Lactation & Lactation Suppression
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
In general, breastfeeding can be encouraged for all mothers, including those who are HIV infected after appropriate counselling
- Wherever possible, avoid separation of a mother from her newborn baby
- Encourage early suckling (within 1-2 hours of birth)
- Ensure correct positioning of the infant during suckling
- Avoid formula, water or other oral supplementation of healthy newborns
- Encourage unrestricted (‘demand’) breastfeeding
- Avoid prescribing combined oral contraceptives to women who want to breastfeed – give progestin-only preparations
Insufficient milk supply
- Ensure correct positioning of the infant during suckling
- Encourage unrestricted breastfeeding
- Encourage adequate fluid intake
- Avoid the temptation to supplement the infant
- Provide emotional & practical support
- If true milk insufficiency is suspected, prescribe domperidone, if available, 10 mg orally 3 times daily, or metoclopramide 10 mg orally 3 times daily for 7-10 days then taper off for one week
- Consider Sheehan’s syndrome (pituitary failure seconday to postpartum haemorrhage & hypovolaemic shock) if there appears to be no milk at all
Breast engorgement
- Ensure correct positioning of the infant during suckling
- Encourage unrestricted breastfeeding
- Give analgesia, e.g. paracetamol 1 g orally 6 hourly
- Express the breast(s) if engorgement is severe, and give cold compresses, e.g. with fresh cabbage leaves
- If infective mastitis is suspected, prescribe broad spectrum antibiotics including cover for Staphylococcus aureus (flucloxacillin 500 mg orally 6 hourly)
Painful cracked nipples
- Give analgesia, e.g. paracetamol 1 g orally 6 hourly
- Continue breastfeeding with the unaffected breast
- Suspend feeding with the affected breast, but express at regular intervals
- Resume feeding when the cracks have started to heal
- Ensure correct positioning of the infant during suckling
Lactation suppression
Women may request assistance to suppress milk production. This may be because of HIV, perinatal death, or their own choice on infant feeding. Breast engorgement is the main problem in postpartum women who do not breastfeed.
- The breasts must not be expressed except to release small amounts of milk if needed, only to reduce discomfort
- A firm bra, cold compresses with cold cabbage leaves, & paracetamol 1 g orally 4 times daily, may provide relief for engorged breasts
- Bromocriptine 2.5 mg orally 12 hourly for two weeks is effective
- Bromocriptine may cause nausea, dizziness, drowsiness, rebound lactation, &, rarely, acute severe hypertension, thromboembolism, myocardial infarction & stroke
- Avoid bromocriptine in women with hypertension or other cardiovascular disease
- Cabergoline 1 mg orally as a single dose, is as effective and has fewer side effects than bromocriptine