Lactation Suppression: Forgotten Aspect of Care for the Mother of a Dying
Child
Posted 01/07/2004

Debra Busta Moore; Anita Catlin

In April 2001, an End-of-Life Palliative Care Protocol for Newborns was
published in Journal of Perinatology and Neonatal Network (Catlin & Carter,
2001a & b). The protocol covers such issues as (a) definition of and need
for palliative care in the NICU; (b) description of palliative care for
newborns, including categories of candidates; (c) planning and education
needed to begin palliative care services for newborns; (d) relationships
between community and tertiary centers and palliative care; (e) essential
components of optimally supporting neonatal death; (f) family care:
cultural, spiritual, and practical needs; (g) ventilator withdrawal,
including pain and symptom management and medications; (h) when death does
not occur after cessation of life-extending interventions; (i) family
follow-up care; and (j) necessary ongoing staff support. The protocol has
been well accepted and the primary investigators, Dr. Brian Carter from
Vanderbilt University and Anita Catlin, DNSc, FNP, have been traveling to
assist facilities in the implementation of the protocol on their units.

At a recent training in Berkeley, CA, at Alta Bates Summit Medical Center,
internationally board certified lactation consultant (IBCLC) Debra Busta
Moore, MSN, noted an important issue was missing from the protocol.
Although emotional care for the bereaved mother was listed, no mention was
made of the issue of breast milk cessation or donation. Busta Moore
suggested a procedure be added to the protocol to handle the milk
production of a woman whose baby is dying. Whether the mother has just
given birth, has a child that has lived a time in the NICU or at home, or
one that is a bit older and dies unexpectedly when in the hospital for a
corrective surgical procedure, supporting her with valid information on
stopping breast milk production is an essential nursing concern. The
following information will provide a review of what is known about milk
cessation and how this ties into Busta Moore's suggestions for assisted
palliative care.

In our efforts to meet the Healthy People 2010 recommendations, nationwide
support for breast feeding initiatives have taken place (Hill, 2000;
Tiedje, Schiffman, Omar, Wright, Buzzitta, McCann, & Metzger, 2002). About
64% of women in the United States are now breast feeding in the hospital,
up from 61% in 1982 (Hill, 2000). It is uncertain how many women are
encouraged to breast feed their infants in neonatal or pediatric intensive
care units. For premature infants, worldwide estimates range from 33% to
91%, with the United States in the lower range and Scandinavian countries
at the higher ranges (Pinelli, Atkinson, & Saigal, 2001).

Very little information exists in the literature on lactation suppression
for those women who cannot or do not breast feed. In a comprehensive
educational review of alternative nutrition with bottle feeding for
newborns (PBM Products, 2001), no mention is made of lactation suppression.
Spitz, Lee, and Peterson (1998), in a 100-year review of the literature,
found nothing new or helpful to induce milk suppression or to treat the
pain or discomfort of engorged breasts. Yet a mother who has established a
full milk supply through breastfeeding or pumping will need counseling on
strategies to diminish her milk production. Under the tragic circumstances
of a baby's death, the mother's comfort must not be overlooked (Merewood &
Philipp, 2001). Abrupt cessation of breastfeeding or pumping may lead to
severe engorgement, extreme pain in the breasts, and possibly to mastitis.

Suppression of lactation prior to the 1990s was done with medications that
influenced the brain's directions to the breast regarding milk production,
such as parlodel and bromocriptine. These were eventually found to have
other brain-related side effects and taken off the market for milk
cessation (Stehlin, 1990). Ice use was suggested in 1966 (Bristol, 1966),
and both fluid restriction and forced fluids had time of popularity. Breast
binding with ace wraps became the next form of care, with little scientific
supportive evidence. A recent clinical study by Swift and Janke (2003)
compared a control group using a support bra with an experimental group
having their breasts bound. Swift and Janke found the women with bound
breasts had more leakage, more pain, and needed more pain medication than
the non-bound group. A study by a group of nurses in Sweden (Radestad,
Nordin, Steineck, & Sjogren, 1998) did find that for women who had lost a
baby, breast binding served as a concrete reality of the loss and aided in
the grieving process. The use of cabbage leaves has often been suggested to
ease the pain of lactation suppression. Several early reports indicated
comfort to mothers, and this is a frequently recommended practice. Yetina
Cochrane Library examination of evidence (Snowden, Renfrew, & Woolridge,
2003), cabbage leaves and other vegetable substances on the breast did not
show greater comfort than the placebos. It was suggested that placement of
the leaves on the breast and the massage of placement may be the helpful
issue. The same results of improvement equal to the placebo occurred for
the use of ultra sound to the breasts. Prevention of engorgement was
recommended.

Engorgement, however, does play a function in rapidly stopping milk
production. Accumulation of milk that results in engorgement creates a
chain of events that lead to cessation of the lactation process. If the
breasts remain in an engorged state, a protein called feedback inhibitor of
lactation (FIL) accumulates in the mammary gland. This protein, along with
reduced capillary blood flow and involution of the milk secreting gland,
leads to suppression of milk production (Walker, 2000). Although
engorgement is the stimulus for stopping lactation quickly,painful
engorgement is not required and can be avoided by the following protocol.

Removing just enough milk to reduce the pressure in the breasts, but not
enough to empty them, will gradually diminish milk production without
excessive discomfort for the mother. The frequency and duration of pumping
will vary from one woman to another, depending on the amount of milk she is
producing, the frequency of emptying her breasts, and the length of time
since the birth of her baby. Unless the mother is experienced with manual
expression, she should be provided with a good quality breast pump
(Biancuzzo, 1999). Every effort should be made to secure a breast pump
promptly, as any delay will result in additional pain. A well fitting bra
will provide needed support to heavy breasts. The mother will pump to
comfort and gradually go longer between expressions and pump for shorter
periods. A typical schedule for the mother who has been pumping or feeding
approximately every 3 hours might be:

Day 1, pump for 5 minutes every 4-5 hours
Day 2, pump every 6 hours for 3-5 minutes
Day 3-7, pump just long enough to relieve discomfort


In addition:

Warm showers will help induce milk leakage and reduce pressure

Ice packs or cold cabbage leaves inside the bra will decrease local pain
and swelling

Ibuprofen or acetaminophen can be helpful for pain relief

Continuous support should be provided for a family that is suffering an
unanticipated loss or loss of a desired child

Certain physiological issues should be explained to the woman. It is normal
for drops of milk to be present in the breasts for weeks or even months
after breastfeeding and/or pumping is discontinued. Uterine cramping and
bleeding may occur as the breasts are emptied. The hospital unit should
have peripads available to assist the mother who may still have lochia
being expelled.


Each mother should be made aware of her options. A woman who chooses not to
pump her breasts, either for personal or practical reasons, should wear a
well fitting bra and may use the other comfort measures as described. The
mother who knows that her baby is likely to die within a day or two after
the birth and does not stimulate her breasts may or may not produce enough
milk to cause engorgement. She should, however, be given anticipatory
guidance. Occasionally, a dying baby may still be able to breastfeed. This
option should also be offered to the family when the baby might be capable
and the mother would like to do so.

A woman who has a large amount of milk, either in storage or in production,
may donate milk to a milk bank. Women with dying infants may wish to
continue to pump in order to help other infants. Throughout the world,
donor milk banks are well accepted. In the United States, they may be
considered more like alternative medicine (Arnold, 2001). There is a Human
Milk Banking Association in the United States. In 1999, there were 332,700
ounces of milk processed in seven banks and three new banks opened (Tully,
2000). Donor milk is used for infants with HIV-AIDS, adopted infants,
infants with feeding intolerance or growth failure on formula, infants
whose mothers are on chemotherapy (Tully, 2000), mothers with active
tuberculosis, or mothers without breast tissue from surgery or radiation
(PBM, 2001). In the United States, screening of breast milk is conducted
(Tully, 2000; Tully, Jones, Tully, 2001). Of 770 potential donors in the
year 2000, initial screening was positive for 4 mothers with various
hepatitis antigens, which proved negative for disease on follow up.
Pasteurization at 62.5 degrees centigrade for 30 minutes is recommended
(Tully et al., 2001; Wight, 2001) to eliminate risks of transmission of
viral and bacterial infectious agents. Pasteurization does not affect the
transfer of immunoglobins, enzymes, hormones, and growth factor. Donor milk
is often recommended for necrotizing enterocolitis and sepsis. Donation of
milk may help the grieving mother to find some meaning in the experience of
her baby's death.

Provision of culturally-sensitive emotional and spiritual support have been
well documented and have been incorporated into the practice of all nurses
who support women with dying infants (MCN, 2001). This article serves as a
reminder to consider, too, the physical needs of the previously
breastfeeding woman who has lost a child.

Pediatric Ethics, Issues, & Commentary focuses on exploring the interface
between ethics and issues in clinical practice. If you have suggested
topics or cases for consideration in the column, please contact Anita J.
Catlin, DNSc, FNP; [log in to unmask]




----------------------------------------------------------------------------
----




Debra Busta Moore, MSN, RN, IBCLC, has worked in maternal child health
since 1973. She currently provides lactation support to families in the
NICU at Alta Bates Summit Medical Center in Berkeley, CA. She also lectures
on a variety of breastfeeding topics.

Anita Catlin, DNSc, FNP, teaches at Sonoma State University in California
and serves as ethics editor for Pediatric Nursing.



Pediatr Nurs 29(5):383-384, 2003. © 2003 Jannetti Publications, Inc.

             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(R)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html