What are the recommendations for managing difficulties with lactation?

Management of Difficulties with Lactation

Lactation difficulties should be addressed through a multidisciplinary approach involving lactation consultants, healthcare providers, and specialists to ensure optimal breastfeeding outcomes and support for the mother and infant.

Understanding Lactation Challenges

• Lactation insufficiency affects an estimated 3-6 million infants annually, with chronic lactation insufficiency (CLI) affecting approximately 5-15% of lactating individuals 1, 2
• Lactation difficulties can stem from both extrinsic factors (e.g., infant feeding challenges) and intrinsic factors (e.g., endocrine or metabolic disorders) 2
• The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life due to numerous demonstrated health benefits for both infants and mothers 1, 3

Professional Support Recommendations

Lactation Specialist Consultation

• Dedicated lactation specialists play a crucial role in providing education and support to improve breastfeeding outcomes 3
• Breastfeeding interventions using lactation consultants and counselors increase breastfeeding initiation rates (odds ratio = 1.35) and improve both any breastfeeding rates (odds ratio = 1.49) and exclusive breastfeeding rates (odds ratio = 1.71) 3
• A comprehensive lactation management program should include:
  • Prenatal guidance
  • Skilled immediate postpartum assistance
  • Telephone consultation services
  • Evaluation of lactation progress and problem solving in a specialized lactation clinic 4

Multidisciplinary Approach

• Recommendations from obstetrics, neonatology, and pediatrics teams should be incorporated into shared decision-making regarding maternal and neonatal risks and benefits of breastfeeding 1
• Team-based, interprofessional approaches to breastfeeding support are needed for mothers and their families 5
• Improving interdisciplinary collaboration could lead to better integration of lactation consultants who are educated and experienced in providing lactation support 5

Nutritional Management for Lactating Women

• Adequate nutrition is essential for successful lactation:

  • Ensure sufficient protein intake (≥70g daily during lactation) 1
  • Maintain appropriate fat intake (at least 20% of diet) to support milk fat content 1
  • Include adequate iodine (250 μg daily) and other essential vitamins and minerals 1
  • For women consuming seafood, limit to 8-12 ounces/week from a variety of types, avoiding high mercury fish (tilefish, shark, swordfish, king mackerel) 1

• For women following restrictive diets (vegan, vegetarian):

  • Consider consultation with a dietitian to ensure nutritional adequacy 1
  • Monitor for potential nutrient deficiencies 1

Medication Management During Lactation

• For women with heart failure who choose to breastfeed:

  • Review medications with neonatology and pediatrics teams for neonatal safety during lactation, ideally with pharmacist consultation 1
  • ACE inhibitors that may be appropriate include enalapril or captopril (with monitoring of neonatal weight) 1
  • Beta blockers, particularly metoprolol, may be used (with monitoring of neonatal heart rate) 1
  • Diuretics can suppress lactation, but furosemide may be appropriate with proper neonatal follow-up 1

• For women with rheumatic diseases:

  • Compatible medications during breastfeeding include hydroxychloroquine, chloroquine, azathioprine, mercaptopurine, cyclosporine, tacrolimus, sulfasalazine, and colchicine 1
  • The benefits of breastfeeding should be weighed against the potential risks of medication exposure 1

Common Complications and Management

• Inflammatory conditions, disorders of lactogenesis, dermatologic conditions, and persistent pain with lactation are common complications that may require clinical intervention 6
• For women with peripartum cardiomyopathy (PPCM):
  • Bromocriptine treatment may be considered for severe cases (LVEF <25% or cardiogenic shock) but must be weighed against the downsides of prohibiting breastfeeding 1
  • If bromocriptine is used, it should be accompanied by at least prophylactic-dosed anticoagulation due to potential hypercoagulability 1

Barriers to Effective Lactation Support

• Healthcare providers often lack knowledge about lactation difficulties, leading to:

  • Patients not being believed or taken seriously about their lactation challenges 2
  • Discrepancies between providers resulting in fragmented care 2
  • Inconsistent advice and little to no diagnostic insight into lactation conditions 2

• Institutional constraints and poor service delivery coordination among healthcare providers contribute to inadequate support for addressing early breastfeeding challenges 5

Improving Lactation Support Systems

• There is an urgent need for improved education and training among healthcare providers to address the complex realities of chronic lactation insufficiency 2
• Personalized approaches to breastfeeding support and expanded research to determine causes and diagnostics for low milk supply are essential 2
• Lactation support services should be provided by healthcare professionals with specialized knowledge and skills in lactation management 4