Breastfeeding women often need to take medicines, and therefore health professionals need to consider the effects of medication on lactation and the breastfed infant, and any associated risks. This commentary discusses the tragic case of a young woman with a history of mental illness who committed suicide in the postpartum period. She was determined to be a 'good mother' and breastfeed, and to avoid any potential adverse effects of medication on her breastfed infant. The final outcome was fatal for both mother and child. We argue that if women require medication during lactation, all risks need to be considered – the risk of not treating the maternal medical condition may greatly outweigh the potential risk to the breastfed infant.

Background

The perceived risk/benefit balance of prescribed and over-the-counter (OTC) medicine, as well as complementary therapies, will significantly impact on an individual’s decision-making to use medicine. For women who are pregnant or breastfeeding, this weighing of risks and benefits becomes immensely more complex because they are considering the effect on two bodies rather than one. Indeed the balance may lie in opposite directions for the mother and baby/fetus. The aim of this paper is to generate a discussion that focuses on the complexity around risk, responsibility and decision-making of medicine use by pregnant and breastfeeding women. We will also consider the competing discourses that pregnant and breastfeeding women encounter when making decisions about medicine.

Discussion

Women rely not only on biomedical information and the expert knowledge of their health care professionals but on their own experiences and cultural understandings as well. When making decisions about medicines, pregnant and breastfeeding women are influenced by their families, partners and their cultural societal norms and expectations. Pregnant and breastfeeding women are influenced by a number of competing discourses. “Good” mothers should manage and avoid any risks, thereby protecting their babies from harm and put their children’s needs before their own – they should not allow toxins to enter the body. On the other hand, “responsible” women take and act on medical advice – they should take the medicine as directed by their health professional. This is the inherent conflict in medicine use for maternal bodies.

Summary

The increased complexity involved when one body’s actions impact the body of another – as in the pregnant and lactating body – has received little acknowledgment. We consider possibilities for future research and methodologies. We argue that considering the complexity of issues for maternal bodies can improve our understanding of risk and public health education.

Background

The CASTLE (Candida and Staphylococcus Transmission: Longitudinal Evaluation) study will investigate the micro-organisms involved in the development of mastitis and "breast thrush" among breastfeeding women. To date, the organism(s) associated with the development of breast thrush have not been identified. The CASTLE study will also investigate the impact of physical health problems and breastfeeding problems on maternal psychological health in the early postpartum period.

Methods/Design

The CASTLE study is a longitudinal descriptive study designed to investigate the role of Staphylococcus spp (species) and Candida spp in breast pain and infection among lactating women, and to describe the transmission dynamics of S. aureus and Candida spp between mother and infant. The relationship between breastfeeding and postpartum health problems as well as maternal psychological well-being is also being investigated. A prospective cohort of four hundred nulliparous women who are at least thirty six weeks gestation pregnant are being recruited from two hospitals in Melbourne, Australia (November 2009 to June 2011). At recruitment, nasal, nipple (both breasts) and vaginal swabs are taken and participants complete a questionnaire asking about previous known staphylococcal and candidal infections. Following the birth, participants are followed-up six times: in hospital and then at home weekly until four weeks postpartum. Participants complete a questionnaire at each time points to collect information about breastfeeding problems and postpartum health problems. Nasal and nipple swabs and breast milk samples are collected from the mother. Oral and nasal swabs are collected from the baby. A telephone interview is conducted at eight weeks postpartum to collect information about postpartum health problems and breastfeeding problems, such as mastitis and nipple and breast pain.

Discussion

This study is the first longitudinal study of the role of both staphylococcal and candidal colonisation in breast infections and will help to resolve the current controversy about which is the primary organism in the condition known as breast thrush. This study will also document transmission dynamics of S. aureus and Candida spp between mother and infant. In addition, CASTLE will investigate the impact of common maternal physical health symptoms and the effect of breastfeeding problems on maternal psychological well-being.

Clinicians, public health advisors, nutritionists and others have been attempting to increase breastfeeding rates for the last few decades, with varying degrees of success. We need social science researchers to help us understand the role of infant feeding in the family. Some researchers in the area of food and nutrition have found Pierre Bourdieu's theoretical framework helpful. In this editorial, I introduce some of Bourdieu's ideas and suggest researchers interested in infant feeding should consider testing these theories.

Background

Many breastfeeding women seek medical care from general practitioners (GPs) for various health problems and GPs may consider prescribing medicines in these consultations. Prescribing medicines to a breastfeeding mother may lead to untimely cessation of breastfeeding or a breastfeeding mother may be denied medicines due to the possible risk to her infant, both of which may lead to unwanted consequences. Information on factors governing GPs' decision-making and their views in such situations is limited.

Methods

GPs providing shared maternity care at the Royal Women's Hospital, Melbourne were surveyed using an anonymous postal survey to determine their knowledge, attitudes and practices on medicines and breastfeeding, in 2007/2008 (n = 640). Content analysis of their response to a question concerning decision-making about the use of medicine for a breastfeeding woman was conducted. A thematic network was constructed with basic, organising and global themes.

Results

335 (52%) GPs responded to the survey, and 253 (76%) provided information on the last time they had to decide about the use of medicine for a breastfeeding woman. Conditions reported were mastitis (24%), other infections (24%) and depressive disorders (21%). The global theme that emerged was "complexity of managing risk in prescribing for breastfeeding women". The organising themes were: certainty around decision-making; uncertainty around decision-making; need for drug information to be available, consistent and reliable; joint decision-making; the vulnerable "third party" and infant feeding decision. Decision-making is a spectrum from a straight forward decision, such as treatment of mastitis, to a complicated one requiring multiple inputs and consideration. GPs use more information seeking and collaboration in decision-making when they perceive the problem to be more complex, for example, in postnatal depression.

Conclusion

GPs feel that prescribing medicines for breastfeeding women is a contentious issue. They manage the risk of prescribing by gathering information and assessing the possible effects on the breastfed infant. Without evidence-based information, they sometimes recommend cessation of breastfeeding unnecessarily.

Jane Scott and colleagues have recently published a paper in the International Breastfeeding Journal showing that health professionals are still giving harmful advice to women with mastitis. We see the management of mastitis as an illustration of health professionals' management of wider breastfeeding issues. If health professionals don't know how to manage this common problem, how can they be expected to manage less common conditions such as a breast abscess or nipple/breast candidiasis? There is an urgent need for more clinical research into breastfeeding problems and to improve the education of health professionals to enable them to promote breastfeeding and support breastfeeding women.

Background

The Breastfeeding Education and Support Services (BESS) is a unit of The Royal Women's Hospital in Melbourne, Australia, staffed by International Board Certified Lactation Consultants (IBCLCs), providing day/short-stay and an outpatient clinic for mothers and infants with breastfeeding problems. It is important to measure women's experience of visiting the service as part of quality assurance. The aim of this project was to conduct an anonymous postal survey of clients' satisfaction with BESS.

Methods

An anonymous survey was posted on 16 November 2005 and again on 31 January 2006, to all women who had attended BESS in September 2005.

Results

The response rate was 60.5% (78/129). Eighty percent (62/78) of respondents attended day-stay, 33% (26/78) attended short-stay and 15% (12/78) attended the outpatient clinic. The percentage of women who responded "strongly agree" to the statement "Overall, I am satisfied with the services" was 49% (35/72) and 50% (6/12) for those who went to day/short-stay and the outpatient clinic respectively. Overall, 56% of all respondents responded that the quality of BESS was "better than expected". The most common breastfeeding problem reported was difficulty attaching the baby to the breast, followed by nipple damage, low milk supply and painful feeding.

Conclusion

BESS seems to have provided a satisfactory service to most clients. Most respondents were clearly satisfied with the support given by the IBCLCs and have also responded that the staff were professional and knowledgeable in their field of work.

The relationship between poverty and human development touches on a central aim of the International Breastfeeding Journal's editorial policy which is to support and protect the health and wellbeing of all infants through the promotion of breastfeeding. It is proposed that exclusive breastfeeding for 6 months, followed by continued breastfeeding to 12 months, could prevent 1,301,000 deaths or 13% of all child deaths under 5 years in a hypothetical year. Although there is a conventional wisdom that poverty 'protects' breastfeeding in developing countries, poverty actually threatens breastfeeding, both directly and indirectly. In the light of increasingly aggressive marketing behaviour of the infant formula manufacturers and the need to protect the breastfeeding rights of working women, urgent action is required to ensure the principles and aim of the International Code of Breastmilk Substitutes, and subsequent relevant resolutions of the World Health Assembly, are implemented. If global disparities in infant health and development are to be significantly reduced, gender inequities associated with reduced access to education and inadequate nutrition for girls need to be addressed. Improving women's physical and mental health will lead to better developmental outcomes for their children.

Background

Breastfeeding behaviour is multifactorial, and a wide range of socio-cultural and physiological variables impact on a woman's decision and ability to breastfeed successfully. An association has been reported between maternal obesity and low breastfeeding rates. This is of public health concern because obesity is rising in women of reproductive age and the apparent association with increased artificial feeding will lead to a greater risk of obesity in children. The aim of this paper is to examine the relationship between maternal overweight and obesity and breastfeeding intention and initiation and duration.

Methods

A systematic review was conducted in January and February 2007, using the following databases: Medline, CINAHL and the Australian Breastfeeding Association's Lactation Resource Centre. Studies which have examined maternal obesity and infant feeding intention, initiation, duration and delayed onset of lactation were tabulated and summarised.

Results

Studies have found that obese women plan to breastfeed for a shorter period than normal weight women and are less likely to initiate breastfeeding. Of the four studies that examined onset of lactation, three reported a significant relationship between obesity and delayed lactogenesis. Fifteen studies, conducted in the USA, Australia, Denmark, Kuwait and Russia, have examined maternal obesity and duration of breastfeeding. The majority of large studies found that obese women breastfed for a shorter duration than normal weight women, even after adjusting for possible confounding factors.

Conclusion

There is evidence from epidemiological studies that overweight and obese women are less likely to breastfeed than normal weight women. The reasons may be biological or they may be psychological, behavioral and/or cultural. We urgently need qualitative studies from women's perspective to help us understand women in this situation and their infant feeding decisions and behaviour.

Background

Mastitis is one of the most common problems experienced by women who are breastfeeding. Mastitis is an inflammation of breast tissue, which may or may not result from infection. The aims of this paper are to compare rates of mastitis in primiparous women receiving public hospital care (standard or birth centre) and care in a co-located private hospital, and to use multivariate analysis to explore other factors related to mastitis.

Methods

Data from two studies (a randomised controlled trial [RCT] and a survey) have been combined. The RCT (Attachment to the Breast and Family Attitudes to Breastfeeding, ABFAB) which was designed to test whether breastfeeding education in mid-pregnancy could increase breastfeeding duration recruited public patients at the Royal Women's Hospital at 18–20 weeks gestation. A concurrent survey recruited women planning to give birth in the Family Birth Centre (at 36 weeks gestation) and women in the postnatal wards of Frances Perry House (private hospital). All women were followed up by telephone at 6 months postpartum. Mastitis was defined as at least 2 breast symptoms (pain, redness or lump) AND at least one of fever or flu-like symptoms.

Results

The 6 month telephone interview was completed by 1193 women. Breastfeeding rates at 6 months were 77% in Family Birth Centre, 63% in Frances Perry House and 53% in ABFAB. Seventeen percent (n = 206) of women experienced mastitis. Family Birth Centre and Frances Perry House women were more likely to develop mastitis (23% and 24%) than women in ABFAB (15%); adjusted odds ratio (Adj OR) ~1.9. Most episodes occurred in the first 4 weeks postpartum: 53% (194/365). Nipple damage was also associated with mastitis (Adj OR 1.7, 95% CI, 1.14, 2.56). We found no association between breastfeeding duration and mastitis.

Conclusion

The prevention and improved management of nipple damage could potentially reduce the risk of lactating women developing mastitis.

Trial registration

Trial registration (ABFAB): Current Controlled Trials ISRCTN21556494

Despite current scientific evidence that artificial feeding is a harmful practice, unquestioned acceptance of breastfeeding as the normal or "default" method of infant feeding remains elusive in the industrialised world. Throughout the developing world the profound consequences of the aggressive marketing strategies of the infant formula industry since the end of the Second World War is well known. A key objective of the International Breastfeeding Journal is to promote breastfeeding through addressing issues that encourage breastfeeding initiation, duration and effective management. Informing this aim is the recognition of artificial feeding as a harmful practice that places infant health at risk. From this perspective it would be unethical for this journal to accept for publication any manuscript that has received funding, sponsorship or any other means of support from infant formula manufacturers. This stance is consistent with the journal's aim of supporting, protecting and promoting breastfeeding. It will also contribute to the promotion of a breastfeeding culture.

Background

Mastitis is a common problem for breastfeeding women. Researchers have called for an investigation into the possible role of maternal nasal carriage of S. aureus in the causation of mastitis in breastfeeding women.

Methods

The aim of the study was to investigate the role of maternal S. aureus nasal carriage in mastitis. Other factors such as infant nasal S. aureus carriage, nipple damage, maternal fatigue and oversupply of milk were also investigated. A case-control design was used. Women with mastitis (cases, n = 100) were recruited from two maternity hospitals in Melbourne, Australia (emergency departments, breastfeeding clinics and postnatal wards). Breastfeeding women without mastitis (controls, n = 99) were recruited from maternal and child health (community) centres and the rooms of a private obstetrician. Women completed a questionnaire and nasal specimens were collected from mother and baby and placed in charcoal transport medium. Women also collected a small sample of milk in a sterile jar.

Results

There was no difference between nasal carriage of S. aureus in breastfeeding women with mastitis (42/98, 43%) and control women (45/98, 46%). However, significantly more infants of mothers with mastitis were nasal carriers of S. aureus (72/88, 82%) than controls (52/93, 56%). The association was strong (adjusted OR 3.23, 95%CI 1.30, 8.27) after adjustment for the following confounding factors: income, private health insurance, difficulty with breastfeeding, nipple damage and tight bra. There was also a strong association between nipple damage and mastitis (adjusted OR 9.34, 95%CI 2.99, 29.20).

Conclusion

We found no association between maternal nasal carriage of S. aureus and mastitis, but nasal carriage in the infant was associated with breast infections. As in other studies of mastitis, we found a strong association between nipple damage and mastitis. Prevention of nipple damage is likely to reduce the incidence of infectious mastitis. Mothers need good advice about optimal attachment of the baby to the breast and access to skilled help in the early postpartum days and weeks.

Background

About 3% of infants are born with a tongue-tie which may lead to breastfeeding problems such as ineffective latch, painful attachment or poor weight gain. The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) has been developed to give a quantitative assessment of the tongue-tie and recommendation about frenotomy (release of the frenulum). The aim of this study was to assess the inter-rater reliability of the HATLFF.

Methods

Fifty-eight infants referred to the Breastfeeding Education and Support Services (BESS) at The Royal Women's Hospital for assessment of tongue-tie and 25 control infants were assessed by two clinicians independently.

Results

The Appearance items received kappas between about 0.4 to 0.6, which represents "moderate" reliability. The first three Function items (lateralization, lift and extension of tongue) had kappa values over 0.65 which indicates "substantial" agreement. The four Function items relating to infant sucking (spread, cupping, peristalsis and snapback) received low kappa values with insignificant p values. There was 96% agreement between the two assessors on the recommendation for frenotomy (kappa 0.92, excellent agreement). The study found that the Function Score can be more simply assessed using only the first three function items (ie not scoring the sucking items), with a cut-off of ≤4 for recommendation of frenotomy.

Conclusion

We found that the HATLFF has a high reliability in a study of infants with tongue-tie and control infants

International Breastfeeding Journal is a new open access peer-reviewed journal with a multidisciplinary focus. The aim of International Breastfeeding Journal is to contribute to understanding all aspects of breastfeeding. Breastfeeding is recognized as an important public health issue with enormous social and economic implications. In order to help women breastfeed successfully there is a need to understand both the physiology of lactation and the social and cultural context within which breastfeeding occurs. International Breastfeeding Journal invites manuscripts from around the world, which address all of these aspects, including the impediments to breastfeeding, the health effects of not breastfeeding for infants and their mothers, and the management of breastfeeding problems.

Background

Few studies have examined the attitude of medical practitioners towards the availability of emergency contraception (EC) without prescription. In Indonesia, EC (either Yuzpe regimen or Postinor-2) is available by prescription only. We aimed to examine the level of knowledge, attitudes and practices of medical practitioners in Indonesia about EC, in particular their attitudes to the availability of EC over-the-counter (OTC), using a questionnaire.

Methods

Data were collected by an anonymous structured questionnaire. Questionnaires were distributed to general practitioners in 36 Community Health Centres and 25 private clinics using stratified random sampling according to area in Jakarta, and to obstetricians practicising in 24 government and private hospitals and eight private clinics in Jakarta. Two hundred and five general practitioners and 142 obstetricians and gynaecologists participated; overall response rate was 75%.

Results

Although most participants were familiar with EC, only 22% received a very good knowledge score (4 or 5/5 answers correct), while 52% received a poor score (0–2/5 correct). Most participants did not support the OTC availability of EC (70%). Logistic regression identified that participants who prescribed EC had an Odds of 3.8 (95% CI 1.90, 7.73) of approving OTC EC, after adjustment for age and speciality.

Conclusion

Although many organisations are working towards OTC availability of EC, it needs to be recognized and addressed that doctors who do not prescribe EC are unlikely to support the increased availability of EC.