Complementary and Alternative Therapies in Breastfeeding Jill Mallory

Complementary and Alternative Therapies in Breastfeeding Jill Mallory, MD, IBCLC Wildwood Family Clinic Madison, WI

Objectives 1. Define “complementary and alternative/integrative” as a general class of approaches 2. How might you create a healing environment? 3. Describe two therapies that involve touch and how they might be used?

Objectives 4. What might acupuncture be beneficial for? 5. When might you suggest chiropractic manipulation? 6. List 2 benefits of craniosacral therapy for the nursing dyad. 7. What is the purpose of remedial co-bathing?

Objectives 8. Why is homeopathy considered safe in breastfeeding dyads? 9. List two herbs you can use safely in lactating mothers?

In 2001, the Institute of Medicine wrote: "The US health care system is in need of a change. Health care today harms too frequently and fails to deliver its potential benefits routinely. As medical science and technology have advanced at a rapid pace, the health care delivery system has floundered. Between the care we have and the care we could have lies not just a gap, but a wide chasm. "

What is Integration? • From the University of Arizona Program in Integrative Medicine: • Integrative Medicine is healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. • It emphasizes therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.

Why should IBCLC’s take an Integrative Approach? • Healthy mother & baby by empowering the dyad • Therapeutic relationship • Prevention • Avoiding unnecessary & costly pharmaceuticals and medical intervention • Optimizing nutrition for both

Why should IBCLC’s take an Integrative Approach? IBLCE states IBCLC’s “have the duty to provide competent services for mothers and families by providing evidence-based information regarding complementary and alternative therapies during lactation and their impact on a mother’s milk production and the effect on her child" (IBLCE, 2008)

National Center for Complementary and Alternative Medicine (NCCAM) 1. Biologically-based 2. Manipulative/body-based 3. Mind-body based 4. Whole medical systems 5. Energy-based (Religious healing not included)

• How Much Do We Know? According to Clinical Evidence, Summer 2007: (Summarizing study results from 1850+ treatments used in Western medicine) ?

The Sliding Scale of Evidence ?

Behavior: The Most Important Predictor of Health Schroeder, NEJM; 357(12), 2007

Environment • Oxytocin • The hormone of love, safety and relaxation

Environment • • Light Color Sound Temperature Smell Privacy Attitude of the practitioner

Home and Office

Hospital Rooms • A new mother is interrupted an average of 54 times in 12 hours of hospital stay • Half of her time alone with her infant is in intervals of 9 minutes or less Morrison, Ludington-Hoe, & Anderson, 2006

Hospital Rooms • • • Close the door Dim the lights Draw the curtains Turn off the TV Calm yourself first

Feng Shui • The art of arranging and decorating space • Chinese astronomy • 4000 BC

Breastfeeding Teaching/Support Environments • 7 groups • Which were successful and why? "comfort, refreshments, temperature, noise" Vs. "cold and uncomfortable" Hoddinott, Britten, Pill 2010

The Power of Touch

Mother the Mother Research done in South Africa showed that women who were talked to, smiled at, and stroked themselves were more likely to talk to, smile at, and stroke their newborns Sosa, Kennell, Klaus, Robertson, & Urrutia 1980

The Birth Environment

The Role of Birth • CDC • The Maternity Practices in Infant Nutrition and Care • "A substantial proportion of facilities used maternity practices that are not evidence-based and are known to interfere with breastfeeding"

Increase in Interventions • • 57% oxytocin 94% continuous EFM 57% delivered on back 83% IV fluids 76% epidural or spinal anesthesia >1/5 are induced → prematurity C-section rate > 30% Sakala & Corry, 2008

C-section • Lower prolactin and oxytocin levels on day 2 postpartum • Delay in onset of lactogenesis II Nissen et al. , 1996 Evans et al. , 2003

Birth Trauma • • Torticollis Mandibular asymmetry Muscular spams Spinal malalignment TMJ dysfunction Cranial trauma Emotional trauma

Separation • 7/34 babies suck correctly if taken away from their mothers for 20 min • 24/38 had correct sucking if left skin-to-skin Righard & Alade 1990 • Mother-infant contact and rooming-in increase breastfeeding Kennell & Klaus 1998

Goal: Mother-Friendly Childbirth and Baby. Friendly Hospitals

The Power of Touch

The Power of Touch

Touch Therapies • • Skin-to-skin Remedial co-bathing Massage Acupuncture Chiropractic Osteopathy Craniosacral therapy

Skin-to-Skin

Skin-to-Skin “As the most ancient and largest sense organ of the body, the skin enables the organism to learn about its environment. It is the medium by which the external world is perceived. ” (Montague, 1986)

Benefits of Skin-to-Skin • Improved attachment behaviors for both mom and baby for 2 years • Improved survival for preemies • Reduced illness and infection • Better breastfeeding success • Reduces crying • Improves cardio-respiratory stability • Warms baby

The Breast Crawl All mammals when placed skin-toskin can crawl to the breast and selfattach

Breastfeeding Success • Research of over 21, 000 infants in 18 different hospitals shows: The more time baby spends skin-to-skin with mom after birth, the longer mom will breastfeed that baby (Bramson et al, 2010)

The First Step You can start nearly all lactation sessions with mother and babies in skin-to-skin contact.

Massage

Massage at Birth • The infant crawl and maternal bleeding • Infant massage of the breast increases oxytocin levels (Matthieson et al. 2001)

Infant Massage • For preemies: – Lower rates of sepsis – Higher BMD – Better bonding with parents – Increases weight gain and – Earlier discharge (Field et al. 1986)

What Does Massage Do? • Stimulates the vagus nerve • Increases gastric motility • Increases insulin and insulin-like GF -1 levels • Decreases cortisol • Reduces metabolic demand through reduced crying Kirchner et al 2000, Field et al 2008, Lahat et al 2007

Infant Massage • Better early weight gain in term babies for the first 4 months (Serrano et al. , 2010) • Improved attachment (Lee, 2006)

Maternal Massage • Lowers stress hormones and blood pressure for mothers too

Signs of Disruption in Maternal. Infant Communication • Mother shopping with screaming infant in stroller • Ignoring feeding cues • Regarding every vocalization as “fussiness ” • Forcibly holding a pacifier in a screaming infant’s mouth • Looking at the clock to regulate feeds

Mother-Infant Massage • Healing a culture of crying and delayed response • Healing interactions that have been negatively influenced by books, expert opinions, family members and the clock • Healing the disconnect caused by hospital practices

Breast Massage • • • Increasing supply Increasing fat content Increasing pumping productivity Increasing infant weight gain Reduced engorgement Reverse-pressure softening

Breast Massage • Cultural tradition – Oketani massage - Japan – Russian mammology – Gua-Sha - China • Di. Sandro massage for recurrent mastitis – Bag of marbles technique • Relief for plugged ducts • Lymphatic drainage

Massage Resources • www. lovingtouch. com • www. infantmassageusa. org • www. iaim. ws

Acupuncture

Acupuncture • Over 5000 years old • Fine needles placed along meridians • Part of TCM • PET scan research • Anesthesia • Acupressure

Acupuncture • NIH endorses for – Labor pains – Fertility – Hyperemesis gravidarium • Used for 1000’s of years for low milk supply in China – Research is limited

Acupuncture • 1 small study showed improved infant weight gain (Li, 2003) • Another small study showed increase in milk supply (Clavey, 1996) • Some studies have shown increase in prolactin and oxytocin

Acupuncture • Sweedish study showed reduced breast tension, redness and pain in patients with mastitis – (Kvist et al. , 2007) • Cochrane review showed improvement in engorgement – (Mangesi et al. , 2011) • Anecdotes abound

Acupunture • Licensure varies from state-tostate • Some insurances do cover • Resources – http: //nccam. nih. gov/health/acupuncture/ – http: //www. acupuncturewisconsin. org/

Chiropractic

Chiropractic • Founded by Dr. David Palmer in 1895 • Defined by the American Chiropractic Association: “a healthcare profession that focuses on disorders of the musculoskeletal and nervous systems, primarily the spine, and seeks to restore the healthy relationship between the body’s structure and function

Chiropractic • Adjustment – Restore joint mobility and alignment by application of controlled force

Chiropractic • A Doctor of Chiropractic – 4 year post-baccalaureate degree – Pass a state licensing exam • 6 main different styles: • • Network Chiropractic Network Spinal Analysis Mixer • Palmer/Straight Reform • Applied Kinesiology • Objective Straight

Chiropractic vs. Osteopathy • Osteopath (DO) attends a 4 year medical school similar to MD’s • Also learn manipulation • Most do not use this in practice

History of Mistrust • Law suits • AMA

Chiropractic • Birth injury – Stiff neck – Tilted jaw – Torticollis

Chiropractic • Indications for baby – Poor latch – Clamping down on mother’s nipple – Poor milk transfer – Can nurse only in one position – Poorly coordinated suck-swallowbreathe – Very fussy and difficult to settle – Vacuum extraction (Le Leche League)

Chiropractic • Indications for mother – Neck pain – Back pain – Low milk supply

Chiropractic • Little published evidence • Case series of 114 babies with sucking difficulties – 78% showed improvement with 4 tx and were able to exclusively breastfeed – Miller et al. , 2009

Chiropractic • Colic or abdominal distress – Can lead to premature weaning – One study of 100 infants showed benefit with chiropractic • Olafsdottir, 2001

A Word About Applied Kinesiology • Mixed study results • Anecdotes abound

Craniosacral Therapy

Craniosacral • Dr. John Upledger, an osteopath • Gentle, non-invasive, hands-on technique • Evaluation of the membranes and CSF • OT’s, PT’s, IBCLC’s

Craniosacral • Indications for baby – Torticollis – Colic and irritability – Infant feeding or sucking difficulties – Restriction in movement – Irregular head shape/asymmetries – Tongue mobility issues – Traumatic delivery, cesarean section, forceps or vacuum

Craniosacral • Indications for baby – Post frenotomy • Indications for mothers – Pain – Anxiety – Frustration – Pelvic tension – Birth trauma

Craniosacral • Evidence is lacking • 1999 meta-analysis of 33 studies found mixed results (Green et al. ) • Studies were small and of poor quality • Difficult to blind or sham • Considered safe

Craniosacral Tips Consider costs Usually 3 -4 session Response arises over time Expect to see changes in postural states • Suck changes may not come till after the second visit • • • www. upledger. com

Remedial Co-Bathing

Remedial Co-Bathing • No research • All theory • Presented by Australian midwife Heather Harris at ILCA 1994 • Combines skin-to-skin time with warm water tub immersion

Remedial Co-bathing • Calm relaxing time for mother and baby together • Chance to re-do their initial meeting • Dyad may or may not feed during the bath • Present it as something new and fun to do with baby

Remedial Co-Bathing • When to consider it – Breastfeeding rehabilitation – Mom wants to breastfeed, but can’t – Mom is not happy and not having fun with her baby – Offset the pressure of a rigorous lactation regimen – Mother is otherwise resistent to skin-to-skin

Remedial Co-Bathing Tips • • Low light Privacy Warmth (98 -102 F) Cup to drizzle water Cool wet washcloth Drink for mother Baby on torso Have help nearby

Homeopathy

Homeopathy • Over 200 years old • Founded by Samuel Hahnemann in Germany in 1790 • Theory: ultra low-doses of a substance stimulate the body’s immune system to react to the disease or condition

Homeopathy • “Like cures like” • For example, ipecac in pharmaceutical doses causes nausea and vomiting • Ipecaucanha can relieve nausea and vomiting • Constitutional vs. acute

Homeopathy Plant, mineral, animal, food Alcohol/water for 1 month Serial dilutions and successions 6 X potency = diluted 610 times The more dilutions, the stronger the remedy • No pharmacologic activity • • •

Homeopathy • Sometimes blended with lactose or sucrose • Melted under the tongue • Dissolved in water or human milk • Cheap • Easy to find • No adverse effects

Homeopathy • Research is little and mixed • Meta-analysis found homeopathy effective in treatment of – Diarrhea – Hay fever – Flu – Pain – URI (Mathie, 2003)

Homeopathy • No research in lactation • Common uses – Phytolacca 30 C for early mastitis or plugged ducts – Conium for breast pain – Chamomilla for teething – Byronia for engorgement – Pulsatilla for oversupply

Herbs

Herbs Keep a list of herbs to avoid • • • • • • (T. Low. Dog) Aloe vera latex (not juice) (Aloe spp. ) Black cohosh (Actaea racemosa) Bladderwrack (Fucus vesiculosus) Blue cohosh (Caulophyllum thalictroides) Borage (Borago officinalis) Buckthorn fruit (Rhamnus cathartica) Bugleweed leaf (Lycopus spp) Cinchona bark (Cinchona spp) Cola seeds (Cola nitida)* Coltsfoot leaf (Tussilago farfara) Comfrey leaf/root (Symphytum officinale) Ephedra (Ephedra spp. ) Guarana (Paullinia cupana)* Jasmine flowers (Jasminum pubescens) Kava (Piper methysticum) Madder root (Rubia tinctorum) Ma Huang (Ephedra sinica) Pulsatilla (Anemone pulsatilla) Queen of the Meadow root/herb (Eupatorium purpureum) Senecio (Senecio aureus) Wormwood herb (Artemesia absinthium)

Fenugreek (Trigonella foenum-graecum) • FDA lists it as GRAS (generally regarded as safe). • 1 -4 capsules (580 -610 mg) 3 -4 times daily • It can also be taken as a tea of ¼ tsp seeds steeped in 8 oz of water for 10 minutes, taken 3 times daily. • Fiber -> GI upset • Maple syrup smell

Fenugreek (Trigonella foenum-graecum) • Huggins reported the use of fenugreek in 1200 women who had increased milk supply within 24 -72 hours. • Swafford S, Berens P: Effect of fenugreek on breastmilk volume. Abstract, 5 th International Meeting of the Academy of Breastfeeding Medicine, September 11 -13, 2000, Tucson, AZ. • Co MM, Hernandez EA, Co BG: A comparative study on the efficacy of the different galactogogues among mothers with lactational insufficiency. Abstract, AAP Section on Breastfeeding, 2002 NCE, October 21, 2002.

Goat’s Rue (Glaega officinalis) • Widely used as a galactogogue in Europe based on the observation that it increased milk supply in cattle in the early 1900’s. • No human trials for effectiveness have been done • Rosti L, Nardini A, Bettinelli ME, Rosti D: Toxic effects of an herbal tea mixture in two newborns. Acta Pediatr 83: 683, 1994.

Goat’s Rue (Glaega officinalis) • Usually used as a tea. 1 tsp dried leaves steeped in 8 oz of water for 10 minutes taken 2 -3 times daily. • Also available in tincture form

Galactagogues • Blessed Thistle leaves: – Cnicus benedictus tincture, twenty drops 24 times daily • Borage leaves: Do not use! – Due to the presence of pyrrolizidine alkaloids – hepatotoxins, which readily pass into the breastmilk (Panter 1990).

Galactagogues • Milk Thistle (Silybum marianum) – Best known for its liver-protecting effects, has been used for lactation for centuries. – There are no human studies evaluating its purported effects on lactation. – No known safety concerns with the seed.

Galactagogues • Milk Thistle (Silybum marianum) – The tea is prepared by simmering one teaspoon crushed seeds in 8 oz of water for 10 minutes. – The dose is 1 -3 cups daily or 1 -3 grams of the ground seeds in capsule form. – (Note that this is not the standardized extract typically used for liver disorders. )

Galactagogues • Fennel/Barley Water • Steel cut oats • Hops: Beer is a convienent source. Can also use tea or infusion.

Wild Asparagus (Asparagus racemosus) • Roots, also known as shatavari • Ayurvedic tradition to increase milk production in lactating women. • Shatavari Kalpa, a combination of wild asparagus root and cardamom. • Handful of animal and human studies that support the lactogenic effect of wild asparagus, given either alone or in combination with other herbs (Goyal 2003)

Wild Asparagus (Asparagus racemosus) • RCT of A. racemosus in women with insufficient milk supply failed to find any effect on milk production or prolactin levels (Sharma 1996). • The dose is 1 gram powdered root per day taken in milk or juice.

Thank You