Session Objectives
On completion of this session, participants will be able to:
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| 1. Discuss nutritional needs of breastfeeding women. | 10 minutes |
| 2. Outline how breastfeeding assists in child spacing. | 10 minutes |
| 3. Discuss breastfeeding management when the mother is ill. | 15 minutes |
| 4. Review basic information on medications and breastfeeding. | 10 minutes |
| Total session time | 45 minutes |
Materials
Slide 13/1: Lactation Amenorrhea Method LAM
Slide 13/2: Recommendation for women who are HIV-positive
MATERNAL ILLNESS AND BREASTFEEDING – a copy for each participant (optional).
BREASTFEEDING AND MOTHER’S MEDICATION SUMMARY – a copy for each participant (optional).
Full copy for display of WHO/UNICEF Breastfeeding and Maternal Medications (2002).
Further Reading for facilitators
Hepatitis B and breastfeeding, UPDATE No.22, November 1996 CHD, WHO Geneva.
Breastfeeding and maternal tuberculosis, UPDATE No. 23, Feb 1998 CHD, WHO Geneva.
WHO. Nutrient requirements for people living with HIV/AIDS – report of a technical consultation. (May 2003) Geneva.
WHO/UNICEF Breastfeeding and maternal medication: Recommendations for drugs in the eleventh WHO model list of essential drugs (2002) CHD, WHO, Geneva.
WHO/UNICEF Acceptable medical reasons for use of breast-milk substitutes. World Health Organization, Geneva 2009.
1. Nutritional needs of breastfeeding women
10 minutes
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Show picture of two mothers in bed talking to nurse or at table talking to each other.
Fatima’s mother told her that she needs to eat special foods to make good milk and that some foods can affect her baby.
Ask: What can you say to a woman who asks about what she should eat or avoid eating when she is breastfeeding?
Wait for a few responses.
All mothers need to eat enough foods and drink enough liquids to feel well and be able to care for their family. If a mother eats a variety of foods in sufficient amounts, she will get the proteins, vitamins and minerals that she needs. Mothers do not need to eat special foods or avoid certain foods when breastfeeding.
A woman’s body stores fat during pregnancy to help make milk during breastfeeding. She makes milk partly from these stores and partly from the food that she eats.
A mother needs to be in a state of severe malnutrition for her breast milk production to decrease significantly. If there is a shortage of food, she first uses her own body stores to make milk. Her milk may be reduced in quantity and slightly lower in fat and some vitamins compared to that of a well-nourished mother, but it is still good quality.
Poor food choices or missing a meal does not reduce milk production. However, a mother who is overworked, lacks time to eat, and does not have sufficient food or who lacks social support may complain of tiredness and a low milk supply. Care for the mother and time to feed the baby frequently, will help to ensure adequate milk production.
Breastfeeding is important for food security for the whole family. If resources are limited, it is better to give the mother food so that she can care for her baby than to give artificial feeds to the baby. Discuss this with the family.
Breastfeeding mothers are often encouraged to drink large quantities of fluid. Drinking more fluid than is needed for thirst will not increase milk supply, and may even reduce it. A mother should drink according to her thirst or if she notices that her urine output is low or concentrated.
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Mention any food assistance programmes that are available in the area for pregnant or breastfeeding women.
2. How breastfeeding helps to space pregnancies
10 minutes
Fatima has heard that breastfeeding helps to space her pregnancies, but she wants to know if this is true.
Ask: What can you tell a mother about how breastfeeding helps to space children?
Wait for a few responses.
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Show slide 13/1: LAM
The LAM method is 98% effective in preventing conception if three conditions are met:
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the mother is not menstruating, and
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the mother is exclusively breastfeeding, (day and night) with no very long intervals between feeds, and
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baby is less than 6 months old.
If any of these three conditions are not met, it is advisable for the mother to use another method of family planning to achieve pregnancy delay.
Most family planning methods are compatible with breastfeeding with exception of oestrogen containing contraceptive pills.
3. Breastfeeding management when the mother is ill
15 minutes
Fatima has heard from a neighbour that if a breastfeeding mother gets a fever or needs to take any medications that she must stop breastfeeding.
Ask: What can you tell a mother about breastfeeding if the mother is ill?
Wait for a few responses.
Women can continue to breastfeed in nearly all cases when they are ill. There are many benefits to continuing breastfeeding during illness:
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A woman’s body makes antibodies against her infections, which go into the breast milk and which can help to protect the baby from the infection.
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Suddenly stopping breastfeeding can lead to sore breasts65 and the mother may develop a fever.
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A baby may show signs of distress, such as crying a lot, if breastfeeding suddenly stops.
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It may be difficult to return to breastfeeding after the mother has recovered as her milk production may have decreased.
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Stopping breastfeeding leaves the baby exposed to all the hazards of artificial feeding.
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Breastfeeding is less work than preparing formula, sitting up to feed and sterilising bottles. The baby can lie beside the mother and feed as needed without her moving.
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Mother and baby can stay together, so she knows her baby is safe and happy.
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The baby continues to receive the benefits of breastfeeding: protects health, best nutrition, optimal growth, and development, less risk of obesity and later health problems.
Mothers with chronic illness may need extra help to establish breastfeeding. For example, a mother with diabetes may experience complications during birth, which can interfere with establishing breastfeeding, but with appropriate help she can breastfeed normally.
Ask: What kind of help with breastfeeding may be needed if a mother is ill?
Wait for a few responses.
To assist breastfeeding when a mother is ill:
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Explain the value of continuing to breastfeed during her illness.
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Minimise separation, keeping mother and baby together.
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Give plenty of fluids, especially if she has a fever.
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Assist the mother to find a comfortable position for feeding or show someone else how to help her to hold the baby comfortably.
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If breastfeeding is difficult or the mother is too unwell, she may be able to (or helped to) express her milk and the baby can be feed breast milk by cup until she is better.
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Choose treatments and medications that are safe for breastfeeding.
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Assist the mother to re-establish breastfeeding after she recovers, if there has been an interruption during the illness.
Ask: Are there any situations related to the mother’s health that may require the use of foods other than breast milk?
Wait for a few responses.
There are very few situations related to maternal health that require the use of artificial feeds. It is important to distinguish if it is the illness that is a contraindication to breastfeeding or the situation surrounding the illness that makes breastfeeding difficult.
Hospitalisation of itself is not a contraindication to breastfeeding. If a mother is hospitalised, the baby should be kept with the mother. If the mother is not able to care for her infant, a family member can be asked to stay and help her with the infant. Maternal use of
substances: Maternal use of nicotine, alcohol, ecstasy, amphetamines, cocaine and related stimulants has been demonstrated to have harmful effects on breastfed babies; alcohol, opioids, benzodiazepines and cannabis can cause sedation in both the mother and the baby. Mothers should be encouraged not to use these substances and given opportunities and support to abstain.
If a mother has a common contagious illness such as a chest infection, sore throat, or gastrointestinal infection, there is a risk to the baby from being near the mother and exposed to the infection though contact, coughing and such. When the mother continues to breastfeed, the baby receives some protection from the infection. If breastfeeding stops at this time, the baby is at higher risk of contracting the mother’s infection. For most maternal infections, including tuberculosis, hepatitis B, and mastitis, breastfeeding is not contraindicated.
If a mother is not able to breastfeed, efforts should be made to find a wet-nurse (of known HIV-negative status) or to obtain heat-treated breast milk from a breast-milk bank.
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Give participants a copy of MATERNAL ILLNESS AND BREASTFEEDING and let them
read through the list in their own time. Clarify any points as needed.
4. Medications and breastfeeding66
10 minutes
If a mother requires medication, it is often possible for the doctor to prescribe a drug that may be safely taken during breastfeeding. Most drugs pass into breast milk only in small amounts and few affect the baby. In most cases, stopping breastfeeding may be more dangerous to the baby than the drug.
A medication the mother takes is more likely to affect a premature baby or a baby less than two months old than an older baby. If there is a concern, it is usually possible to find a drug or treatment that is more compatible with breastfeeding.
If a breastfeeding mother is taking a drug that you are not sure about:
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Encourage the mother to continue breastfeeding while you find out more.
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Watch the baby for side effects such as abnormal sleepiness, unwillingness to feed, and jaundice, especially if the mother needs to take the drug for a long time.
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Check the WHO list, (explain where to get this list or other locally available list that is breastfeeding supportive).
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Ask a more specialized health worker, for example a doctor or pharmacist for more information, and to find an alternative drug that is safer if needed.
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If the baby has side effects and the mother’s medication cannot be changed, consider a replacement feeding method, temporarily if possible.
Traditional treatments, herbal medicines and other treatments may have effects on the baby. Try to find out more about them if they are commonly used in your area. Meantime encourage the mother to continue breastfeeding and to observe the baby for side effects.
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Give participants the summary of “BREASTFEEDING AND MOTHER’S MEDICATION” or tell them where they can obtain the full text of the booklet. Point out the categories of drugs in the summary – contraindicated, and continue breastfeeding with monitoring.
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Ask if there are any questions. Then summarise the session.
Session 13. Summary
Nutritional needs of breastfeeding women
All mothers need to eat enough foods so that they will feel well and be able to care for their families.
Mothers do not need to eat special foods or avoid certain foods when breastfeeding.
If the food supply is limited, it is better for the health and nutrition of both mother and baby and less expensive to give the mother food so that she can care for her baby than to give artificial feeds to the baby.
How breastfeeding helps to space births
Breastfeeding management when the mother is ill
Medications and breastfeeding
Often, if a medication is needed, one can be used that is safe for her baby. Most drugs pass into breast milk only in small amounts and few affect the baby. In most cases, stopping breastfeeding may be more dangerous to the baby than the drug.
Watch the baby for side effects and find out more about the drug if you are worried. Babies under 2 months of age are more likely to show side effects.
Know where to get more information or advice on medications.
Session 13 Knowledge Check
A pregnant woman says to you that she cannot breastfeed because she would need to buy special foods for herself that she could not afford. What can you say to her to help her see that breastfeeding is possible for her?
A co-worker says to you that a mother will need to stop breastfeeding because she needs to take a medication. What can you reply to this co-worker?
Maternal Illness and Breastfeeding
Exclusive breastfeeding in the first six months of life is particularly beneficial for mothers and infants and is the norm. Nevertheless, a small number of health conditions of the infant or the mother may justify recommending that she does not breastfeed temporarily or permanently. These conditions, which concern very few mothers and their infants, are listed below together with some health conditions of the mother that, although serious, are not medical reasons for using breast-milk substitutes.
Mothers who are affected by any of the conditions mentioned below should receive treatment according to standard guidelines.
Mothers who may need to avoid breastfeeding
This category includes women with HIV infection: if replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS).
Mothers who may need to avoid breastfeeding temporarily
Includes mothers with severe illness that prevents a mother from caring for her infant, for example sepsis; Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the mother’s breasts and the infant’s mouth should be avoided until all active lesions have resolved;
In this group are also included those with maternal medication:
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Sedating psychotherapeutic drugs, anti-epileptic drugs and opioids and their combinations may cause side effects such as drowsiness and respiratory depression and are better avoided if a safer alternative is available.
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Radioactive iodine-131 is better avoided given that safer alternatives are available - a mother can resume breastfeeding about two months after receiving this substance.
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Excessive use of topical iodine or iodophors (e.g. povidone-iodine), especially on open wounds or mucous membranes, can result in thyroid suppression or electrolyte abnormalities in the breastfed infant and should be avoided.
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Cytotoxic chemotherapy requires that a mother stops breastfeeding during therapy.
Mothers who can continue breastfeeding, although health problems may be of concernThis group includes:
Breast abscess: breastfeeding should continue on the unaffected breast; feeding from the affected breast can resume once treatment has started.
Hepatitis B: infants should be given hepatitis B vaccine, within the first 48 hours or as soon as possible thereafter.
Hepatitis C;
Mastitis: if breastfeeding is very painful, milk must be removed by expression to prevent progression of the condition.
Tuberculosis: mother and baby should be managed according to national tuberculosis guidelines.
Substance use:
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Maternal use of nicotine, alcohol, ecstasy, amphetamines, cocaine and related stimulants has been demonstrated to have harmful effects on breastfed babies.
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Alcohol, opioids, benzodiazepines and cannabis can cause sedation in both the mother and the baby.
Mothers should be encouraged not to use these substances and given opportunities and support to abstain.
References
HIV and infant feeding: update based on the technical consultation held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Infants; Geneva. 25–27 October 2006; Geneva: World Health Organization; 2007. [accessed 23 June 2008].
http://whqlibdoc.who.int/publications/2007/9789241595964_eng.pdf.
Breastfeeding and maternal medication: recommendations for drugs in the Eleventh WHO Model List of Essential Drugs. Geneva: World Health Organization; 2003.
Hepatitis B and breastfeeding. Geneva: World Health Organization; 1996. (Update No. 22)
Breastfeeding and Maternal tuberculosis. Geneva: World Health Organization; 1998. (Update No. 23)
Background papers to the national clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. NSW Department of Health; North Sydney, Australia: 2006. Commissioned by the Ministerial Council on Drug Strategy under the Cost Shared Funding Model.
Breastfeeding and Mother’s Medication - Summary
Breastfeeding contraindicated
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Anticancer drugs (antimetabolites).
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Radioactive substances (stop breastfeeding temporarily).
Continue breastfeeding
Side-effects possible; monitor baby for drowsiness
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Selected psychiatric drugs and anticonvulsants (see individual drug).
Use alternative drug if possible
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Chloramphenicol, tetracyclines, metronidazole, quinolone antibiotics (e.g. ciprofloxacin).
Monitor baby for jaundice
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Sulfonamides, dapsone, sulfamethoxazole+trimethoprim (cotrimoxazole), sulfadoxine+pyrimethamine (fansidar).
Use alternative drug (may decrease milk supply)
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Estrogens, including estrogen-containing contraceptives, thiazide diuretics, ergometrine.
Safe in usual dosage
Most commonly used drugs:
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Analgesics and antipyretics: short courses of paracetamol, acetylsalicylic acid, ibuprofen; occasional doses of morphine and pethidine.
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Antibiotics: ampicillin, amoxicillin, cloxacillin and other penicillins, erythromycin.
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Antituberculosis drugs, anti-leprosy drugs (see dapsone above).
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Antimalarials (except mefloquine, fansidar), anthelminthics, antifungals.
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Bronchodilators (e.g. salbutamol), corticosteroids, antihistamines.
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Antacids, drugs for diabetes, most antihypertensives, digoxin.
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Nutritional supplements of iodine, iron, vitamins.
(Adapted from “Breastfeeding counselling: A training course”, WHO/CDR/93.3-6)
More information on specific medications can be found in the publication:
WHO/UNICEF Breastfeeding and Maternal Medications (2003) www.who.int/child-adolscent-health/
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The target audience for this course are not expected to recommend medications.
