Complementary Therapies and Lactation Suppression
Complementary Therapies and Lactation Suppression
By Susan T. Marcolina, MD, FACP, and Pamela Denchfield Dr. Marcolina is an internist and geriatrician, and Ms. Denchfield is a technical writer at Siemens Medical Solutions USA, Inc., in Issaquah, WA. Dr. Marcolina reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study. Ms. Denchfield reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.
One of the goals for healthy people 2010 (HP 2010) is to support a high rate of breastfeeding in postpartum women. Recommendations are for 75% of women in the United States to breastfeed their infants in the hospital and for 50% or more to continue this practice until at least six months of age due to the tremendous health benefits to both mother and baby. To meet these recommendations, nationwide support for various breastfeeding initiatives has resulted in a rate of about 64% for in-hospital breastfeeding.1 There is, however, very little information in the medical literature regarding the converse situation, the suppression of lactation for those women who cannot or do not breastfeed. There are a variety of medical situations for both the infant and the mother for which breastfeeding is contraindicated.2,3 (See Table 1.) In the case of infant death, breastfeeding is no longer necessary. It is important to support mothers and families during these times by providing culturally sensitive, supportive verbal and written information with practical suggestions about how to prevent painful engorgement and care for their bodies as their breasts involute and milk production ceases.
Patients who have stillborn infants frequently are discharged from the hospital earlier than women who have had a live birth. In a nationwide, population-based study of 314 Swedish women with stillbirth, Radestad et al found that about half of the women left the hospital within 24 hours after stillbirth and 10% went home within six hours.4 Since the physiologic timeline for engorgement with symptoms of milk leakage and breast pain peaks at three to five days postpartum, if they have not received preparatory instructions, these patients have an additional worry in addition to their grief. Therefore, primary care physicians who have had ongoing relationships with these patients can educate them about breast care and offer treatment options to avoid infectious complications, such as mastitis or abscess, and to help the patients regain a measure of control and comfort during a time of severe stress.
Lactation Physiology
The breast is one of the most complex endocrine target organs. Changes in hormone levels and a complex interplay of circulating pituitary, ovarian, thyroid, adrenal, and pancreatic hormones cause profound changes in the breast's parenchymal structure and growth during pregnancy. During the first trimester, marked increases in ductular sprouting, branching, and lobular formation are stimulated by luteal, pituitary, and placental hormones, including estrogen, progesterone, placental lactogen, prolactin, and chorionic gonadotropin. After the first trimester (third month of gestation), secretory material resembling colostrum appears in the glandular acini. The synthesis of the milk proteins casein and lactalbumin is regulated primarily by prolactin but is facilitated by growth hormone, cortisol, and insulin. Due to the effectiveness of this hormonal stimulation on the breast, a mother who delivers at 16 weeks of gestation secretes colostrum although she has a nonviable infant.2
After delivery of the placenta, levels of placental lactogen, estrogen, and progesterone decline abruptly. The drop in progesterone levels triggers milk secretion.5 For a breastfeeding woman, the tactile effect of postpartum suckling at the breast maintains the high levels of prolactin established during pregnancy and stimulates the release of oxytocin, a posterior pituitary hormone with receptors in the myoepithelial cells of the breast, which causes the milk ejection reflex or "let-down." If a woman does not breastfeed, the lack of suckling stimulus causes prolactin levels to decrease. In addition, the back pressure of the unexpressed milk in the alveoli and lactiferous sinuses causes an increase in the levels of feedback inhibitor of lactation (FIL), which also inhibits prolactin release from the pituitary gland, physiologically diminishing lactation. This distension of the breast ducts with milk occludes the capillary circulation of the alveolar cells, resulting in fluid leakage into the breast interstitial space causing edema. Subsequently, the resulting increased pressure and congestion obstructs lymphatic drainage of the breasts. If the breast is not stimulated after the first week, tissue regression proceeds and breast involution and milk cessation occurs within 10-14 days.2 During this process mothers experience engorgement. Careful attention to breast care is important to prevent pathologic, painful engorgement, which can progress to infectious complications.
Numerous treatment modalities for breast engorgement have been espoused both anecdotally and in the literature. Pugmire has created a brochure for breast care for the bereaved mother that summarizes the following best studied treatments.6
Pharmacologic Methods to Suppress Lactation
Dopamine Receptor Agonists. Prior to 1990, pharmacologic methods, primarily dopamine receptor agonists such as bromocriptine, were used in the United States to suppress lactation. In 1988, however, the FDA recommended against the routine use of pharmacologic methods (except analgesics) for lactation suppression and relief of associated physical symptoms. Although it decreases prolactin levels and lactation in the first week postpartum, bromocriptine use has been associated with "rebound" lactation in 18-40% of patients. In addition, 16-23% of women treated with bromocriptine experience clinical side effects such as dizziness, vertigo, and nausea; adverse events such as puerperal hypertension, seizures, acute myocardial infarction, and stroke noted in patients during therapy made the risks for treatment unacceptably high.7-9
The European Multicenter Study Group for Cabergoline in Lactation Inhibition was a randomized, double-blind, prospective study of single-dose cabergoline, a long-acting dopamine receptor agonist, vs. bromocriptine for inhibition of puerperal lactation. Cabergoline has preferential binding at the D2 sites, and a long elimination half-life of between 63-69 hours.10 In this study, 272 puerperal women not wishing to breastfeed were enrolled in the study. Half were randomized to bromocriptine 2.5 mg bid for 14 days while the other half received 0.5 mg of cabergoline for the first day and placebo tablets for the remaining 14 days. Both initial doses were given within 27 hours of delivery. Cabergoline was as effective as bromocriptine in the prevention of puerperal lactation and had a much lower rate of rebound lactation during the third week postpartum (5% vs. 24%), resulting in a higher rate of complete success (78% for cabergoline, 69% for bromocriptine) up to the end of the three-week observation period. Adverse events occurred in 16% of women randomized to the cabergoline group vs. 27% in the bromocriptine group; the most common side effects were dizziness, headache, nausea, and vertigo. No adverse clinical events occurred during safety monitoring throughout the study.11
Cabergoline, however, is not FDA approved for puerperal lactation suppression due to the adverse clinical events noted previously with bromocriptine.
Proteolytic Enzymes. Kee et al evaluated the use of serrapeptase, a proteolytic enzyme in the proprietary product Danzen (Takeda Chemical Industries, Ltd.), in a double-blind, randomized, placebo-controlled study of 70 women with breast engorgement. Subjects were divided randomly into a treatment group and a placebo group. A single observer assessed the severity of the signs and symptoms of breast engorgement prior to treatment and daily during therapy administration (a three-day period). Danzen was significantly superior to placebo for improving breast pain, swelling, and induration (P < 0.05). No adverse effects were reported in this short-term study. However, serrapeptase and other types of proteolytic enzymes do interact with anticoagulant medications and increase the absorption and tissue levels of antibiotics, including amoxicillin, tetracycline, chloramphenicol, and penicillin. Proteolytic enzymes should not be used in persons receiving anticoagulant medications or antibiotics.12,13
Nonpharmacologic Lactation Suppression
Some mothers who experience stillbirth or the death of their infant shortly after birth regard the expression of breast milk as something positive. Therefore, it is quite possible that practical, nonpharmacologic activities required to reduce the pain and swelling in the breasts constitute a confrontation of the reality of a mother's loss, which can assist with the closure process. However, there have been no studies of how specific nonpharmacological methods of lactation inhibition affect a woman's grief reaction and the prevalence of long-term symptoms.
Previous breastfeeding experience, but not parity, affect the lactation process that a woman experiences for a given pregnancy. Second-time breastfeeding mothers experience greater levels of engorgement sooner with faster resolution then mothers who are first-time breast feeders. Breast engorgement for multiparous mothers who breastfeed for the first time is similar to that of primiparous breastfeeding mothers.14
Breast Binding. In 1966, Bristol compared the continuous use of a compression breast binder to that of a support bra for lactation suppression in two groups of 19 women for the first 14 postpartum days.15 There were no significant differences between the two groups in terms of degree of breast engorgement or in the presence and amount of breast leakage but there was a significant difference in reported breast tenderness by the women in the support bra group. Janke and Swift performed a systematic replication of this study design in a group of 60 women from a private south-central U.S. hospital.16 Half of the women were assigned randomly to placement of a breast binder made of standard elastic and cotton bandage and half to a support bra fitted to standardized criteria. The women assigned to breast binders had significantly more tenderness (P = 0.043), more leakage (P = 0.015), and more pain as evidenced by increased use of pain relief techniques including ice applications and narcotic and non-narcotic pain medication (P = 0.024).
Fluid Restriction. Restricting fluids does not decrease milk volume.17 Drinking to thirst and heeding body cues regarding urinary output frequency is a more physiologic way to avoid the problems of milk stasis and ductal blockage, particularly in hot weather. Acutely decreasing fluid intake for the purpose of preventing engorgement in non-lactating women is not effective and causes inconvenience and discomfort for the patient.2
Cold Compress and Cabbage Leaf Applications. In a randomized clinical trial with two experimental groups comparing the effects of cold cabbage leaf applications or chilled gelpaks on engorgement, Roberts showed that although both treatments offered some pain relief, no significant difference in reducing breast engorgement was found between the two treatments.18 Hill conducted a randomized, controlled trial with two experimental groups, one using chilled cabbage leaves and one using chilled gelpaks and an untreated control group.19 No significant differences in the degree of engorgement or duration of pain were found among the three groups. Nikodem et al performed a controlled trial of 120 breastfeeding women randomized at 72 hours postpartum to receive either experimental application of green cabbage leaves (Brassica oleracea) to their breasts or routine postpartum care.20 Although the experimental cabbage leaf group tended to report less breast engorgement, this trend was not statistically significant compared to the control group.
Roberts et al randomly assigned 28 lactating women to two treatment groups: Women in one group received chilled cabbage leaves on the right breast and room temperature cabbage leaves on the left breast, while women in the other group had the reverse treatment.21 Perceptions of pain in the study patients were assessed with a validated visual analogue scale. The mean pretreatment rating of pain on the pain scale was 5.4, which was classified as moderate pain. The post-treatment pain scale rating was 3.4 for the room temperature cabbage leaves and 3.3 for the chilled cabbage leaves. These ratings represented statistically significant pain reductions of 37% for the room temperature cabbage leaf application (P = 0.0001) and 38% for the chilled cabbage leaf application (P = 0.0001). Since the patients were not blinded in the trial, placebo effect cannot be excluded.21 Also, the massage of the breasts required in placement of the cabbage leaves may exert the beneficial effects instead of the cabbage leaves themselves.22
Manual Expression of Breast Milk. Milk production will diminish gradually without excessive discomfort if the woman removes just enough milk by gentle manual expression to reduce pressure in the breasts, but not enough to empty them. Suspension of the breasts in a bowl of warm water to stimulate the milk ejection reflex and initiate milk flow is another technique that can be used adjunctively to relieve painful engorgement.2
Milk Bank Donations
Some women may choose to deal with their grief by donation of their milk supply to a milk bank so their milk can be used to benefit a baby whose mother cannot provide milk. Such women can use manual or electric breast pumps to express their milk with gradual withdrawal of the pumping sessions to slowly lessen and stop their milk supply. Eight milk banks exist in the United States.23 The donors undergo a screening process that includes a physician-verified medical and health history questionnaire and specific blood tests. The current serologic panel includes testing for HIV-1 and -2 antibody and antigen, HTLV-1 and -2 antibody, hepatitis B surface antigen, hepatitis C antibody, and syphilis. Milk that tests positive is not accepted for donation. Donors must freeze their expressed milk immediately after expression in the containers provided by the milk bank. To ensure that recipients receive a safe product, the FDA and the Centers for Disease Control require all donated milk to be pasteurized to eliminate the risks of transmission of viral and bacterial infectious agents. No milk is dispensed unless postpasteurization bacterial counts are zero. Pasteurization does not affect the transfer of immunoglobulins, enzymes, hormones, and growth factor.2,24
The questionnaire for donation should be reviewed with the woman prior to her application to be a donor to avoid a possible decline of the breast milk, which can further exacerbate the grief and stress the patient is experiencing. Table 2 lists reasons that potential donors are excluded.
Recommendation
Practical nonpharmacologic suggestionssuch as wearing comfortable support bras, maintenance of adequate hydration, and application of green cabbage leaveshave been shown in studies to be effective for the prevention and management of breast engorgement. Milk bank donation may be an option for women who have experienced the death of an infant. For women with personal or medical reasons for not breastfeeding, lactation suppression by nonpharmacologic means can enable the body's natural mechanisms for involution and milk cessation to occur. Women who develop fevers and painful localized areas of induration and erythema of their breasts should be evaluated immediately and managed with antibiotics and surgical drainage as indicated clinically.
References
1. Hill PD. Update on breastfeeding: Healthy People 2010 objectives. MCN Am J Matern Child Nurs 2000;25:248-251.
2. Lawrence RA. Contraindications to and disadvantages of breastfeeding. In: Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 3rd ed. St. Louis, MO: CV Mosby Company; 1989.
3. American Academy of Pediatrics. Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics 2001;108:776-789.
4. Radestad I, et al. A comparison of women's memories of care during pregnancy, labour and delivery after stillbirth or live birth Midwifery 1998;14:111-117.
5. The mechanism of milk secretion. In: Neville MC, Niefert MR, eds. Lactation: Physiology, Nutrition and Breastfeeding. New York, NY: Plenum Press; 1983.
6. Pugmire L. Breast Care for the Bereaved Mother. Seattle, WA: Breastfeeding Coalition of Washington; 1998. Reproducible brochure available through the Breastfeeding Coalition of Washington: (800) 322-2588.
7. Postpartum hypertension, seizures and stroke reported with bromocriptine. FDA Drug Bull 1984;14:3-4.
8. Duchesne C, Leke R. Bromocriptine mesylate for prevention of postpartum lactation. Obstet Gynecol 1981;57:464-467
9. Iffy L, et al. Acute myocardial infarction in the puerperium in patients receiving bromocriptine. Am J Obstet Gynecol 1986;155:371-372.
10. Cabergoline. Mosby's Drug Consult Monograph. St. Louis, MO: Mosby, Inc.; 2005.
11. Single dose cabergoline versus bromocriptine in inhibition of puerperal lactation: Randomized, double blind, multicenter study. European Multicenter Study Group for Cabergoline in Lactation Inhibition. BMJ 1991;302:1367-1371.
12. Kee WH, et al. The treatment of breast engorgement with Serrapeptase (Danzen): A randomized, double-blind controlled trial. Singapore Med J 1989;30:48-54.
13. Lactation, Breastfeeding and the Post-partum Period. In: Low Dog T, Micozzi M. Women's Health in Complementary and Integrative Medicine: A Clinical Guide. St. Louis, MO: Elsevier; 2005.
14. Hill PD, Humenick SS. The occurrence of breast engorgement. J Hum Lact 1994;10:79-86.
15. Bristol WM. Comparative effectiveness of compressional and supporting breast binders in suppressing lactation. Nurs Res 1966;15:203-206.
16. Swift K, Janke J. Breast binding: Is it all that it's wrapped up to be? J Obstet Gynecol Neonatal Nurs 2003;32:332-339.
17. Olsen A. Nursing under conditions of thirst or excessive ingestion of fluids. Acta Obstet Gynecol Scand 1940;20:313.
18. Roberts KL. A comparison of chilled cabbage leaves and chilled gelpaks in reducing breast engorgement. J Hum Lact 1995;11:17-20.
19. Hill C. Midwifery treatment of breast engorgement and pain during initiation of lactation: A comparative study. Aust Coll Midwives (WA Branch) Newsl 1991:7:17-21.
20. Nikodem VC, et al. Do cabbage leaves prevent breast engorgement: A randomized, controlled study. Birth 1993;20:61-64.
21. Roberts KL, et al. A comparison of chilled and room temperature cabbage leaves in treating breast engorgement. J Hum Lact 1995;11:191-194.
22. Snowden HM, et al. Treatments for breast engorgement during lactation. Cochrane Pregnancy and Childbirth Group. Cochrane Database Syst Rev 2001;CD000046.
23. Human Milk Banking Association of North America. Donate Milk. Available at: www.hmbana.org/index.php?mode=donations. Accessed Aug. 2, 2005.
24. Arnold LD. How to order banked donor milk in the United States: What the health care provider needs to know. J Hum Lact 1998;14:65-67.
Marcolina ST, Denchfield P. Complementary therapies and lactation suppression. Altern Ther Women's Health 2005;7(11):81-85.Subscribe Now for Access
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