Issues & concerns - maternal

HIV positive mothers in developing countries
advised to breastfeed for 6 months and then abruptly wean.

Breastfeeding best for infant, HIV mothers in Africa told

By STEPHANIE NOLEN

Research shows health benefits for the newborn outweigh the risks of transmitting disease through milk, STEPHANIE NOLEN writes

Globe and Mail Update, Tuesday, January 6, 2004

HARARE -- On health-clinic walls across Africa, the posters have shouted the same cheery message for years now: “Breast is best!”

Breastfeeding passes on crucial antibodies to babies, protects them against allergies, promotes their cognitive development and is much safer than formula that must be mixed with possibly contaminated water.

But then came AIDS. Ninety per cent of people with HIV in Africa don’t know they have it and many women first learn they carry the virus when they're already pregnant and are tested at a prenatal clinic.

Half of the children with HIV in sub-Saharan Africa today were infected with the disease through breast milk from their HIV-positive mothers.

Doctors in North America first discovered that a woman with the virus could pass it on in breast milk in 1985. Soon, Western women with HIV were being strongly advised not to breastfeed.

But in Africa, it’s the poorest women -- those least able to afford formula or have access to clean water with which to mix it -- that are statistically the most likely to be infected with HIV.

“You can’t just say, ’don’t breastfeed.' That’s a death sentence for many babies. Fine, they won’t get HIV, but they will die of diarrhea,” said Jean Humphrey, who heads Zvitambo, a research project funded in part by Canada that examines HIV and breastfeeding in Zimbabwe.

The issue soon pitted Western scientists against doctors in sub-Saharan Africa. From the West came pressure on the World Health Organization to adopt the policy that HIV-positive women should not breastfeed; from doctors in Africa and elsewhere in the Third World came the reply: So then what?

“It’s a real dilemma, and I’m not pretending it’s easy to solve, but what I resent is the old colonial attitude, 'Look, the U.S. does it and Canada does it, so why don’t we do it?'” said Hoosen Coovadia, professor of HIV/AIDS research at the Nelson Mandela School of Medicine at the University of KwaZulu-Natal. “This is a huge cultural question.”

African researchers, including Prof. Coovadia, assessed the relative risks of transmitting HIV versus diarrhea, and decided the way forward might be better breastfeeding.

The early results are surprising. They suggest the best thing a mother with HIV can do for her baby is to breastfeed, all the time. “Unicef didn’t believe us when we told them the results [of the first studies],” Dr. Coovadia said. “Now, they’ve stopped subsidizing formula.”

While the researchers are still puzzling over exactly why this is, they have found that breast milk really is best. Anything else given to an infant -- water, bits of porridge or cooking oil (given in this region to combat constipation) irritate the lining of the gut, increasing the possibility that the baby’s body will absorb the HIV virus. So researchers are now proposing that women practise “exclusive breastfeeding and abrupt weaning.” That is, nothing at all except breast milk for six months, and then an abrupt cutoff.

Six months is the current best guess at an optimal length of time that allows babies to get the most important benefits of breast milk while trying to minimize the length of exposure to the virus.

But safer breastfeeding is not as easy as a quick conversation at the clinic. If women are being encouraged to wean abruptly at six months, they must receive intense support from counsellors and their community as it can be deeply traumatic for both mothers and their infants, explained Katherine Semrau, project co-ordinator for the Zambia Exclusive Breastfeeding Study run at a Lusaka clinic. Mothers can end up with breast diseases such as mastitis, and anguished babies can become malnourished.

Mothers also need to be taught the safest possible techniques for breastfeeding to reduce the risk of problems such as cracked nipples, which will increase the possibility of blood being passed to the baby along with breast milk.

Dr. Humphrey said her team has also realized the importance of looking at issues of consent since many rural Zimbabwean women don’t make the decisions about child-rearing. Rather, they must follow instructions from their partners or mothers-in-law.

Dr. Coovadia believes that if women with HIV choose to breastfeed and are shown the safest way to do it, and follow the guidelines, their risk of transmission to their babies may be as low as 6 per cent. “Safer breastfeeding is now the only real choice,” Dr. Humphrey said.

Breastfeeding and Guilt

One of the most powerful arguments many health professionals, government agencies and formula company manufacturers make for not promoting and supporting breastfeeding is that we should “not make the mother feel guilty for not breastfeeding.” Even some strong breastfeeding advocates are disarmed by this “not making mothers feel guilty” ploy.

Because, indeed, it is nothing more than a ploy.

It is an argument which deflects attention from the lack of knowledge and understanding of most health professionals about breastfeeding. This allows them not to feel guilty for their ignorance of how to help women overcome difficulties with breastfeeding, which could have been overcome and usually which could have been prevented in the first place if mothers were not so undermined in their attempts to breastfeed. This argument also seems to allow formula companies and health professionals to pass out formula company literature and free samples of formula to pregnant women and new mothers without pangs of guilt, though it has been well demonstrated that this literature and the free samples decrease the rate and duration of breastfeeding.

Let’s look at real life.

If a pregnant woman went to her physician and admitted she smoked a pack of cigarettes, is there not a strong chance that she would leave the office feeling guilty for endangering her developing baby? If she admitted to drinking a couple of beers every so often, is there not a strong chance that she would leave the office feeling guilty? If a mother admitted to sleeping in the same bed with her baby, would most physicians not make her feel guilty for this even though it is the best thing for her and the baby? If she went to the office with her one week old baby and told the physician that she was feeding her baby homogenized milk, what would be the reaction of her physician? Most would practically collapse and have a fit. And they would have no problem at all making that mother feel guilty for feeding her baby cow’s milk, and then pressuring her to feed the baby formula. (Not pressuring her to breastfeed, it should be noted, because “you wouldn’t want to make a woman feel guilty for not breastfeeding”.)

Why such indulgence for formula?

The reason of course, is that the formula companies have succeeded so brilliantly with their advertising to convince most of the world that formula feeding is just about as good as breastfeeding, and therefore there is no need to make such a big deal about women not breastfeeding. As a vice president of Nestle here in Toronto was quoted as saying “Obviously, advertising works.” It is also a balm for the consciences of many health professionals who themselves did not breastfeed, or their wives did not breastfeed. “I will not make women feel guilty for not breastfeeding, because I don’t want to feel guilty for my child not being breastfed.”

Let’s look at this a little more closely.

Formula is certainly theoretically more appropriate for babies than cow’s milk. But, in fact, there are no clinical studies which show that there is any difference between babies fed cow’s milk and those fed formula. Not one. Breastmilk and breastfeeding, which is not the same as breastmilk feeding, have many more theoretical advantages over formula than formula has over cow’s milk (or other animal milk). And we are just learning about many of these advantages. Almost every day there are more studies telling us about these theoretical advantages. But there is also a wealth of clinical data showing that, even in affluent societies, breastfed babies, and their mothers incidentally, are much better off than formula fed babies. They have fewer ear infections, fewer gut infections, a lesser chance of developing juvenile diabetes and many other illnesses. The mother has a lesser chance of developing breast and ovarian cancer, and is probably protected against osteoporosis. And these are just a few examples.

So how should we approach support for breastfeeding?

All pregnant women and their families need to know the risks of formula feeding. All should be encouraged to breastfeed, and all should get the best support available for starting breastfeeding once the baby is born. Because all the good intentions in the world will not help a mother who has developed terribly sore nipples because of the baby’s poor latch at the breast. Or a mother who has been told, almost always inappropriately, that she must stop breastfeeding because of some medication or illness in her or her baby. Or a mother whose supply has not built up properly because she was given wrong information. Make no mistake about it - health professionals' advice is often the single most common reason for mothers' failing at breastfeeding!

If mothers get the information about the risks of formula feeding and decide to formula feed, they will have made an informed decision.

This information must not come from the formula companies themselves, as it often does. Their pamphlets give some advantages of breastfeeding and then go on to imply that their formula is actually just as good. If mothers get the best help possible with breastfeeding, and find breastfeeding is not for them, they will get no grief from me. It is important to know that a woman can easily switch from breastfeeding to bottle feeding. In the first days or weeks - no big problem. But the same is not true for switching from bottle feeding to breastfeeding. It is often very difficult or impossible, though not always.

Finally, who does feel guilty about breastfeeding?

Not the women who make an informed choice to bottle feed. It is the woman who wanted to breastfeed, who tried, but was unable to breastfeed. In order to prevent women feeling guilty about not breastfeeding what is required is not avoiding the promotion of breastfeeding, but rather the promotion of breastfeeding coupled with good, knowledgeable and skillful support. This is not happening in most North American or European societies.

Breastfeeding and Guilt. August 1997.
Written by Jack Newman, MD, FRCPC
May be copied and distributed without further permission

Blocked Duct vs Mastitis - A Summary

• Presentation • Symptoms • Treatment • Breastfeeding Management • Other •

Presentation

Predisposing factors
Blocked duct	Mastitis
Poor drainage of breast causing milk immobility due to poor attachment or poor sucking with inadequate emptying of one or more ducts Trauma due to pressure on one spot caused by mother holding breasts too tightly while expressing, tight or ill fitting bra or other clothing, sleeping on a full breast, kick from older baby or child Maternal exhaustion, anaemia or poor nutrition, a diet high in saturated fat may contribute to this problem	Can be non-infective which occurs when foreign body inflammatory reaction occurs following leakage of milk into the surrounding tissue from a blocked milk duct or Infective: there are two forms of this Cellulitis of the interlobular connective tissue. Pus is not found in the milk as the infection is outside the ductile system. This is the most common form of mastitis. Adenitis where infection occurs within the ductile system. Pus may appear in the milk but systemic symptoms are less severe. Predisposing factors of mastitis include those of blocked duct as well as the following: Abrupt weaning, poor general health, stress, tiredness, infection from the infant’s nose (staph carriage) mouth, eyes, (conjunctivitis) or other sites, use of contaminated nipple creams, and occasionally following strenuous upper arm activity as with housework or strenuous exercise

Symptoms
	Blocked duct	Mastitis
General	Painful, swollen, firm mass in the breast, skin quite red	Red skin, more intense than blocked duct, intense pain, more than blocked duct, rigors “flu-like” aches
Fever	Not usually	38.5 degrees C
Malaise	Not usually	Yes, generally feeling very ill
Local	Firm mass in breast, skin quite red	Red skin, more intense than blocked duct
Symptoms during a feed	Baby may be fussy due to reduced milk flow	Breast refusal may occur since breastmilk tastes more salty during mastitis

Treatment
	Blocked duct	Mastitis
	Should clear within 24 - 48 hours	If symptoms persist for more than 24 hours, begin treatment with antibiotics
Antibiotic	No	Yes
Which one?	N/A	Suitable antibiotics include: Dicloxacillin 500mg orally 6 hourly OR Flucloxacillin 500 mg to 1 gm orally every 6 hours or Cephalexin 500 mg orally every 6 hoursor Erythromycin 500 mg orally every 12 hours or Roxithyromycin150 mg every 12 hours Treatment should be started early and continue for 10 days Note: If severe cellulitishas developed, antibiotics should be given intravenously eg. Flucloxacillin 1 to 2 gm intravenously every 6 hours NB: The medications mentioned in the above summary may or may not be available in your country. If this is the case, please see your doctor for alternative medications.
Analgesia	Paracetamol oracetaminophen or ibuprofen, as needed NB: The medications mentioned in the above summary may or may not be available in your country. If this is the case, please see your doctor for alternative medications.	Paracetamol oracetaminophen oribuprofen, as needed NB: The medications mentioned in the above summary may or may not be available in your country. If this is the case, please see your doctor for alternative medications.
Local pain relief	Hot packs before and during feed to help let-down (not too hot and not for too long so as not to injure the skin), gently massage affected area towards nipple while feeding or expressing Cold packs for comfort after feeds	Hot packs before and during feed to help let-down, gently massageaffected area towards nipple while feeding or expressing Cold packs for comfort after feeds
Activity	Rest	Bed rest

Breastfeeding Management
Blocked duct	Mastitis
Continue breastfeeding	Continue breastfeeding
Check positioning and attachment (latch)	Check positioning and attachment (latch)
Frequent feeding starting with the affected side and pointing baby’s chin towards the blocked duct helps drain the breast and remove the blockage Dr. Jack Newman suggests Breast compression while the baby is feeding, getting the mother’s hand around the blocked duct and having her apply steady pressure	Frequent feeding and complete emptying of the breast. Pointing baby’s chin towards affected area helps drain the breast and remove blockage if there is one
Dr. Newman suggests rest. Take the baby to bed if necessary	Bed rest and discussion of ways of coping with household concerns (get extra help) Drink adequate amounts of fluids

Other
Blocked duct	Mastitis
According to Dr. Jack Newman, a toothpaste like material may flow out of the affected breast, which will effectively unlock the duct. If the blocked duct does not resolve within 48 hours, therapeutic ultrasound often works. The dose is 2 watts/cm squared, continuous for 5 minutes to the affected area, once daily for up to 2 doses. It usually resolves with one treatment but if 2 treatments over two days have not worked, there is no point in continuing with ultrasound. At this point the blocked duct will need to be re-evaluated by a doctor. Lecithin, one capsule (1200 mg) 3 or 4 times a day also seems to help prevent recurrent blocked ducts, at least for some mothers. Note: In addition to the above many mothers find relief for a blocked duct by soaking the affected breast in a bowl or sink filled with 2 tbsp Epson salts in 4 litres of hot water. Soak for 10 minutes every 3 hours for 24 hours.	According to Dr. Jack Newman: If a mother has symptoms consistent with mastitis for more than 24 hoursshe should start antibiotics. If the mother has consistent symptoms for less than 24 hours, he will prescribe the antibiotic but suggest she wait before taking it. If over the next 8 - 12 hours, her symptoms are worsening, then the mother should start the antibiotics. If over the next 24 hours her symptoms have not improved and not worsened, she should start antibiotics. However, if the symptoms start to decrease, there is no need to start the antibiotics. The symptoms will continue to resolve and should disappear over the next 2-5 days.

References:

Lawlor-Smith, C: "Blocked Duct/Mastitis"

Jack Newman, MD: "Blocked ducts & mastitis", Revised January 2003

Dr. Lenore Goldfarb’s Note: I’ve indicated where Dr. Newman has made suggestions that differ from C. Lawlor-Smith. Otherwise the information from the two websites are in agreement. Most of the information for this article came from Lawlor-Smith’s "Blocked Duct/Mastitis". I’ve quoted virtually word for word from both of these authors with some exceptions and have reorganized the information into this format.

Blocked Ducts & Mastitis

Mastitis is due to an infection (almost always due to bacteria rather than other types of germs) that usually occurs in breastfeeding mothers. However it can occur in any woman, even if she is not breastfeeding and can even occur in newborn babies of either sex. Nobody knows exactly why some women get mastitis and others do not. Bacteria may enter the breast through a crack or sore in the nipple but women without sore nipples also get mastitis and most women with cracks or sores do not.

Mastitis is different from a blocked duct because a blocked duct is not thought to be an infection and thus does not need to be treated with antibiotics. With a blocked duct, a mother has a painful, swollen, firm mass in the breast. The skin overlying the blocked duct is often red, but less intensely red than the redness of mastitis. Unlike mastitis, a blocked duct is not usually associated with fever, though it can be. Mastitis is usually more painful than a blocked duct, but both can be quite painful. Thus seeing the difference between a “mild” mastitis and a “severe” blocked duct may not be easy. It is also possible that a blocked duct goes on to become mastitis, so things become even more complicated.However, without a lump in the breast, there is no mastitis or blocked duct for that matter. In France, physicians recognize something they call lymphangite when the mother has a painful, hot redness of the skin of the breast, associated with fever, but there is no painful lump in the breast. Apparently, most do not believe this lymphangite requires treatment with antibiotics. I have seen a few cases that fit this description and yes, in fact, the problem goes away without the mother taking antibiotics. But then, often a full-blown mastitis also goes away without the mother taking antibiotics.

As with almost all breastfeeding problems, a poor latch, and thus, poor emptying of the breast sets the mother up for blocked ducts and mastitis.

Blocked ducts

Blocked ducts will almost always resolve without special treatment within 24 to 48 hours after starting. During the time the block is present, the baby may be fussy when breastfeeding on that side because the milk flow will be slower than usual. This is probably due to pressure from the lump collapsing other ducts. A blocked duct can be made to resolve more quickly if you:

Continue breastfeeding on that side and draining the breast better. This can be done by:
- Getting the best latch possible (see the information sheet Latching On as well as the video clips on how to latch a baby on at the website ibconline.ca).
- Using compression to keep the milk flowing (see the information sheet Breast Compression as the video clips on how to latch a baby on at the website ibconline.ca). Get your hand around the blocked duct and compress it as the baby is breastfeeding if it is not too painful to do so.
- Feeds the baby in such a position that the baby’s chin “points” to the blocked duct. Thus, if the blocked duct is in the bottom outside area of the breast (7 o’clock), then feeding the baby in the football position may be helpful.
Apply heat to the affected area. You can do this with a heating pad or hot water bottle, but be careful not to burn your skin by using too much heat for too long a period of time.
Try to rest. Of course, with a new baby it is not always easy to rest. Try going to bed. Take your baby with you into bed and breastfeed him there.

A bleb or blister

Sometimes, but not always by any means, a blocked duct is associated with a bleb or blister on the end of the nipple. A flat patch of white on the nipple is not a bleb or blister. If there is no painful lump in the breast, it is confusing to call a bleb or blister on the nipple a blocked duct. A bleb or blister is, usually, painful and is one cause of nipple pain that comes on later than the first few days. Some mothers get blisters in the first few days due to a poor latch. Nobody knows why a mother would suddenly get a bleb or blister out of the blue several weeks after the baby is born.

A blister is often present without the mother having a blocked duct.

If the blister is quite painful (it usually is), it is helpful to open it, as this should give you some relief from the pain. You can open it yourself, but do this one time only. However, if you need to repeat the process, or if you cannot bring yourself to do it yourself, it is best to go to see your doctor.

Flame a sewing needle or pin, let it cool off, and puncture the blister.
Do not dig around; just pop the top or side of the blister.
Try squeezing just behind the blister; you might be able to squeeze out some toothpaste-like material through the now opened blister. If you have a blocked duct at the same time as the blister, this might result in the duct unblocking. Putting the baby to the breast may also result in the baby unblocking the duct.

Once you have punctured the bleb or blister, start applying the "all purpose nipple ointment" after each feed for a week or so. The reason for this is to prevent infection and also to decrease the risk of the bleb or blister returning. See the information sheet All purpose nipple ointment. You need a prescription for the ointment.

Ultrasound for blocked ducts

Most blocked ducts will be gone within about 48 hours. If your blocked duct has not gone by 48 hours or so, therapeutic ultrasound often works. Most local physiotherapy or sports medicine clinics can do this for you. However, very few are aware of this use of ultrasound to treat blocked ducts. An ultrasound therapist with experience in this technique has more successful results.

Some mothers have used the flat end of an electric toothbrush to give themselves “ultrasound” treatment. And apparently have had good results.

If two treatments on two consecutive days have not helped resolve the blocked duct, there is no point in getting more treatments. Your blocked duct should be re-evaluated by your doctor. Usually, however, one treatment is all that is necessary. Ultrasound may also prevent recurrent blocked ducts that occur always in the same part of the breast.

The dose of ultrasound is 2 watts/cm² continuous for five minutes to the affected area, once daily for up to two treatments.

Lecithin is a food supplement that seems to help some mothers prevent blocked ducts. It may do this by decreasing the viscosity (stickiness) of the milk by increasing the percentage of polyunsaturated fatty acids in the milk. It is safe to take, relatively inexpensive, and seems to work in at least some mothers. The dose is 1200 mg four times a day.

Mastitis

If you start getting symptoms of mastitis (painful lump in the breast, redness and pain of the breast, fever), try to get some rest. Go to bed and take the baby with you so you can continue breastfeeding while remaining in bed. Rest is good to help fight off infection.

Continue breastfeeding on the affected side. It should go without saying that you should continue on the other breast as well. Of course, if you are in so much pain that you cannot put the baby to the affected breast, continue on the other side and as soon as your breast is less painful put the baby to the breast with the mastitis. Sometimes expressing your milk may be less painful, but not always, so if you can, continue breastfeeding on the affected side. Mothers and babies share all their germs.

Heat helps fight off infection. It also may help with draining of the breast. Use a hot water bottle or heating pad but be careful not to burn the skin.

Fever helps fight off infection. Adults usually feel terrible when they have a fever and you may want to bring down the fever for this reason. But you don’t need to bring down the fever just because it’s there. Fever does not cause the milk to go bad!

Potatoes (adapted from Bridget Lynch, RM, Community Midwives of Toronto). Within the first 24 hours of your symptoms beginning, you may find that applying slices of raw potato to the breast will reduce the pain, swelling, and redness of mastitis.

Cut 6 to 8 washed raw potatoes lengthwise into thin slices.
Place in a large bowl of water at room temperature and leave for 15 to 20 minutes.
Apply the wet potato slices to the affected area of the breast and leave for 15 to 20 minutes.
Remove and discard after 15 to 20 minutes and apply new slices from the bowl.
Repeat this process two more times so that you have applied potato slices 3 times in an hour.
Take a break for 20 or 30 minutes and then repeat the procedure.

Mastitis and Antibiotics

Generally, it is better to avoid antibiotics if possible since mastitis may improve all on its own and antibiotics may result in your getting a Candida (yeast, thrush) infection of the nipples and/or breast. Our approach is as follows:

If you have had symptoms consistent with mastitis for less than 24 hours, we would give you a prescription for an antibiotic, but suggest you wait before starting to take the medication.

If, over the next 8 to 12 hours, your symptoms are worsening(more pain, more spreading of the redness or enlarging of the painful lump), start the antibiotics.
If over the next 24 hours, your symptoms are not worse but not better, start the antibiotics.
If over the next 24 hours, your symptoms are lessening, then they will almost always continue to lessen and disappear without your needing to take the antibiotics. In this case, the symptoms will continue to lessening and will have disappeared over the next 2 to 7 days. Fever is often gone by 24 hours, the pain within 24 to 72 hours and the breast lump disappears over the next 5 to 7 days. Occasionally the lump takes longer than 7 days to disappear completely, but as long as it’s getting small, this is a good thing.

If you have had symptoms consistent with mastitis for more 24 hoursand the symptoms have not improved, you should start the antibiotics straight away.

If you are going to take an antibiotic, you need to take the right one. Amoxicillin, plain penicillin and some other antibiotics used frequently for mastitis do not kill the bacterium that almost always causes mastitis (Staphylococcus aureus). Some antibiotics which kill Staphylococcus aureus include: cephalexin (our usual choice), cloxacillin, dicloxacillin, flucloxacillin, amoxicillin combined with clavulinic acid, clindamycin and ciprofloxacin. Antibiotics that can be used for community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA): cotrimoxazole and tetracycline.

All these antibiotics can be used when mothers are breastfeeding and do not require her to interrupt breastfeeding.

You should not interrupt breastfeeding if you are infected with MRSA! Indeed, breastfeeding decreases the risk of the baby getting infection.

Medication for pain/fever (ibuprofen, acetaminophen, and others) can be helpful to get you through this. The amount that gets into the milk, as with almost all medications, is tiny. Acetaminophen is probably less useful than those drugs (e.g. ibuprofen) that have an anti-inflammatory affect.

Breast Abscess

The treatment of choice now for breast abscess is no longer surgery. We have had much better results with ultrasound to locate the abscess and a catheter inserted into the abscess to drain it. Mothers going through this procedure do not stop breastfeeding even on the affected side, and complete healing occurs often within a week. This procedure is done by an intervention radiologist, not a surgeon. Ask your doctor to check out this study: Dieter Ulitzsch, MD, Margareta K. G. Nyman,MD, Richard A. Carlson, MD. Breast Abscess in Lactating Women: US-guided Treatment. Radiology 2004; 232:904–909

For small abscesses, aspiration with a needle and syringe plus antibiotics often is all that is necessary, though it may be necessary to repeat the aspiration more than once.

A lump that isn’t going away.

If you have a lump that is not going away or not getting smaller over more than a couple of weeks, you should be seen by a breastfeeding-friendly physician or surgeon. You don’t have to interrupt or stop breastfeeding to get a breast lump investigated (ultrasound, mammogram and even biopsy do not require you to stop breastfeeding even on the affected side). A breastfeeding friendly surgeon will not tell you that you have to stop breastfeeding before s/he can do tests to investigate a breast lump.

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