1. Mary is a first time mum and is worried how long she should breastfeed her daughter, Alice, for. She knows how much misinformation is out there on the internet so comes to you, her GP, for some advice about breastfeeding and nutrition. Mary doesn't want to breastfeed for too long as she doesn't want Alice to miss out on important nutrients from solid foods. At what age should you recommend that Mary introduce other foods into Alice's diet?
2. Breastmilk is comprised of many antimicrobial, anti-inflammatory, and immunomodulating agents that compensate for delays in the development of the immune system of the infant. Infants, children and adults who were breastfed are at a reduced risk of developing some diseases;
- Name 3 diseases an infant currrently being breastfed is at a reduced risk of developing.
- 2 diseases for a child who was breastfed.
- 1 disease for an adult who was breastfed.
3. Suckling is require to maintain milk production as the increase in nerve stimulation increases the secretion of which two lactation hormones?
4. Why is bromocriptine, a dopamine agonist, contraindicated in breastfeeding?
- 6 months. See .GOV and WHO guidence.
- Please refer to the table on the page 'The science of breastmilk'.
- Prolactin and oxytocin.
- It supresses lactation by supressing prolactin secretion.
Question block 1: MCQ + explanation of answers
- There are two main hormones involved in lactaion. Which of these hormones is secreted from the anterior pituitary and what hormone inhibits it's secretion?
- There are two main hormones involved in lactaion. Which of these hormones is produced in the hypothalamus and how is it secreted?
- Regarding milk production, what is the role of thyrotropin-releasing hormones?
- A breastfeeding mother presents to you, her GP, with a UTI. Her infant is 4 months old. She has no drug allergies or past medical history. What antibiotic, if any, would you prescribe?
Chloe was born 14 weeks premature following a pregnancy complicated by maternal pre-eclampsia. She required ventilation and started to tolerate milk feeds using a ‘low birthweight’ milk formula. However, she became unwell at 1 week of age with a distended and tender abdomen. An abdominal X ray showed ‘pneumatosis intestinalis’. What is your diagnois and management?
- The two main hormones involved in lactation are prolactin and oxytocin. Prolactin is secreted by the anterior pituitary whereas oxytocin is secreted by the posterior pituitary. Prolactin is inhibited by dopamine from the hypothalamus. Prolactin inhibits its own secretion by increasing the production of dopamine, via a positive feedback loop, which in turn decreases prolactin secretion.
- Oxytocin is produced in the paraventricular nucleus of the hypothalamus and is secreted by the posterior pituitary. Oxytocin is stored in the posterior pituitary. Oxytocin has many roles, including the induction of labor, but regarding milk production, oxytocin stimulates contraction of smooth muscles in the breast to facilitate milk ejection.
- Thyrotropin-releasing hormone (TRH) increases prolactin secretion. TRH is produced in the hypothalamus and stimulates the release of thyroid stimulating hormone from the anterior pituitary as well.
- Nitrofurantoin is actively transported into breast milk The use of nitrofurantoin in breastfeeding mothers is generally safe, as only small amounts transfer into the breast milk. Although some suggest that nitrofurantoin be avoided in infants younger than 1 month, studies have noted that glutathione stability might be established by the eighth day of life. In infants younger than 1 month, an alternative antibiotic might be preferred; however, if an alternative were not available, the use of nitrofurantoin would not be a reason to avoid breastfeeding. The infant should be monitored.
- Necrotising Enterocolitis (NEC). In this scenario, enteral feeds were discontinued, and antibiotics started. She remained stable and milk feeds were re-started after 10 days ‘nil by mouth’.
Question block 2.
1. The production of certain components of the foetal immune system is delayed throughout pregnancy. What are the two potential evolutionary reasons for these physiologic delays? Choose 2.
- Organs involed in the immune system don't develop till the third trimester.
- The foetus is not exposed to many pathogens whe inside the womb.
- The amniotic fluid contain anti-inflammatory cytokines which prevent a foetus from mounting an immune response to maternal pathogens.
- The delay prevents tissue rejection by the foetus against the mother and vice versa.
- The foetus has not been exposed to any bacteria so has no immune cells created.
2. A breastfeeding woman presents to you, her GP, as she has red, painful and swollen nipples. You suspect she is suffering from mastitis which is commonly due to milk stasis. Sometimes this milk can become infected leading to infective mastitis. What is the most common pathogen in this scenario?
- Group A streptococcus
- S. aureus
- Herpes simplex.
3. If untreated, mastitis can lead to what other pathology?
- Maternal prolactin deficiency
- Areolar eczema
- Breast abscess
4. A 30 year old female wants to breastfeed her first child. She requests information on contraception choices. She has previously had an IUD but had it removed due to severe bleeding and she also states that she wouldn't one put in again as the procedure was too painful. What contraception would you recommend?
- Combined pill
- Progesterone only pill
- Progesterone implant
- Nothing as breastfeeding is a natural form of contraception.
- Answers 2&4. The foetus is not exposed to most microbial pathogens and therefore does not require the full fledged defence system required for independent survival. This means that energy and nutrients can be directed towards developing other organ systems required for immediate extrauterine life. Also, a delayed immune system helps to avoid immunologic reactions to maternal tissues, allowing for prolonged gestation.
- S. aureus (answer 3). Milk stasis can occur due to: a baby not properly attaching to the breast during feeding, a baby having problems sucking, and infrequent feeds or missing feeds.
- Failure to remove milk from the affected breast may predispose the breastfeeding woman to a lactation abscess. In the absence of systemic signs, conservative treatment of mastitis involves continuing breastfeeding, making sure breast milk is removed from the breast frequently and regularly, which may involve breast expression if the baby is not feeding well, resting and application of heat to the affected area. Effective treatment and support for breastfeeding continuance are essential.
- Both the progesterone pill and implant would be appropriate. Oestrogen containing formulations may suppress lactation. You would not recommend the IUS if they patient has disclosed the fact that they found the fitting of the IUD extremely painful as the procedure is the same. Lactational amenorrhea is only effective if the mother is fully breastfeeding the infant every 4 hour during the day and 6 hours at night (intervals can be NO longer), and is less than 6 months postpartum. It is therefore possible to not become pregnant whilst breastfeeding but it is not the most effective form of contraception.