When should mastitis be treated with antibiotics?

April 13, 2009 — Elizabeth Jay

pillsMastitis – inflammation of the breast tissue – is a common problem for breastfeeding women. Although it can be associated with bacterial infection, this is rarely its primary cause (see milk stasis – not infection – is the main cause of mastitis). Many doctors nevertheless choose to treat it with antibiotics, ‘just in case’ infection is present. Given the uncertain relationship between bacteria and mastitis, what are the benefits – and drawbacks – of taking antibiotic medication?

There are disappointingly few properly controlled studies looking at the antibiotic treatment of mastitis. A recent Cochrane Review analyzing all the research in this area found only two studies that were sufficiently well designed or reported to provide unbiased evidence1. One study looked at the effects of two different types of antibiotic (Amoxicillin and Cephradine), and found that they were equally good at relieving symptoms. Unfortunately, as the study didn’t have a control group of women who did not take any medication, it is not clear whether the antibiotics actually helped them recover, or whether the mothers would simply have recovered over time anyway.

In the second study, mothers who had ‘infectious mastitis’ (diagnosed when both bacteria and white blood cell counts were higher than normal) were assigned to three groups. In the first group, the women were advised to treat the mastitis by emptying the affected breast every six hours (feeding their baby as normal and then expressing any remaining milk); in the second, mothers were asked to follow the same breast emptying routine, and were also prescribed a course of antibiotics (Penicillin, Ampicillin or Erythromycin); in a third control group no treatment was recommended. The results showed that antibiotics did indeed have a beneficial effect: whilst women in the breast-emptying group recovered more quickly than those who weren’t treated, those taking the medication recovered fastest of all.

This single study does appear to show that antibiotics can help treat mastitis associated with bacterial infection. Does this provide adequate evidence for treating all cases of mastitis in this way? Well, not really, for a number of reasons.

Firstly, the antibiotics were shown to be effective when infection was present. In many cases of mastitis, infection is not present, so antibiotics wouldn’t be any use. A risk of prescribing antibiotics without diagnosing infection is that it may not treat the root of the problem. As mastitis is more commonly caused by milk stasis than infection, it is vital to tackle this issue to ensure proper recovery and avoid reoccurrence.

Inappropriate antibiotic treatment is also problematic as it increases the chance that the bacteria may become resistant to the drug. Staphylococcus aureus is the bacteria most commonly associated with mastitis, and a well-known strain of this – MRSA – is already resistant to antibiotics, so this is potentially a serious problem2.

There is also the possibility that antibiotics taken by breastfeeding mothers may have adverse effects on their babies. Exposure to antibiotics through breast milk has been linked with problems such as minor infant breathing difficulties3 and diarrhoea4. Although such complications are not regarded as serious enough stop women from taking medication when they need it (particularly if it enables them to continue breastfeeding), it seems sensible to avoid putting babies at any unnecessary risk, particularly given that this area is currently under-researched1.

So, what does all this mean for mothers who have mastitis, and health professionals who are trying to treat it? There is some evidence that antibiotics help treat mastitis when infection, diagnosed using both bacteria and white blood cell counts, is known to exist. Ideally, antibiotics would be prescribed only in this situation, as using them unnecessarily increases the chance bacteria will develop resistance to them – leading to strains such as MRSA – and may expose babies to unnecessary health problems. Diagnosing infection is notoriously difficult, however, as the bacteria which potentially cause infection can be present even when infection itself isn’t5, and measuring both white blood cell and bacteria counts is rarely going to be practical in a normal health care setting, such as a GP surgery. In a paper published last year discussing this difficult issue, Linda Kvist and colleagues recommend a daily follow-up of mothers with mastitis, and the prescription of antibiotics when symptoms are persistent. In the meantime (and indeed, in the first instance) treating milk stasis, the primary cause of mastitis, remains the top priority.

  1. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD005458
  2. Int Breastfeed J. 2008 Apr 7;3:6.
  3. Pediatrics. 2007 Jan;119(1):e225-31
  4. Am J Obstet Gynecol. 1993 May;168(5):1393-9.
  5. Mastitis: causes and management. World Health Organization; 2000.
Posted in Antibiotics, Mastitis, Research. Tags: , , , , , , . 4 Comments »

Battle with the bottle: persistence pays off

April 12, 2009 — Elizabeth Jay

bottle_2When C was about 10 weeks old, she started refusing to feed from a bottle. Initial reluctance rapidly turned into violent resistance, and if I actually managed to get the teat near her mouth, it was met only by screams.

My despair at the situation was tempered only by the fact that it turned out not to be particularly unusual. Two mothers I knew had had the same experience – trouble free bottle feeding morphing into complete refusal – and several others (including, ahem, my own mother) had never managed to get their babies to feed from a bottle.

On the web, several discussion forums were devoted to the topic, and here I found a glimmer of hope: many parents who had experienced similar problems had eventually been able to get their babies to accept bottles. Reading the advice was nevertheless confusing. There were a multitude of conditions that apparently dictated whether infants would feed from a bottle: mothers needed to be around to provide comfort/mothers needed to be completely out of the house; babies shouldn’t be really hungry (they might get too upset)/babies should be really hungry (they won’t let themselves starve); silicon teats were better than rubber/rubber teats were better than silicon…

The only thing that all the success stories had in common was that the parents persisted in offering their children bottles. This in itself is not a great revelation – if a bottle isn’t offered, then it cannot be accepted – but it was reassuring to know that just because a baby resolutely refuses a bottle at one point, it doesn’t necessarily mean she always will.

Keeping this in mind, we started to offer C a bottle everyday, containing just an ounce of expressed milk to start with. I abandoned my frustration, and decided not to worry too much whether she took it or left it. Perhaps because I was no longer anxious, C stopped crying when the bottle was near her. Sometimes she drank a little bit of milk, sometimes she just chewed on the teat, sometimes she spat it out. Eventually, she became so comfortable feeding this way that she’d grab the bottle with both hands and help push it into her mouth! Whether it was decoupling the stress from the situation, the increasing familiarity of the bottle, or a sudden turnaround that would have happened regardless of what we had done is impossible to know, but for now at least, bottle refusal is thankfully in the distant past.

Posted in Bottle feeding, Journal. Tags: , , , , , , , . 4 Comments »

Could a laid-back approach to breastfeeding help your baby latch on?

April 9, 2009 — Elizabeth Jay

baby_cryingAlthough it’s perfectly feasible to feed your baby any way that feels comfortable, four positions are commonly recommended. These are the cradle hold, the football hold, lying on your side, and the cross-cradle hold. This last position requires you to sit up with a straight back, hold your baby sideways on, and carefully position him with his nose opposite your nipple so he has a large mouthful of breast when he latches on. It can seem like quite a complicated process for a beginner, particularly when a crying baby is added to the equation. Nevertheless, it is particularly recommended to new mothers, as it is apparently the best position in which to ensure your baby is latching on correctly – something that many women (and babies) can find quite difficult.

Despite the strong recommendation of these feeding positions, there appears to be virtually no scientific evidence to justify their use. In practical terms, it is easy to see why being able to discreetly breastfeed whilst sitting up is a useful skill to master, but for a new mother, simply being able to comfortably nourish her baby may be a more immediate priority.

A recent study conducted at hospitals in the UK and France calls into question the idea that the traditionally recommended feeding positions are automatically the best ones1. During the study, 40 women whose babies were less than a month old were videotaped breastfeeding in a series of recording sessions. As long as feeding was going well, mothers were not advised or guided in any way: they were simply left to get on with it in whichever was most comfortable for them. In the ‘best’ recorded feeding session 21 of the mothers sat upright to feed their babies, one lay flat on her back, and one lay on her side; the remaining 17 were semi-reclined with their babies lying on their tummies (a behaviour termed ‘Biological Nurturing’).

There were some striking differences in the feeding process when mothers adopted a reclining position, as opposed to sitting upright. When babies lay on their mothers’ tummies, their mothers’ hands were free to gently guide them. Stroking their babies’ feet seemed to be particularly helpful, as it released mouth and tongue reflexes that helped them to latch on. By contrast, when babies were held in their mothers’ arms, their legs and feet were left in thin air, and the foot-to-mouth connection was lost.

The reclinining group did not need to line up the nose and nipple, and make sure the baby’s mouth was open wide enough before initiating the latch: as the baby was on top, gravity pulled his tongue and chin forward, allowing him to attach himself, even when he was sleepy. Gravity also automatically ensured a close fit between the baby’s chin and the mother’s breast, facilitating deep suckling and producing the ear and jaw movements that indicate successful feeding.

Perhaps the most interesting result, however, was that babies exhibited reflexes that helped feeding when their mothers were reclined, but hindered it when their mothers were upright. When they were lying on their mothers’ tummies, head-righting and -lifting reflexes allowed the baby to orientate himself for successful latching on. When mothers were upright however, these irregular, jerky head movements had the opposite effect: the head bobbing that resembled ‘nodding’ when a mother was reclined was perceived as ‘head butting’ when a baby was held sideways against an upright mother. The gravitational forces that had helped attachment in reclining postures dragged babies away from their mothers when they sat up. It was harder to keep the baby latched on, and mothers reacted by tightening their grip, resulting in back arching and arm and leg cycling that appeared like thrashing or flailing.

It is important to view these results in context: this was an observational, rather than a controlled study, so the data cannot ‘prove’ that one feeding method is better than another. Many of the mothers who participated fed quite happily whilst sitting upright – as do many women every day – so it’s clear that a reclining posture is not required for successful feeding.

Nevertheless, this research does call into question the idea that a position like the cross-cradle hold is the best one to recommend to new mothers. Innate early breastfeeding behaviours were observed to help attachment when a mother lay back with her baby lying on her tummy, but not when she sat up;  reflexes and gravitational forces which aided latching on when a mother reclined, hindered it when she was upright. If, as this study suggests, women can just lie back and let nature take its course, the often fraught early days of breastfeeding could potentially be a much more relaxed affair.

  1. Early Hum Dev. 2008 Jul;84(7):441-9.
Posted in Biological Nurturing, Feeding positions, Research. Tags: , , , , , , , , , , , , . 6 Comments »

Not enough milk? The “symptoms” you don’t need to worry about.

March 15, 2009 — Elizabeth Jay

glass of milkA huge proportion of women worry that they aren’t satisfying their babies through breastfeeding alone, and many give up as a result. Much of the time, however, they are worrying about nothing. Although the precise relationship between perceived and actual milk supply isn’t well researched (see insufficient milk: all in the mind?), it is certainly the case that many of the “symptoms” that women think indicate they aren’t producing enough milk are actually completely normal, and can in fact be indicators that breastfeeding is going well.

In an article for Australian Family Physician journal, Dr Lisa Amir summarizes the common misconceptions of low supply. They include your breasts feeling softer, your baby taking less time to feed or feeding more frequently, your baby seeming unsettled or settling better on formula, and your baby’s growth appearing to slow down after three months1. In the absence of any genuine indicators of ill health, none of the above are a cause for concern, yet they perturb many mothers to the extent that they stop breastfeeding. Why do mothers interpret these commonplace occurrences as signs that their milk production is diminishing, and what actually causes them? The sections below address each ‘symptom’ in turn, outlining why they can be misconstrued as a problem with milk supply, and explaining what actually causes them.

•    Your breasts feel softer

After the problems with engorgement that can occur in the post-birth period, it should come as a relief when breasts go back to a softer, more normal consistency. In reality, it can be somewhat unnerving. If you’re used to rapidly filling up with milk, any decline in this can give the impression of a dwindling supply. In fact, your breasts are simply adjusting to maximize their efficiency, by producing as much milk as your baby needs, but not going overboard – an important process, given how energy intensive it is to produce milk. Initially, production is controlled by hormones that are released after giving birth, causing a significant amount of milk to appear regardless of whether a woman intends to breastfeed. Within a few days, however, the amount produced starts to be determined by the amount of milk that your baby takes at a feed2. The quantity of milk required by your baby increases rapidly to start with, but by the end of the first month it has stabilized, and your production becomes fine-tuned too, so you can supply your baby with exactly what she requires, without wasting energy by producing too much3. This isn’t to say you can’t make more if necessary, but simply that you won’t do it unless the demand is there.

•    Your baby takes less time to feed

Whilst the amount of milk a baby has at each feed remains relatively consistent as he gets older, the speed at which he takes it on board increases. A five month old baby sucks more frequently and ingests more milk with each suck than a two-month old, meaning that he can get through a meal much faster4. Although this gives the impression that he isn’t getting as much milk, you can be reassured he is – he’s simply getting it in a shorter time.

•    Your baby is unsettled, or seems to settle better on formula

The research into colic, crying and the type of food a baby receives presents a confusing picture. Some studies show babies sleep longer if they are breastfed5, while others say formula fed infants are more settled6. One problem that frequently arises with the research in this area is that feeding method is confounded with style of care-giving, and cross cultural studies indicate that the the latter might have a much greater impact on how irritable babies are than the former5. The main thing to remember is that there are many factors affecting how much your baby cries: if you are feeding on demand, a problem with your milk supply is unlikely to be one of them.

•    Your baby feeds more often

A long term study in Sweden has shown that the number of feeds a baby takes in a day can vary by a huge amount, both from baby to baby, and for the same baby over time7. A change in feeding frequency is not unusual, and is not associated with a problem with your milk supply.

•    Your baby’s growth slows after three months

What if your baby has been gaining weight steadily, and then suddenly starts to falter?  The amount of weight babies put on may vary over time for many reasons, but an apparent slow-down from around three months should pretty much be expected. Although the new WHO growth charts were published in 2006, many health care providers (including my own) still aren’t using them, so your baby’s growth is being compared with that of formula fed infants. The really important thing to remember in this situation is that it is actually the breastfed babies’ pattern of weight gain that is considered desirable, so formula fed infants whose growth curve continues to climb are actually gaining too much weight. Or at least this is what the WHO states – presumably the rest of the medical profession will catch up in the next few years.

The issues discussed above frequently cause mothers to worry that they aren’t producing enough milk when in reality their supply is absolutely fine. A baby may cry, fuss or feed more frequently because she is hungry, but this does not mean that her mother is unable to provide her with sufficient milk. The efficient nature of milk production means that if a baby indicates that he needs more milk by taking more at a feed, then the breasts will increase production as required.

The only time to worry is if your baby appears physically ill. If her growth has genuinely stalled, or she is continually tired, weak and listless, there may be a problem: if you’re in any doubt, consult a professional. Just keep in mind that any other ‘symptoms’ of low supply are probably nothing of the sort: as long as your baby is healthy, you almost certainly have nothing to worry about.

  1. Aust Fam Physician. 2006 Sep;35(9):686-9.
  2. Exp Physiol. 1993 Mar;78(2):209-20
  3. J Midwifery Womens Health. 2007 Nov-Dec;52(6):564-70.
  4. J Reprod Fertil. 1999 Mar;115(2):193-200.
  5. Early Hum Dev. 2000 May;58(2):133-40.
  6. Early Hum Dev. 1998 Nov;53(1):9-18.
  7. Acta Paediatr. 1999 Feb;88(2):203-11.
Posted in Insufficient milk, Research. Tags: , , , , , , , . 1 Comment »

Where does fore-milk end and hind-milk begin (and does it actually matter?)

March 3, 2009 — Elizabeth Jay

milk-creamAccording to the World Health Organization, breastfeeding provides all the nutrition your baby requires for the first six months of life. This entails satisfying both hunger and thirst, and to meet both these needs you might have heard that your breasts produce two distinct types of milk: thin, watery ‘fore-milk’ to quench thirst; and creamy, calorie-rich ‘hind-milk’ to satisfy hunger.

These apparently different types of breast milk are described in various ways, but a distinction is generally drawn between a watery/creamy consistency, and thirst/hunger. There is also an implication that you need to make sure your baby gets enough hind-milk in order to gain weight. According to DrPaul.com:

‘Foremilk is the milk which is first drawn during a feeding. It is generally thin and lower in fat content, satisfying the baby’s thirst and liquid needs.
Hindmilk is the milk which follows foremilk during a feeding. It is richer in fat content and is high in calories. The high fat and calorie content of this milk is important for your baby’s health and continuing growth.’

ParentingWeb.com carries a similar description:

‘Foremilk, a bluish-white milk that is lower in fat than the hindmilk is the milk your baby receives in the first part of the feeding.
The hindmilk, which follows the foremilk, is richer and higher in fat than the foremilk. The hindmilk provides most of the nutrients your baby needs to gain weight and grow, and it satisfies his hunger.’

Valorie Delp on Families.com goes a step further, and says you can actually see the difference between the two:

‘If you’re really into science, pump a bottle of milk and let it sit out on the counter for awhile. You’ll see the milk separate into two distinctive layers. . .one being much fattier than the other. That’s hind milk and foremilk.’

Valorie’s demonstration is appealing, but it’s unfortunately some way off the mark. The separation she describes is simply the fat in the milk rising to the surface, not a different type of milk. This illustrates quite neatly the problem with using the terms ‘fore’ and ‘hind’: it reinforces the impression that the breast produces two types of milk, when in fact it makes only one. The descriptions shown above aren’t entirely inaccurate – milk does indeed change consistency during a feed – but this happens gradually, rather than suddenly.

The change occurs due to an increase in the fat content of the milk as a feed progresses – hence the ‘creamy’ label attached to hind-milk. It isn’t simply the case of the longer the feed, the fattier the milk, however. A study published in Experimental Physiology demonstrates that the fat content is related to the ‘emptiness’ of the breast: the less milk it contains, the greater the proportion of fat in the milk1. This means that if a baby has a 4oz feed when the breast is only storing half its potential milk volume, it will contain more fat than a 4oz feed taken when the breast is three-quarters full.

The amount of fat in your milk therefore varies considerably throughout the day, depending on the time since the last feed, the amount of milk consumed at the last feed, the amount of milk consumed at the current feed… It sounds complicated – how on earth do you make sure that your baby is getting enough? The short answer is that you don’t need to. Whilst fat is an important constituent of your baby’s diet, so are protein and carbohydrate, and both of these are found in the watery rather than the fatty part of the milk. The evidence also suggests that weight gain is related simply to the volume of milk consumed, and not its fat content2, underlining the nutritional importance of all the components of breast milk.

If you are breastfeeding on demand, the bottom line is that you don’t need to worry about the ‘type’ of milk your baby is getting. Babies can show a wide variety of feeding patterns, suckling for varying lengths of time and at varying intervals over the course of a day, and maintain a healthy weight3. The terms ‘fore-milk’ and ‘hind-milk’ do have their place: in scientific studies, they are used to describe the samples of milk taken at the beginning and end of a feed. In more general usage, however, they often produce a confused and inaccurate picture. They split milk into two types (when there is actually only one), and imply that the fat contained in milk is somehow more nutritious than the rest of it. In fact, nutrients that are important for health and growth are contained in both components of breast milk, so the implication that the fatty part is for ‘eating’ and the watery part for ‘drinking’ is somewhat misleading. The important thing to remember is that ensuring your baby’s thirst and appetite are satisfied is not a complicated undertaking – it’s simply a matter of letting her feed when she wants to.

  1. Exp Physiol. 1993 Nov;78(6):741-55.
  2. Paediatr Perinat Epidemiol. 2002 Oct;16(4):355-60.
  3. Pediatrics. 2006 Mar;117(3):e387-95.Click here to read
Posted in Fore/hind milk, Research. Tags: , , , , , , , , , . 40 Comments »
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