between the hair loss, sleep deprivation, and extreme weight loss I looked a little like a prisoner of war.)  A few years ago I polled you (open with Explorer) on this topic, and I think the results show this, um, spread.

So, do you feel guilty for loving the calorie burn?

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Nipple creams in the Skin Deep database

I was recently playing around with the Environmental Working Group's Skin Deep database, checking to see exactly how bad my shampoo is for me, when I noticed that the database includes information on nipple creams.

Had any of you noticed that, or used the information to decide which one you use (if any)? 

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Guest post: Was your baby an "impostor?"

I'm very pleased to share a guest post by Dr. Marianne Neifert, author of Great Expectations: The Essential Guide to Breastfeeding.  I had been wanting to write about "late preterm" babies - born between 34 and 36 weeks gestation for a while now.  Those of you who have had a baby born at this age know that these babies can pose particular breastfeeding challenges. 

I hope that you find this post useful!

Just a Few Weeks Early
Breastfeeding Challenges in Late-Preterm Infants
By Marianne Neifert, M.D.,

Until recently, babies born a few weeks early -- between 34 and 36 weeks gestation -- were referred to as near term infants. However, the designation, near term, implies that an infant is almost term or almost fully mature, and the misnomer has often caused health professionals and parents to underestimate the medical risks in this large, vulnerable population of infants. Recently, the American Academy of Pediatrics has recommended that infants born at 34, 35, or 36 weeks gestation be referred to as late-preterm infants to emphasize that these babies are physiologically immature and have special health care needs compared to full term infants (born between 37 to 41 weeks). In addition, the mothers of late-preterm infants are more likely to have medical complications themselves, such as gestational diabetes, high blood pressure, or C-section delivery.

The Rising Incidence of Late-Preterm Births

The proportion of all U.S. births that are late preterm has increased over the past 15 years. Late-preterm infants now comprise over 9% of all births, and account for more than 70% of all preterm births (<37 weeks gestation), representing nearly 400,000 babies each year. Although the reason for the increase in late-preterm deliveries is not well understood, one explanation is the increased use of fertility treatments, which has lead to a rise in pregnancies with twins and higher multiples. Half of all twins and 90% of all triplets are born preterm. Other possible contributors to the rise in late-preterm births include the rise in cesarean section births (now 30% of all deliveries), the need to deliver some infants early due to medical complications, and more pregnancies occurring among women at an older age. In addition, performing elective labor inductions or elective cesarean sections for no clear medical or obstetrical reason sometimes leads to the unintentional delivery of a late-preterm infant. Both expectant mothers and obstetricians need to know the importance of avoiding late-preterm delivery unless it is medically necessary.

Medical Complications among Late-Preterm Infants

Because many late-preterm babies are the size of infants born at full term, health care professionals may not always give these at-risk infants the special treatment and careful screening they deserve. Instead, hospital personnel and parents tend to treat these apparently healthy infants as if they were developmentally mature. Late-preterm infants have been called imposter babies because many of these "slightly early" newborns masquerade as full-term infants, appearing to need no special care after birth and being discharged as early as term babies. Yet, babies born even a few weeks early have an increased risk of medical complications after birth and may require a longer hospital stay than full-term infants. Late-preterm infants are more likely to develop low blood sugar, severe jaundice, breathing difficulties, and infections; to have difficulty maintaining their body temperature; and to experience feeding problems and excessive weight loss after birth. Late-preterm infants also are more likely to be re-admitted to the hospital in the early weeks of life for medical complications, including newborn jaundice, breastfeeding difficulties, dehydration, and possible infections.

The brain and nervous system are among the last systems to mature during fetal development, and some studies show that late-preterm infants have a higher risk of developmental and behavioral problems compared to full-term babies. Late-preterm infants also have a higher rate of birth defects and an increased risk of sudden infant death syndrome. For all these reasons, late-preterm infants require close monitoring, evaluation, and follow-up after birth.

Breastfeeding Challenges among Late-Preterm Infants

The initiation of successful breastfeeding can be especially challenging for smaller, developmentally immature, late-preterm infants. These babies often have trouble latching on to the breast correctly and may be unable to breastfeed effectively at first because of their lower muscle tone and tendency to tire easily. Inadequate breastfeeding increases a newborn's risk for severe jaundice and excessive weight loss.