Various clinical practices have been found to be associated with breast-feeding problems. However, little is known about the effect of pain, obstetrical procedures and analgesia on breast-feeding behaviour. We designed a retrospective study with a questionnaire concerning pain, obstetrical procedures and breast-feeding practices mailed to 164 primiparae in Lapland. Altogether 99 mothers (60%) returned completed questionnaires that could be included in the analysis, which was carried out in two steps. Firstly, all accepted questionnaires were grouped according to the success or failure to breast-feed fully during the first 12 weeks of life. Secondly, an ad hoc cohort study was performed on the sub-sample of 64 mothers delivered vaginally. As many as 44% of the 99 mothers reported partial breast feeding or formula feeding during the first 12 weeks. Older age of the mother, use of epidural analgesia and the problem of "not having enough milk" were associated with the failure to breast-feed fully. Caesarean section, other methods of labour analgesia and other breast-feeding problems were not associated with partial breast feeding or formula feeding. In the sub-sample, 67% of the mothers who had laboured with epidural analgesia and 29% of the mothers who laboured without epidural analgesia reported partial breast feeding or formula feeding (P = 0.003). The problem of "not having enough milk" was more often reported by those who had had epidural analgesia. Further studies conducted prospectively are needed to establish whether a causal relationship exists between epidural analgesia and breast-feeding problems.

OBJECTIVE:The purpose of this study was to describe the circumstances, clinical features, role, and results of chiropractic management of infants who were referred to a chiropractic clinic for failure to adequately feed at the breast.

METHODS:Clinical case series of 114 infant cases of hospital-diagnosed or lactation consultant diagnosed feeding problems that were treated with chiropractic therapy in addition to routine care and followed to short-term result.

RESULTS:The most common age of referral was 1 week (mean, 3 weeks; range, 2 days-12 weeks), and the most common physical findings were cervical posterior joint dysfunction (89%), temporomandibular joint imbalance (36%), and inadequate suck reflex (34%). Treatment was chiropractic therapy in addition to any support given elsewhere. All children showed some improvement with 78% (N = 89) being able to exclusively breast feed after 2 to 5 treatments within a 2-week time period.

CONCLUSION:Cooperative multidisciplinary care to support breastfeeding was demonstrated in this population. Chiropractic treatment may be a useful adjunct to routine care given by other professionals in cases of diagnosed breastfeeding problems with a biomechanical component.

OBJECTIVE:To observe the effect differences between acupoint Tuina and simple instruction and education to improve the lactation of the parturient after delivery.

METHODS:Fifty-six cases of primipara were divided into an acupoint Tuina group (28 cases) and a control group (28 cases) according to the order of entering group, the acupoint Tuina group was treated with Tuina intervention at local acupoint of the breast and distant acupoint on the basis of the instruction and education of breast feeding; the control group was treated with simple instruction and education of breast feeding. The differences of lactation amount, the level of serum prolactin at 48 h after delivery and the time start to lactate of the parturient in both groups were observed.

RESULTS:The serum prolactin of the parturient at 48 h after delivery of (416.33 +/- 144.29) ng/mL in acupoint Tuina group was obviously higher than that of (320.06 +/- 187.55) ng/mL in control group, there were much more parturient with sufficient milk in acupoint Tuina group after treatment, and the time start to lactate was earlier than that of control group.

CONCLUSION:The acupoint Tuina is good for parturient to lactate early and lactate more, it is necessary to make further research.

OBJECTIVE:to compare the early breast-feeding behaviours of full-term newborns whose mothers had received epidural analgesia (EDA) during an uncomplicated labour, with a group of newborns whose mothers had not received EDA.

DESIGN AND SETTING:a retrospective comparative study design was used and the study was carried out in a labour ward in Stockholm, Sweden between January 2000 and April 2000. The ward has about 5500 deliveries per year.

PARTICIPANTS:all maternity records of women who had received EDA during labour (n=585) were included in the study. For each EDA record, a control record was selected, matched for parity, age and gestational age at birth. Women with emergency caesarean section, vacuum extraction/forceps, twin pregnancy, breech presentation or an intra-uterine death, as well as neonates with an Apgar score<7 at 5 mins were excluded. After exclusion, the study population consisted of 351 healthy women and babies in each group.

METHOD:logistic regression was performed. The dependent variables: (1) initiation of breast feeding after birth; (2) artificial milk given during hospital stay; and (3) breast feeding at discharge were studied in response to: (a) parity; (b) gestational age at birth; (c) length of first and second stage of labour; (d) administration of oxytocin; (e) administration of EDA; and (f) neonatal weight, as independent variables.

FINDINGS:significantly fewer babies of mothers with EDA during labour suckled the breast within the first 4 hours of life [odds ratio (OR) 3.79]. These babies were also more often given artificial milk during their hospital stay (OR 2.19) and fewer were fully breast fed at discharge (OR 1.79). Delayed initiation of breast feeding was also associated with a prolonged first (OR 2.81) and second stage (OR 2.49) and with the administration of oxytocin (OR 3.28). Fewer newborns of multiparae received artificial milk during their hospital stay (OR 0.58). It was also, but to a lesser extent, associated with oxytocin administration (OR 2.15). Full breast feeding at discharge was also positively associated with multiparity (OR 0.44) and birth weight between 3 and 4 kg (OR 0.42).

KEY CONCLUSIONS:the study shows that EDA is associated with impaired spontaneous breast feeding including breast feeding at discharge from the hospital. Further studies are needed on the effects of EDA on short- and long-term breast-feeding outcomes.

OBJECTIVE: The aim of the study was to compare the maternal and neonatal morbidity associated with elective cesarean sections with planned vaginal delivery. METHODS: A total of 178 women with elective cesarean section were compared with the next parity- and age-matched women presenting in spontaneous labor. Our analysis was restricted to a sample of low-risk obstetrical women. Maternal and neonatal outcomes were the main outcome variables of interest. Maternal morbidity outcome variables included wound infection, trauma, puerperal febrile morbidity and significant blood loss (>500 ml). Neonatal outcomes were captured by Apgar scores, cord pH as well as the occurrence of neonatal infections. RESULTS: A significantly higher rate of puerperal febrile morbidity (n = 46 vs. 14, p = 0.0001) and wound infections (n = 16 vs. 2, p = 0.0001) could be detected in the elective cesarean section group. Additionally, a significant blood loss>500 ml was more than twice as frequent in the cesarean section group (n = 22 vs. 10, p = 0.03) with non-significant lower postpartum hemoglobin levels being observed (10.4 vs. 11.2 g/dL, p>0.05). A significant increase for the use of iron supplementation (n = 146 vs. 122, p = 0.002), analgesics (n = 168 vs. 60, p = 0.0001) and antibiotics (n = 48 vs. 18, p = 0.0001) could be found in the puerperal period and hospital admission was prolonged in elective cesarean section (6.8 vs. 3.5 days, p = 0.0001). Additionally, problems in breastfeeding occurred more frequently in this group (n = 18 vs. 4, p = 0.002). Neonatal complications were generally low in both the groups with no significant differences being observed (p>0.05). CONCLUSION: The increased maternal morbidity in elective cesarean section included puerperal febrile morbidity, wound infections as well as breastfeeding problems in the postpartum period. Women should be sufficiently counseled regarding the increased risk of these complications.

OBJECTIVE: The population subgroups with the highest proportion of overweight and obese women often are characterized by the lowest rates of initiation and shortest durations of breastfeeding. We previously documented that these 2 population-level trends may be related. In a population of white women who lived in a rural area, we observed that prepregnant overweight and obesity were associated with failure to initiate and also to sustain lactation. The means by which being overweight or obese negatively affect lactational performance is unknown and likely to be multifactorial in origin, including the simple mechanical difficulties of latching on and proper positioning of the infant. In addition, we have shown that prepregnant body mass index (BMI) is negatively associated with the timing of lactogenesis II, the onset of copious milk secretion. Although the effects of obesity on the prolactin response to infant suckling have never been studied, we postulated that maternal obesity could compromise this important response. We proposed that this might occur because obesity alters the 24-hour spontaneous release of prolactin and also because prolactin secretion is blunted in response to various stimuli among obese subjects. The fall in progesterone concentration that occurs immediately postpartum is the trigger for the onset of copious milk secretion, but maintenance of prolactin and cortisol concentrations is necessary for this trigger to be effective. Adipose tissue concentrates progesterone. We proposed that this additional source of progesterone would lead to consistently higher progesterone concentrations among obese compared with normal-weight women. This, in turn, would lead to a delay in reaching the appropriate concentration to trigger the onset of lactogenesis II. We tested the hypotheses that a reduced prolactin response to suckling and higher-than-normal progesterone concentration in the first week after delivery might be among the means by which maternal overweight could compromise early lactation.

METHODS: We enrolled 40 mothers of term infants from the same population that we studied previously. We measured serum prolactin and progesterone concentrations by radioimmunoassay before and 30 minutes after the beginning of a suckling episode at 48 hours and 7 days after delivery. We used path analysis to develop a parsimonious multivariate prediction of the prolactin response to suckling at 48 hours and 7 days postpartum. RESULTS: As expected, prolactin values decreased from 48 hours to 7 days postpartum. Women who were overweight or obese (using the Institute of Medicine's cutoff for women of a BMI>26 kg/m2) before conception had a lower prolactin response to suckling than normal-weight women at 48 hours but not at day 7. In multivariate analyses, overweight/obesity, primiparity, and birth weight were negatively associated with the prolactin response to suckling at 48 hours. After adjustment for confounding by time since delivery and the duration of the nursing episode, only overweight/obesity remained a significant negative predictor of prolactin response to suckling at day 7. Concentrations of progesterone decreased dramatically from 48 hours to 7 days postpartum but did not differ between normal-weight and overweight/obese women at either time. In addition, the decreases in progesterone concentrations from 48 hours to 7 days postpartum did not differ between the prepregnant BMI groups.

CONCLUSION: The unique and important finding from this study is that overweight/obese women had a lower prolactin response to suckling. This would be expected to compromise the ability of overweight/obese women to produce milk and, over time, could lead to premature cessation of lactation. These findings are important because, during our observation period (just before and after lactogenesis II, the time of onset of copious milk secretion), the prolactin response to suckling is more important for milk production than it is later in lactation. We have previously shown that a high proportion of the overweight and obese women in women in this population who give up on breastfeeding do so at this time. This finding thus provides evidence of a biological basis for this association, and additional study of it is likely to be informative. We postulated that there would be consistently higher progesterone concentrations in the early postpartum period among obese compared with normal-weight women because adipose tissue is an extraplacental source of this hormone. This hypothesis was not supported in this study because there were no significant differences between normal-weight and overweight/obese women in progesterone concentrations at either 48 hours or 7 days postpartum. The values that we observed at these times were similar to those reported by others in the early postpartum period. The findings from this study add plausibility to our observation that initiation, not just duration of breastfeeding, is negatively affected by maternal overweight/obesity. Although women should begin pregnancy at a healthy weight and gain reasonably during gestation, not all will. Pediatricians can help overweight/obese women to succeed at breastfeeding by targeting them for contact with a lactation consultant before discharge from the hospital to be sure that they have received optimal advice on breastfeeding techniques. In addition, early contact with the mother after discharge--by calling her at home to offer her support and counseling for breastfeeding, by scheduling the first pediatric visit earlier than for other patients, or by enlisting the assistance of public health nurses for a home visit if this is possible--would help overweight/obese women to continue to breastfeed. Being overweight or obese is negatively associated with the prolactin response to suckling in the first week postpartum and, thus, may contribute to early lactation failure.

Group B streptococcus (GBS) is a major cause of severe systemic infections among the newborn. Both recurrent and maternal mastitis-associated, group B streptococcus diseases are uncommon. Persistence of GBS colonization of infants' mucous membrane is postulated to influence the pathogeneses of recurrent GBS infection. The authors describe a term infant who was treated for GBS sepsis and meningitis and then later developed recurrent GBS sepsis, without meningitis, due to feeding of infected breast milk. Randomly amplified polymorphic DNA polymerase chain reaction assay was performed to demonstrate that the GBS isolates from the first and second episode of infection and the maternal milk are identical. The authors conclude that transmission of GBS through breast milk should be considered in cases of recurrent neonatal GBS infection and bacterial culture of breast milk should be routinely performed in such cases.