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Care of the breastfeeding mother in medical-surgical areas.

As the rate of breastfeeding in the United States continues to rise, the likelihood that a medical-surgical nurse will participate in the care of a breastfeeding mother also increases (Li, Mokdad, Barker, & Grummer-Strawn, 2003). Professional organizations including the World Health Organization (WHO, 2001), the American Academy of Pediatrics (AAP, 2001), and the American Academy of Family Physicians (2001) recommend that babies be breastfed for at least 1 year, with exclusive breastfeeding for the first 6 months of life (Garner et al., 2005). However, maternal contact with the health care system during breastfeeding can lead to premature weaning or supplementation with formula. Knowledge regarding breastfeeding, maternal medications, pumping, and storage of breast milk is vital to the nurse's role as patient advocate in sustaining the breastfeeding relationship. In the author's experience, breastfeeding women have been hospitalized for varied issues, including urinary tract infection, Caesarean section wound infection, cholecystectomy, and high blood pressure.

Benefits of Breastfeeding

Documentation of breastfeeding benefits to mothers and infants is extensive and compelling (Biancuzzo, 2003; Department of Health and Human Services [DHHS], Office on Women's Health, 2000; Garner et al., 2005; Hale, 2006; Lawrence, 1997; Riordan, 2005). Infants who are breastfed are hospitalized less often, and are less likely to suffer from certain childhood cancers, gastroenteritis, ulcerative colitis and Crohn's disease, bronchitis, pneumonia, sudden infant death syndrome, juvenile diabetes, otitis media, asthma, and eczema (DHHS, 2000; Garner et al., 2005; Riordan, 2005). No formula can provide the benefits of autoimmunization, the process of antibody production in the breast milk in response to maternal and infant exposure to organisms (DHHS, 2000; Garner et al., 2005; Riordan, 2005). Maternal benefits include decreased risk of osteoporosis and hip fractures, as well as decreased risk of ovarian and breast cancer (DHHS, 2000; Garner et al., 2005; Riordan, 2005).

Care of the Hospitalized Lactating Woman

In most instances, a mother can continue to breastfeed her infant during hospitalization or outpatient procedures. The anxiety and stress of separation from a child are compounded in the breastfeeding mother who is concerned about her health and the emotional and nutritional needs of an infant who is dependent upon her. Inadequate pumping of the breasts and/or feeding may result in the pain and discomfort of engorgement. Oxytocin release during breastfeeding results in relaxation and a diminished response to stressors and pain in the mother (Riordan, 2005). Another caretaker feeding the infant may seem to enhance maternal recovery, but time spent pumping breast milk and the loss of the maternal benefits of breastfeeding make this option ill advised unless absolutely necessary (Garner et al., 2005).

If available, the assistance of a lactation consultant and/or maternal-child nursing personnel is recommended. In a facility without maternal-child services, the nurse can contact community assistance as needed (see Table 1). Rooming with the infant is the most desirable alternative, if allowed. Another adult may be required to stay with the mother to assist with infant care. The infant should be brought to the hospital to breastfeed as often as possible if not able to room in. Basics of supporting the breastfeeding mother include the following (Biancuzzo, 2003; Riordan, 2005):

* Encourage rest, good nutrition, and hydration.

* Support efforts to breastfeed and reinforce the benefits for mother and infant.

* Provide privacy as needed.

* If abdominal surgery is performed, assist mother with supporting the surgical area with pillows.

* Encourage mother to take postoperative analgesia to alleviate pain.

* Good hand washing, limited contact with the infant's face, and continued breastfeeding are the best ways to prevent transfer of infection from mother to infant.

* Reassure mother that medications and procedures have been investigated and breastfeeding will not harm the infant.

Surgical Procedures

The AAP (2001) lists the following analgesics as maternal medications usually compatible with breastfeeding: acetaminophen (Tylenol[R], Tempra[R] paracetamol), codeine (Empirin[R] #3 #4, Tylenol[R] #3 #4), fentanyl (Sublimaze[R]), ibuprofen (Advil[R], Nuprin[R], Motrin[R], Pediaprofen[R]), ketorolac (Toradol[R], Acular[R]), meperidine (Demerol[R]), methadone (Dolophine[R]), morphine (Duramorph[R], Infumorph[R]), naproxen (Anaprox[R], Naprosyn[R], Aleve[R]), and secobarbital (Seconal[R]). Other analgesics should be assessed on a case-by-case basis, but the AAP classification lists no analgesics as drugs for which the effect on nursing infants is unknown or may be of concern. Mothers who have outpatient or inpatient surgical procedures can return to breastfeeding after awaking from surgery in most cases (Hale & Berens, 2002; Riordan, 2005; Ting, 2001). Most anesthetic agents are used for brief periods and attain extremely low levels in breast milk (Hale & Berens, 2002; Riordan, 2005; Ting, 2001). Age and clinical condition of the infant should be considered when resuming breastfeeding. Care of the breastfeeding mother having surgery includes the following (Biancuzzo, 2003; Riordan, 2005):

* Breastfeed or fully pump breasts immediately before surgery to decrease engorgement.

* Assist with breastfeeding as soon as the mother wakes from anesthesia and is able to breastfeed.

* Breastfeeding following breast surgery, depending on the procedure and the mother's level of comfort, may be resumed within 12 hours. If the infant's mouth will touch the incision during breastfeeding, that breast should be pumped. The infant should be fed on the other breast (Biancuzzo, 2003; Riordan, 2005).

* Very few situations require discarding breast milk (also known as "pumping and dumping"). Mastitis or other acute infectious diseases do not necessitate stopping breastfeeding or discarding breast milk (Biancuzzo, 2003; Lawrence, 1997; Riordan, 2005; WHO, 2000).

Medications and Mother's Milk

According to the AAP (2001), most drugs likely to be prescribed to the nursing mother "should have no outward effect on milk supply or on infant well-being" (p. 776). Hale (2006) explained, "All medications transfer into human milk to some degree. The amount that usually transfers is quite small, averaging with most drugs less than 1% of the maternal dose. Only rarely does the amount transferred into milk produce clinical doses in the infant" (p. 6). Drugs that are usually contraindicated in lactating women include amiodarone (Cordarone[R]), antineoplastic agents, bromocriptine (Parlodel[R]), chloramphenicol (Chloromycetin[R]), ergotamine (Wigraine[R], Cafergot[R], Ergostat[R], Ergomar[R], D.H.E. 45[R]) gold salts (Ridaura[R], Myochrysine[R], Solganal[R]), lithium (Carbolith[R], Duralith[R], Lithane[R], Camcolit[R], Liskonum[R]), phenindione (Athrombon[R]), radio-pharmaceuticals, retinoids, tetracyclines, and pseudoephedrine (Sudafed[R], Halofed[R], Novafed[R]) (Hale, 2006; Lawrence, 1997).

The nurse's role as patient advocate includes alerting physicians to the mother's breastfeeding status and assisting in obtaining accurate information regarding medications and mother's milk. When selecting a resource, the nurse should keep in mind that "virtually all of the package inserts recommend against the use of their drug in breastfeeding mothers because of liabilities, not an accurate representation as to how much is really present in the milk" (Hale, 2006, p. 6). This conflict is addressed by obtaining and using references containing accurate information about drug transfer into breast milk and effects upon the infant. See Table 2 for recommended references. Consideration of the effect of a medication upon the infant should be combined with the effect that the medication could have upon the mother's letdown reflex, milk production, or milk secretion. Basics of medication use while breastfeeding include (Hale, 2006):

* Take medications immediately after a feeding to ensure that the least amount of the medication gets into the milk.

* Fat content of breast milk is highest at midday; therefore, fat-soluble medications can be taken at bedtime when the baby usually does not feed often.

* Encourage mother to express her desire to continue breastfeeding to her physician.

Care of the Mother Who Is Pumping Her Breasts

A lactating mother who is unable to continue breastfeeding must pump her breasts to maintain milk supply and prevent engorgement, plugged ducts, and mastitis. Abrupt weaning at this time is not recommended, as it may result in these complications (Biancuzzo, 2003; Riordan, 2005). A number of factors should be considered when caring for the mother who is pumping her breasts (Biancuzzo, 2003; Jones & Tully, 2006; Riordan, 2005):

* Good hand washing is essential when handling pumping equipment or breast milk.

* A hospital-grade double electric breast pump is preferable.

* Pumping schedules should mimic infant's usual feeding times.

* Breasts should be emptied fully at each pumping.

* Pump pieces and milk containers should be rinsed with cool water first and then washed with warm soapy water and rinsed well. Sterilizing is unnecessary.

Storage of Expressed Breast Milk (EBM)

Storage of breast milk in dietary or medication refrigerators on nursing units is not advised. The preferred alternative for storage is a cooler with frozen gel packs or separate refrigerator located in the mother's room (Jones & Tully, 2006).

The following recommendations should guide storage of EBM (Jones & Tully, 2006; Riordan, 2005):

* Store in clean glass or plastic bottles with screw caps or special bags designed for storage of breast milk. Breast milk storage in ordinary plastic storage bags or formula bottles is not advised.

* Label storage container with date and time that milk was expressed.

* Warm breast milk using a bottle warmer or place container in a cup or small container of warm water. Never microwave breast milk as uneven heating and scalding of the infant may result.

* Swirl breast milk gently; do not shake vigorously when preparing.

* Breast milk will not look like cow's milk out of the carton. It will separate when left to stand and the fat will rise to the top. The color of milk may vary from yellow-orange to bluish-white or colors reflecting foods that the mother has eaten.

Storage guidelines. Freshly ex pressed milk can be stored at room temperature for 4 hours at no greater than 26[degrees] C/79[degrees]F; 24 hours at 15[degrees]C in a cooler with frozen gel packs; in a refrigerator at 0-4[degrees]C for 8 days; or 12 months at -20[degrees]C (Jones & Tully, 2006). Previously frozen thawed but not warmed breast milk can be stored at room temperature for 4 hours or refrigerated for 24 hours, and should not be refrozen. Previously frozen thawed and warmed breast milk can be kept at room temperature until the completion of the feed and refrigerated for 4 hours. Any breast milk left after a feeding should be discarded.

Complications

A change in the usual breastfeeding schedule may result in several complications (Riordan, 2005). The breast with pathological engorgement is tight and shiny, and the milk flow may be compromised. Infrequent or inadequate drainage of the breast predisposes women to engorgement. Treatment includes frequent nursing or pumping of breast, breast massage and warm compresses prior to emptying the breast, and anti-inflammatory drugs.

A plugged duct is a blockage in a milk duct caused by accumulated milk or cast off cells (Riordan, 2005). Symptoms include tenderness, heat and possible redness in one area of the breast, or a palpable lump with well-defined margins without a generalized fever. Poor drainage from physical obstruction, such as tight-fitting or underwire bras or incomplete emptying of the breasts, may cause plugged ducts. Treatment includes frequent feedings starting on the affected breast to promote drainage, massaging the affected breast before and during feedings, applying warm compresses prior to feedings, and positioning the infant with nose pointing toward the plugged duct during the feeding.

Mastitis is usually a benign, self-limiting infection of the breast (Lawrence, 1997; Riordan, 2005; WHO, 2000). Symptoms include fatigue, localized breast tenderness, headache, and flu-like muscle aches followed by fever, rapid pulse, and a hot, reddened tender area on the breast. It usually is limited to one breast. Risk factors include stress, fatigue, cracked nipples and/or nipple pain, plugged ducts, a decrease in the number of feedings, and engorgement. Treatment includes 10-14 days of antibiotic therapy, analgesia for pain, moist heat to the affected area, frequent nursing or pumping of the affected breast, increased fluids, and bed rest. It is safe and advisable for the mother to continue breastfeeding on the affected breast (Lawrence, 1997; Riordan, 2005; WHO, 2000).

Maternal contact with the health care system need not result in premature weaning or unnecessary supplementation. The support and advocacy of nurses empowered with accurate breastfeeding information and resources are essential to the breastfeeding mother. Extra time and care will positively influence the health and well-being of infant and mother.

References

American Academy of Family Physicians. (2001). American Academy of Family Physicians policy and position statement on breastfeeding. Leawood, KS: Author.

American Academy of Pediatrics (AAP), Committee on Drugs. (2001). The transfer of drugs and other chemicals into human milk. Pediatrics, 108, 776789.

Biancuzzo, M. (2003). Breastfeeding the newborn: Clinical strategies for nurses. St. Louis, MO: Mosby, Inc.

Department of Health and Human Services (DHHS), Office on Women's Health. (2000). HHS blueprint for action on breastfeeding. Washington, DC: Author.

Garner, L.M., Morton, J., Lawrence, R.A., Naylor, A.J., O'Hare, D., Schanler, R.J., et al. (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2), 496-506.

Hale, T.W. (2006). Medications and mother's milk. Amarillo, TX: Hale Publishing.

Hale, T.W., & Berens, P. (2002). Clinical therapy in breastfeeding patients. Amarillo, TX: Pharmasoft Medical Publishing.

Jones, F., & Tully, M.R. (2006). Best practice for expressing, storing, and handling human milk in hospitals, homes, and child care settings. Raleigh, NC: Human Milk Banking Association of North America, Inc.

Lawrence, R.A. (1997). A review of the medical benefits and contraindications to breastfeeding in the United Sates (Maternal and Child Health Technical Information Bulletin). Arlington, VA: National Center for Education in Maternal and Child Health.

Li, R., Mokdad, A., Barker, L., & Grummer-Strawn, L. (2003). Prevalence of breastfeeding in the United States: The 2001 national immunization survey. Pediatrics, 111(5), 1198-1201.

Riordan, J. (2005). Breastfeeding and human lactation. Sudbury, MA: Jones and Bartlett Publishers.

Shaikh, U., & Scott, B. (2005). Extent, accuracy, and credibility of breastfeeding information on the Internet. Journal of Human Lactation, 21(2), 175-183.

Ting, P. (2001, July). Breastfeeding and anesthesia. Anesthesiology Info. Retrieved February 9, 2007, from http:// www.anesthesiologyinfo.com/articles/01052002.php

World Health Organization (WHO), Department of Child and Adolescent Health and Development. (2000). Mastitis: Causes and management. Geneva, Switzerland: Author.

World Health Organization (WHO). (2001). Expert consultation on the optimal duration of exclusive breastfeeding. Geneva, Switzerland: Author.

Lori Wenner, BSN, RNC, IBCLC, is a Lactation Consultant and Professional Nurse, Christus St. Elizabeth Hospital, Beaumont, TX. She is also Chair of the Magnet Breastfeeding Council, and a Member of the La Leche League, AWHONN, and ILCA.
Table 1.

Resources for Breastfeeding Assistance

* African-American Breastfeeding Alliance 1-877-532-8535

* National Breastfeeding Warmline 1-800-994-9662

* http://www.lalecheleague.org/WebIndex.html (to locate a local La
  Leche League leader)

* http://breastfeeding.com

* http://www.breastfeedingonline.com

* http://4woman.gov

* http://gotmom.org

* http://breastfeeding.org

Source: Shaikh & Scott, 2005.


Table 2.
Resources for Medications and Breastfeeding Information

Hale, T.W., & Berens, R (2002). Clinical therapy in breastfeeding
patients. Amarillo, TX: Pharmasoft Medical Publishing.

Hale, T.W. (2006). Medications and mother's milk. Amarillo, TX: Hale
Publishing.

U.S. National Library of Medicine. (2007). Toxicology data network:
Drugs and lactation database (LactMed). Retrieved January 16, 2007,
from http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
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Title Annotation:Clinical Practice
Author:Wenner, Lori
Publication:MedSurg Nursing
Article Type:Author abstract
Geographic Code:1USA
Date:Apr 1, 2007
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