Breastfeeding after pituitary resection: support for a theory of autocrine control of milk supply?

Arginine vasopressin deficiency: diagnosis, management and the relevance of oxytocin deficiency

Polyuria-polydipsia syndrome can be caused by central diabetes insipidus, nephrogenic diabetes insipidus or primary polydipsia. To avoid confusion with diabetes mellitus, the name 'central diabetes insipidus' was changed in 2022 to arginine vasopressin (AVP) deficiency and 'nephrogenic diabetes insipidus' was renamed as AVP resistance. To differentiate the three entities, various osmotic and non-osmotic copeptin-based stimulation tests have been introduced in the past decade. The hypertonic saline test plus plasma copeptin measurement emerged as the test with highest diagnostic accuracy, replacing the water deprivation test as the gold standard in differential diagnosis of the polyuria-polydipsia syndrome. The mainstay of treatment for AVP deficiency is AVP replacement with desmopressin, a synthetic analogue of AVP specific for AVP receptor 2 (AVPR2), which usually leads to rapid improvements in polyuria and polydipsia. The main adverse effect of desmopressin is dilutional hyponatraemia, which can be reduced by regularly performing the so-called desmopressin escape method. Evidence from the past few years suggests an additional oxytocin deficiency in patients with AVP deficiency. This potential deficiency should be further evaluated in future studies, including feasible provocation tests for clinical practice and interventional trials with oxytocin substitution.

Evaluating the Effect of a 14-Day Course of Domperidone on Breast Milk Production: A Per-Protocol Analysis from the EMPOWER Trial

BACKGROUND

Galactogogues are often considered when mothers of very preterm infants experience challenges in producing adequate amounts of breast milk. We conducted a per-protocol analysis of those mothers who completed a 14-day course of domperidone during the EMPOWER trial. Our primary aim was to evaluate the response to a completed course of domperidone and whether the response was affected by the timing of the initiation of intervention.

METHODS

For this analysis, 83 mothers of infants ≤29 weeks gestation were included: 45 mothers who received domperidone from days 1 to 14 of the trial study treatment period and 38 mothers who received domperidone from days 15 to 28. Domperidone was given at a dose of 10 mg thrice daily for 14 days. The primary outcome was the proportion of mothers who achieved a modest 50% increase in breast milk volume from the volume at the end of the 2-week period of treatment of domperidone.

RESULTS

When adjusted for the initiation of domperidone treatment, the proportion of mothers in the days 1-14 group (77.8%) was similar compared to those in the days 15-28 group (65.8%), OR 1.96 (95% CI 0.72-5.32; p = 0.19).

CONCLUSION

Taking into consideration potential limitations in power, this secondary analysis was able to show that the mothers in the EMPOWER study who were identified as actually completing a 14-day treatment course responded irrespective of the timing of their initiation of domperidone and demonstrated a modest increase in breast milk volume.

The experience of breastfeeding infants affected by congenital diaphragmatic hernia or esophageal atresia

Background

Newborns with congenital diaphragmatic hernia (CDH) and esophageal atresia (EA) might experience breastfeeding difficulties. The aim of this study was to detect the prevalence of breastfeeding in newborns with CDH and EA at different time points.

Methods

We performed an epidemiological study and retrospective survey on the prevalence of breastfeeding in CDH and EA affected newborns. We identified 40 CDH and 25 EA newborns who were fed through breastfeeding procedures according to WHO categorized definitions, and compared the breastfeeding procedures at the beginning of hospitalization and at three months of life.

Results

Although all the mothers attempted breastfeeding after birth, only 44 (67.7%) were still breastfeeding at the time of discharge. Exclusive breastfeeding was successful for only 19 (29%) mothers. The rate of exclusive breastfeeding at three months of life did not differ statistically from discharge and between the two groups of study.

Conclusion

A large percentage of mothers of children with CDH and EA who breastfed at the beginning of hospitalization did not continue at three months. It would be important to increase the breastfeeding rate in CDH and EA affected newborns by following specific steps for vulnerable infants and sustaining breastfeeding after discharge.

Supporting Mothers of Very Preterm Infants and Breast Milk Production: A Review of the Role of Galactogogues

Human milk, either mother’s own milk or donor human milk, is recommended as the primary source of nutrition for very preterm infants. Initiatives should be in place in neonatal units to provide support to the mother as she strives to initiate and maintain a supply of breast milk for her infant. The use of galactogogues are considered when these initiatives alone may not be successful in supporting mothers in this endeavor. Although there are non-pharmacologic compounds, this review will focus on the pharmacologic galactogogues currently available and the literature related to their use in mothers of very preterm infants.

Oxytocin Mediates a Calming Effect on Postpartum Mood in Primiparous Mothers

OBJECTIVES

The current study sought to characterize changes in salivary oxytocin (OT) secretion patterns across the breastfeeding cycle, and to evaluate whether breastfeeding has a positive effect on mood disturbances related to postpartum depression, via endogenous OT release.

MATERIALS AND METHODS

Twenty-four primiparous mothers who delivered vaginally at term and were exclusively breastfeeding were examined 4-5 days postpartum. Salivary OT was measured using enzyme immunoassays at 30 minutes before breastfeeding (baseline), during breastfeeding (feeding), and 30 minutes after completing breastfeeding (postfeeding). In addition, maternal mood changes were evaluated at baseline and postfeeding using the Profile of Mood States (POMS) questionnaire.

RESULTS

OT levels rose significantly during feeding (p_corr < .05) and postfeeding (p_corr < 0.05), compared with baseline. POMS scores for Tension-Anxiety were decreased postfeeding compared with baseline (p < 0.001). This decrease was significantly associated with increased OT (feeding minus baseline: r = -0.52, r_part = -0.51, postfeeding minus baseline: r = -0.53, r_part = -0.52, ps < 0.05). POMS scores for Fatigue and Confusion also decreased, while Vigor significantly increased. Significant correlations were found between Fatigue decreases and OT increases (feeding minus baseline: r = -0.48, r_part = -0.53, postfeeding minus baseline: r_part = -0.60, ps < 0.05). This result partially contradicted with the finding of no correlation between increased Vigor and increased OT.

CONCLUSIONS

OT is released across the breastfeeding cycle and can be detected with salivary measurement. This OT release exhibited a temporary anxiolytic-like calming effect on postpartum maternal mood disturbances.

Biphasic effects of moderate drinking on prolactin during lactation

BACKGROUND

Contrary to the popular lore that encourages women to drink alcohol as an aid to lactation, we previously showed that alcohol consumption disrupted lactational performance and the hormonal milieu of the lactating mother in the short term.

METHODS

Thirteen lactating women participated in a 4-session, double-blind, 2 x 2 within-subject study to test several hypotheses related to the effects of alcohol on prolactin (PRL) responses and milk yield over time. The two within-subject factors were beverage condition (control or 0.4 g/kg dose of alcohol) and pumping condition (pumping occurred at fixed intervals once or twice during the 5.3-hour session). Plasma PRL, blood alcohol concentrations (BAC), and milk yield were measured.

RESULTS

Alcohol consumption increased basal PRL levels (p < 0.0001) and modified the PRL response to pumping (p < 0.0001) but the directionality of the response depended on when pumping occurred along the BAC curve. Pumping enhanced PRL response when it occurred during the ascending BAC limb but blunted the response when it occurred during the descending limb, providing evidence that the effects were transient and of a biphasic nature. The slower the alcohol was metabolized, the greater the relative PRL response to breast pumping (p < 0.05). The dynamics of the PRL response between pumping sessions was also altered if women drank. If women pumped within the hour after drinking alcohol, the PRL response during the next pumping some 1.5 hours later, was delayed by a few minutes. Milk yield was significantly lower after drinking alcohol but such deficits were not significantly related to PRL or the speed at which alcohol was eliminated.

CONCLUSIONS

Effects of alcohol on suckling-induced PRL were biphasic in nature, but could not explain the deficits in lactational performance. Such findings provide further evidence that the dynamic changes in neuroendocrine state are integrally involved in alcohol's effects over time and underscore the complexity of lactation.

Breastfeeding, wage labor, and insufficient milk in peri-urban Kathmandu, Nepal

This article presents a case study of breastfeeding mothers who are working as carpet-makers in peri-urban Kathmandu, Nepal. A sample of women surveyed about their current infant feeding practices revealed that half of the infants aged three to four months had been introduced to non-breast milk foods and liquids. During in-depth interviews some mothers explained that they supplemented breastfeeding with either milk or solids if they felt that they did not have enough breast milk for their infants. Reports of insufficient milk (IM) among these Nepali women is discussed within the larger context of IM as a worldwide phenomenon that is often associated with the cessation of breastfeeding and the switch to bottle-feeding based on commercial milk products. On average, the women in this study breastfed their infants until the latter were approximately three years of age. A status quo method for determining median duration of breastfeeding indicates that there is no significant difference in the duration of breastfeeding between mothers who work in carpet-making factories and those who spin wool at home. It is argued that reports of IM in this setting are not associated with the abandonment of breastfeeding, for a number of reasons including: the cultural approbation of breastfeeding; the low usage of baby bottles among peri-urban mothers, and the flexible labor practices of the carpet-making industry.

Serum prolactin in breastfeeding: state of the science

Prolactin is one of two major hormones involved in lactation. While the role of infant suckling and oxytocin in the lactation process are well understood, the role of prolactin is less clear. A variety of factors related to prolactin have been investigated, and these are used as an organizing framework for this article. Factors include pregnancy, lactation, nursing frequency, prior lactation experience, milk production, and pharmacologic agents. The literature, while substantial in amount, presents inconsistencies. Implications for practice are discussed.

Smoking relapse and early weaning among postpartum women: is there an association?

BACKGROUND

Smoking in the postpartum period may contribute to early weaning, although the nature and temporal aspect of the relationship are poorly understood. The objective of this study was to examine the association between early weaning and smoking relapse among women who stopped smoking during pregnancy.

METHODS

A secondary analysis of data from a randomized controlled trial was conducted. The participants were 228 women who had stopped smoking for pregnancy, who participated in a smoking relapse prevention trial, and who breastfed. Women who relapsed to daily smoking postpartum were compared with those who remained abstinent or smoked occasionally. The dependent variable was breastfeeding for less than 26 weeks (early weaning). Potential covariates included intended duration of breastfeeding, parity, partner's smoking, nicotine dependence, emotional health, return to paid employment, and various sociodemographic variables.

RESULTS

Approximately two-thirds (65.1%) of the women who relapsed to daily smoking weaned before 26 weeks compared with 33.8 percent of the women who remained abstinent or smoked occasionally. Controlling for intended duration of breastfeeding, education, and return to paid employment, women who resumed daily smoking were almost four times more likely to wean early than those who abstained or smoked occasionally.

CONCLUSIONS

Early weaning may result from psychological or physiological changes associated with tobacco use. Smoking relapse prevention in the postpartum period may be one of the most effective interventions in ensuring that women who stop smoking for pregnancy remain stopped and breastfeed their babies for the recommended duration.

The effect of sequential and simultaneous breast pumping on milk volume and prolactin levels: a pilot study

Mothers who must express milk for a prolonged period frequently report that milk volumes decrease. The purpose of this pilot study was to assess the feasibility of having a sample of lactating mothers of preterm infants follow a specific breast pumping protocol, express milk mechanically for six weeks, and have a subsample consent to venipuncture. This pilot study compared the effects of pumping breasts sequentially or simultaneously on milk volume and prolactin levels in mothers of preterm infants. Nine lactating mothers were randomly assigned to a sequential single or simultaneous double electric breast pumping system. Prolactin levels were examined in four mothers on days 21 and 42 postpartum. The sequential single and simultaneous double groups had mean baseline prolactin levels of 50.8 ng/ml and 40.6 ng/ml, respectively on day 21, and 26.6 ng/ml and 34.5 ng/ml, respectively, on day 42 postpartum. At 9 and 12 weeks postpartum mothers were queried about their lactational status. The results suggested that milk yield may be maintained or increased with frequent use of the simultaneous double pumping system. Further study is needed to confirm results of this pilot study.

Swimming upstream: breastfeeding care in a nonbreastfeeding culture

Women once gave birth and began breastfeeding within the cultural context of a traditional system of care; now they begin breastfeeding in a hospital. Historically, hospital care was arranged to fit artificial feeding. Little was known about the science of breastfeeding until recently. Basing our breastfeeding care on the cultural norm of bottle feeding has led to the development of many unfavorable attitudes and practices. Given an opportunity to learn how breastfeeding works and to improve our breastfeeding care skills, hospital nurses can play an important part in current efforts to make breastfeeding the community norm.

Serum lactogens possessed normal bioactivity in patients with lactation insufficiency

OBJECTIVE

Insufficient breast milk is the most common reason for premature termination of breast-feeding. The causes of lactation insufficiency are usually multifactorial; in a small percentage of cases it is due to primary lactation failure of unknown origin. The aim of this study was to investigate whether lactation insufficiency of unknown origin could be caused by serum lactogens that had reduced biological activity.

DESIGN

Women with lactation insufficiency of unknown origin and normal lactating controls were subjected to a standardized breast-feeding test for assessment of milk production. Thirty minutes later, serum samples were obtained for determination of total lactogen bioactivity, using an in-vitro bioassay, and levels of prolactin (PRL) and growth hormone (GH) using radioimmunoassay (RIA).

PATIENTS

Twelve lactating mothers with a clinical diagnosis of lactation insufficiency of unknown origin were compared with 12 matched mothers with normal lactation.

MEASUREMENTS

The Nb2 lymphoma cell bioassay was used to measure total lactogen bioactivity in sera. Conventional RIA kits were used to estimate serum PRL and GH concentrations.

RESULTS

Mean milk yield on standardized test feed was 21.6 ml for patients and 146.5 ml for controls. In both patient and control groups the total serum lactogen bioactivity ranged from about 150 to 5000 mIU/l, while the serum RIA (PRL+GH) levels ranged from about 350 to over 7000 mIU/l. There was no evidence of lactogens with reduced bioactivity in the patients' sera.

CONCLUSION

Lactation insufficiency in the women studied cannot be explained by serum lactogens that possess unusually low bioactivity.