Jan 24, 2019

Dr. Jones: Getting let down. Getting let-down. The first is a psychological consequence and the second is about breastfeeding. How are they connected? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health. This is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: There's a world of data that suggest for newborns "Breast is Best." That puts a lot of pressure on new moms to be successful breastfeeders. In the days before formula, a newborn's life depended on a mom's ability to provide breast milk, and a mom's health might already be precarious after what might have been a dangerous delivery. For this reason, many cultures have a time after delivery, several weeks or a month, to allow moms to heal and breastfeed.

Okay. That's all good. But after that in the US of A many moms have to go to work. That means if moms are still going to provide breast milk, that breast pumping pump at work becomes a reality. Now, to provide breast milk, a mom has to be at least moderately well-nourished and well-hydrated. But almost all American moms can accomplish that in the workplace. Then, there's the problem of let-down.

To make milk, moms need to be in reasonable health. They have to be breastfeeding, meaning they have to suckle. When the infant suckles, their nerves on the chest wall and the nipple feed information back to the brain to release the hormone prolactin from the pituitary gland. This hormone helps the breast make milk. But the milk just doesn't come out in a continuous dribble. It's made in the far parts of the breast called the alveoli and collected in tubes or ducts in the breast waiting for, you got it, let-down.

When the infant suckles, nerve fibers in the nipple cause the posterior pituitary to release oxytocin, which stimulates myoepithelial cells. These are little muscular cells to squeeze milk from the milk producing part of the breast called the alveoli so it can drain into the lactiferous ducts and then squeezes the milk down the pipeline to the nipple. It takes less than a minute from the time when the infant begin suckling -- the latent period -- until the milk is secreted -- the let-down. But what happens if the baby isn't there?

You're in your office or you're in the ladies restroom with your breast pump or if you're lucky you have a private room with a lock and an electric outlet and an electric breast pump and a rocking chair. Nice, but you still have to get let-down. Many experienced breastfeeding moms know that just the sound of their baby giving a hungry cry can begin let-down and that could be embarrassing if the baby isn't close and you start to leak through your clothes. However, for new moms, pumping at work let-down can be difficult to get started.

If let-down is a neuroendocrine reflex from the brain, many things can get in the way of timely let-down. Anxiety, pain, embarrassment, stress, stimulants like caffeine and nicotine, too much alcohol gets in a way but a little bit of alcohol might be relaxing, but not in the workplace. Acute fear or anxiety can suppress let-down. The fight or flight mechanism inhibits let-down, as it should if you're running away from tigers or something else.

Many years ago, when I was a young obstetrician back at work shortly after the birth of our son and pumping when I could find the time, my residents gave me as a joke, I think, a pager duct taped to a breast pump. Now, there isn't anything less conducive to let-down in my world than my beeper going off and a disaster happening to some poor laboring woman on labor and delivery. What a let-down.

So what's a new mom at work to do? Some suggestions include bringing a picture of your baby to look at when you're pumping. Bring something like a little t-shirt that smells like your baby with you. Try to get your head in a calm space before you put the breast pump to work. Deep breathing, focused visualization of having your baby at your breast and instead of that pump can be useful. Turning up the vacuum on the breast pump or just pumping harder with the hand pump won't do. The problem is let-down, not suction.

In an effort to increase the success at milk production and future breastfeeding for moms of very premature infants, some research has been illuminating. You can imagine that having a very sick newborn that you've never been able to nurse because they're too little and you're sitting in a pumping room next to the intensive care nursery might not be conducive to let-down.

A paper published in advances in neonatal care took 162 mothers of premature babies who were trying to provide breast milk for their babies and divided them into four groups. One group had standard instructions in a breast pumping room. The other group was taught guided imagery, imagining their babies and imagining themselves in a safe, warm, quite place with their newborns. Another group was given soothing music. And the fourth was given imagery and soothing music.

Women who were taught guided imagery or given soothing music had more output of milk. And the women who had music and guided imagery together has the most milk of all. Now, this wasn't just a little difference. Moms who had the interventions had two to three times more milk than moms who didn't. Mothers who had interventions to decrease stress also had more milk fat, had richer milk in the first days of the study.

So what else is out there? Last year the annual Make the Breast Pump, Not Suck Hackathon -- isn't that a great meeting -- awarded the Technology Frontiers Award to group that were testing out virtual let-down by transforming pumping rooms at work and in public places into a nursery decorated with pictures and videos and sounds of their babies by using a virtual reality headset.

So what do you do? For a new mom committed to breastfeeding and is returning to the workplace or needs to travel away from their baby, what do you do? Practice using your pump at home in your baby's room before you take it to a strange place. Get your head in the right place. This can take time and practice before you're rushing into a pumping place or a bathroom in the airport or your workplace. Get some soothing music and, yes, there are YouTube videos with music and guided imagery and meditation that you can use. You can just power it up on your phone, put in your headphones.

But use these first with your baby so the association can be stronger. Stay well-hydrated. And if you're struggling, get a coach through your hospital nurse lactation specialist or a La Leche League. This is hard, but you can do it. Don't get let down.

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