Triangle Breastfeeding Alliance, Inc.

Michelle Obama has a new initiative about preventing obesity and she believes as we do that it begins with breastfeeding.  This is great to her as an advocate in our favor.

BF Let’s move Michelle Obama Initative-1

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Alison Stuebe, MD, MSc

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,
University of North Carolina
Chapel Hill, Chapel Hill, NC

“Health outcomes in developed countries differ substantially for mothers and infants who formula feed compared with those who breastfeed. For infants, not being breastfed is associated with an increased incidence of infectious morbidity, as well as elevated risks of childhood obesity, type 1 and type 2 diabetes, leukemia, and sudden infant death syndrome. For mothers, failure to breastfeed is associated with an increased incidence of premenopausal breast cancer, ovarian cancer, retained gestational weight gain, type 2 diabetes, myocardial infarction, and the metabolic syndrome. Obstetricians are uniquely positioned to counsel mothers about the health impact of breastfeeding and to ensure that mothers and infants receive appropriate, evidence-based care, starting at birth.”
Rev Obstet Gynecol. 2009;2(4):222-231 doi: 10.3909/riog0093]

Click here for rest of article

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Check out USLCA  February newsletter                              

This issue has articles that include:

Chapter news, Committees and Liaisons, mourning of two Pioneers in lactation, lactation survey, and upcoming webinars

click here for the newsletter

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Morbidity and Mortality Weekly Report (MMWR)

Transmission of Yellow Fever Vaccine Virus Through Breast-Feeding

Brazil, 2009
Weekly
February 12, 2010 / 59(05);130-132

In April, 2009, the state health department of Rio Grande do Sul, Brazil, was notified by the Cachoeira do Sul municipal health department of a case of meningoencephalitis requiring hospitalization in an infant whose mother recently had received yellow fever vaccine during a postpartum visit. The Field Epidemiology Training Program of the Secretariat of Surveillance in Health of the Brazilian Ministry of Health assisted state and municipal health departments with an investigation. This report summarizes the results of that investigation, which determined that the infant acquired yellow fever vaccine virus through breast-feeding. The mother reported 2 days of headache, malaise, and low fever occurring 5 days after receipt of yellow fever vaccine. The infant, who was exclusively breast-fed, was hospitalized at age 23 days with seizures requiring continuous infusion of
intravenous anticonvulsants. The infant received antimicrobial and antiviral treatment for meningoencephalitis. The presence of 17DD yellow fever virus was detected by reverse transcription–polymerase chain reaction (RT-PCR) in the infant’s cerebrospinal fluid (CSF); yellow fever–specific immunoglobulin M (IgM) antibodies also were present in
serum and CSF. The infant recovered completely, was discharged after 24 days of hospitalization, and has had normal neurodevelopment and growth through age 6 months. The findings in this report provide documentation that yellow fever vaccine virus can be transmitted via breast-feeding.  Administration of yellow fever vaccine to breast-feeding women should be avoided except in situations where exposure to yellow fever viruses cannot be avoided or postponed.

On March 23, the mother, aged 22 years, delivered a healthy female infant at 39 weeks’ gestational age by elective cesarean delivery. During that same month, a yellow fever epidemic had spread to a nonendemic area in Rio Grande do Sul state where the mother resided (1). On April 7, when the mother was 15 days postpartum, she visited her health-care provider to have the sutures removed from her caesarean incision. While in the provider’s office, she received 17DD yellow fever vaccine. She had not been vaccinated
for yellow fever previously. On April 12, 5 days after receiving the vaccine, she reported a headache, malaise, and low fever, which persisted for 2 days. The mother did not seek medical care for her symptoms.

On April 15, 2009, the mother’s infant, aged 23 days, developed fever, and irritability and refused to nurse. The next day, the infant exhibited seizure-like activity and was admitted to the hospital for evaluation of possible meningoencephalitis. Upon admission, the infant experienced unilateral left upper extremity clonic convulsions of increasing frequency
requiring intravenous diazepam (0.15 mg). Perioral cyanosis was noted and oxygen saturation measured by arterial blood gas was pO2 60 (normal: pO2 80–100). A chest radiograph showed no infiltrate. Peripheral white blood cell (WBC) count was 25,400/mm3 (normal: 5,000–20,000 WBC/mm3) and platelet count was 393,000/mm3 (normal: =150,000 platelets/mm3). Laboratory examination of CSF was unremarkable, with a WBC count of 1/mm3 (normal: 0–5 WBC/mm3), slight elevation of protein (67 mg/dL [normal: 15—45 mg/dL]), and decreased glucose concentration (37 mg/dL [normal: 42—78 mg/dL]). Gram stain of the CSF specimen revealed no bacteria. The infant received oxygen therapy, intravenous dipyrone (0.1 mL every 6 hours) and phenytoin (10 mg every 12 hours), and empiric treatment for bacterial infection with ampicillin and gentamicin. On April 18, empiric acyclovir treatment was added. No specimens for bacterial or fungal cultures were obtained. Other etiologies for meningoencephalitis were ruled out by testing of serum and CSF samples for dengue-specific IgM; viral culture for herpes simplex, cytomegalovirus, and varicella; and RT-PCR for enteroviruses, all of which were negative.

The infant alternated between periods of somnolence and irritability, without clinical improvement. On April 19, convulsions became more frequent (one episode every 10 minutes) and difficult to control, with persistent perioral cyanosis, resulting in transfer to the pediatric ICU for continuous infusion of anticonvulsants and monitoring of oxygen saturation. A second CSF examination showed a WBC count of 128/mm3, a protein concentration of 106 mg/dL, and a glucose concentration of 24 mg/dL. Computerized tomography of the head demonstrated bilateral symmetrical areas of diffuse low density suggestive of inflammation consistent with encephalitis.

After the second CSF examination on April 19, the mother mentioned receiving yellow fever vaccine 8 days before the infant’s onset of symptoms, and a serum and CSF sample from the infant were sent to the arbovirus reference laboratory at Adolfo Lutz Institute in São Paulo, Brazil, to test for the presence of 17DD yellow fever vaccine virus. Yellow
fever-specific IgM antibodies were detected in serum and CSF. Yellow fever viral RNA was amplified by RT-PCR (2,3) from a CSF specimen collected on April 19; the nucleotide sequence of the amplified PCR product was identical to 17DD yellow fever vaccine virus. No breast milk or maternal serum was collected for yellow fever virus testing.

The infant recovered completely and was discharged from the hospital without sequelae on May 10, 2009. Follow-up of the infant showed normal neurodevelopment and growth through age 6 months. The Brazilian Committee on Vaccine-Associated Adverse Events classified the child’s encephalitis as yellow fever vaccine–associated neurologic disease. To rule out the possibility that the infant had received yellow fever vaccine inadvertently, the investigators reviewed all procedures documented in the medical record performed between the infant’s birth and onset of symptoms. The child had received intramuscular vitamin K and hepatitis B vaccine on the day of birth. Two other children born on the same day had received hepatitis B vaccine from the same lot of vaccine as the one registered in the child’s vaccination record, and neither experienced similar symptoms.

Reported by
A Mallmann Couto, MD, M Ribeiro Salomão, MD, Hospital de Caridade de Cachoeira do Sul; MT Schermann, MD, R Mohrdieck, MD, Rio Grande do Sul State Health Dept, Porto Alegre; A Suzuki, Adolfo Lutz Institute, São Paulo; SM Deotti Carvalho, National Immunization Program, Secretariat of Surveillance in Health (SVS), Ministry of Health (MoH), Brasilia; DM de Assis, Brazilian Field Epidemiology Training Program (EPISUS) and Vector-borne Diseases and Anthropozoonoses Surveillance, SVS, MoH, Brasilia; W Navegantes Araújo, DVM, EPISUS, SVS, MoH, Brasilia, and Gonçalo Moniz Institute, Oswaldo Cruz Foundation, MoH, Salvador; B Flannery, PhD, Pan American Health Organization, Brasilia, Brazil.

Editorial Note

This report describes the first laboratory-confirmed case of yellow fever vaccine–associated neurologic disease occurring in an infant secondary to the transmission of yellow fever vaccine virus through breast milk. The infant described in this report also is the youngest reported case of yellow fever vaccine–associated neurologic disease. The presence of yellow fever-specific IgM in CSF, and 17DD yellow fever vaccine viral RNA in the CSF of the infant indicates transmission and infection with yellow fever vaccine. Following primary vaccination, IgM antibodies generally appear 4–7 days after receipt of vaccine (4). Maternal IgM antibodies can be excreted in breast milk and the presence of serum IgM in the infant alone is not diagnostic of yellow fever virus infection. The detection of IgM antibodies in the infant’s CSF indicates intrathecal antibody production in response to a nervous system infection because IgM does not normally cross the blood brain barrier (5).

Based on the mother’s receipt of yellow fever vaccine on April 7, and onset of symptoms in the infant on April 15, the infant’s infection likely occurred during the expected peak of viremia following vaccination. Neurologic adverse events, including encephalitis, have been described previously in association with yellow fever vaccination; children aged <6
months have the highest incidence of vaccine-associated neurologic events (6). However, only one previous episode of encephalitis, which was not confirmed as vaccine-associated, has been described in an infant exposed to yellow fever vaccine virus through breast-feeding (Public Health Agency of Canada, personal communications, 2009).

Yellow fever vaccine is a live, attenuated virus preparation made from various strains of the 17D yellow fever virus lineage. In Brazil, yellow fever vaccine from the 17DD strain is produced by Bio-Manguinhos, a public sector vaccine manufacturer of the Oswaldo Cruz Foundation of the Brazilian Ministry of Health. Yellow fever vaccine–associated neurologic disease (YEL-AND, formerly known as postvaccinal encephalitis) is reported to occur at a rate of 0.4 cases per 100,000 persons vaccinated in the U.S. population, with highest rates reported among persons aged =60 years (1.6 per 100,000) (6). However, the incidence among infants aged <6 months has been estimated as 0.5–4.0 cases per 1,000 infants vaccinated (4). For this reason, administration of 17D-derived yellow fever vaccines is contraindicated in infants aged <6 months (4,7,8).

Yellow fever virus, either wild-type or 17D, has not been reported to have been isolated from or detected in human breast milk. West Nile virus (WNV), another flavivirus, has been detected in milk from WNV-infected, lactating women (9), and one case of probable WNV transmission through breast-feeding has been reported (10). The actual risk for 17DD virus transmission through breast-feeding cannot be characterized because the number of breast-feeding women who have been vaccinated without negative sequelae in their infants is unknown. Based on the theoretical risk for yellow fever vaccine virus transmission through breast milk, the Advisory Committee on Immunization Practices recommends that yellow fever vaccination of nursing mothers be avoided, except when travel of nursing mothers to high-risk yellow fever–endemic areas cannot be avoided or postponed (7). Vaccine recommendations from the World Health Organization do not include considerations for breast-feeding mothers (8).

In Brazil, yellow fever vaccination is recommended for all residents of municipalities considered at risk for yellow fever transmission, and for travelers to at-risk areas (1). As a result of this investigation, the Brazilian Ministry of Health is revising its recommendations to caution against administration of yellow fever vaccine to breast-feeding women, except in situations where the risk for contracting yellow fever is unavoidable. Further studies on excretion of 17DD virus in breast milk of vaccinated, lactating women would help to define a risk period for viral transmission in cases where vaccination of nursing mothers is necessary.

Acknowledgments

The findings in this report are based, in part, on contributions from M Dallagnol, Municipal Dept of Health and Environment, Cachoeira do Sul; M Corrêa Lenz, M Assunta Bercini, MD, Rio Grande do Sul State Health Dept, Porto Alegre; R de Cássia Compagnoli Carmona, S Pires Curti, Adolfo Lutz Institute, São Paulo; and C Guedes Ramos, G Lima Nascimento, and MA Nunes Medeiros, Brazilian Field Epidemiology Training Program, Brasilia, Brazil.

References
1. Brazilian Ministry of Health. Emergências em Saúde Pública de Importância Nacional (ESPIN) de Febre Amarela Silvestre em São Paulo e no Rio Grande do Sul e a Situação Epidemiológica Atual no Brasil (2008/2009). [Portuguese] Available at
http://portal.saude.gov.br/portal/arquivos/pdf/boletim_febre_amarela_09_12_09.pdf

Embedded image moved to file: pic27595.gif)Adobe PDF fileExternal Web Site Icon. Accessed February 9, 2010.
2. dos Santos CN, Post PR, Carvalho R, Ferreira, II, Rice CM, Galler R.
Complete nucleotide sequence of yellow fever virus vaccine strains
17DD and 17D-213. Virus Res 1995;35:35–41.
3. Wang E, Weaver SC, Shope RE, Tesh RB, Watts DM, Barrett AD. Genetic variation in yellow fever virus: duplication in the 3′ noncoding region of strains from Africa. Virology 1996;225:274–81.
4. Monath TP, Centron MS, Teuwen DE. Yellow fever vaccine. In: Plotkin SA, Orenstein WA, Offit PA, eds. Vaccines. 5th ed. Philadelphia, PA: WB Saunders; 2008.
5. McMahon AW, Eidex RB, Marfin AA, et al. Neurologic disease associated with 17D-204 yellow fever vaccination: a report of 15 cases. Vaccine 2007;25:1727–34.
6. Khromava AY, Eidex RB, Weld LH, et al. Yellow fever vaccine: an updated assessment of advanced age as a risk factor for serious adverse events. Vaccine 2005;23:3256–63.
7. CDC. Yellow fever vaccine; recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2002;51(No. RR-17).
8. World Health Organization. Yellow fever vaccine: WHO position paper.
Wkly Epidem Rec 2003;78:349–59.
9. Hinckley AF, O’Leary DR, Hayes EB. Transmission of West Nile virus through human breast milk seems to be rare. Pediatrics 2007;119:e666–71.
10. CDC. Possible West Nile virus transmission to an infant through breast-feeding—Michigan, 2002. MMWR 2002;51:877–8.

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Please post this notice to the Triangle Breastfeeding Alliance about the B.E.S.T. for Babies Alliance breastfeeding support groups for African Americans. It would be great if Alliance members could refer any moms who they think could benefit from these sessions. The one thing I should point out is that we ask that Alliance members encourage mothers to call and find out more information about the support groups and not to collect any personal information from the mothers themselves. I’m attaching recruitment guidelines, which will expand upon this.

Recruitment guidelines

We actually plan to add a session on March 15th from 6 pm – 8 pm to make up for a canceled session from Feb. 1st due to the weather. We will be distributing new fliers reflecting this once they are approved. For now I am attaching the current version.

Here is the link for flyer to pass out

BESTflyer

Please let me know if you have any questions.

Many thanks!

Elizabeth Woods

–
Liz Woods, MA, MPH
Community Health Liaison
Durham B.E.S.T. for Babies Alliance
Community Health Coalition, Inc.
407 Crutchfield St.
PO Box 15176
Durham, NC  27704
Phone: 919.470.8681 or 919.470.8680
Fax: 919.470.8688
Cell: 323.205.0044
eliz.woods08@gmail.com

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Dear Friend,

I am hoping that you read this posting, and share it widely among your contacts – mothers and birthing / breastfeeding professionals alike.

Childhood sexual abuse is a very common experience among American women, which is known to have significant consequences throughout the lifespan.  The lack of public health analysis of child sexual abuse means that we have major limitations as to how we can work to prevent this type of problem, and how we can help survivors when it occurs.  Childhood sexual abuse can impact women’s experiences of breastfeeding, but there is very little information about how.  By sharing their stories, women can teach public health professionals about what the problems are, and how they can respond.

To this end, I have created a survey where women are able to share their experiences.  By clicking HERE, you can learn more about the survey, and complete the survey.  It’s pretty open-ended so that people can take as much space as they need to write about their experiences with breastfeeding, and how they may have been impacted by childhood sexual abuse.  The stories will be shared, with no identifying information, at the Breastfeeding & Feminism Symposium, as well as being part of an exciting new book due out Fall 2010.  Since there is a time crunch, please complete the survey by Friday, February 26.

There are no more than minimal risks of harm for participation, and the potential benefits to society are boundless.  (Participants won’t be asked for any identifiers like name, phone number, city, etc.)  NOTE: All participants must be 18 years of age or older.  The study is approved by the UNC-CH IRB, so if you have any concerns, call them at 919.966.3113.  If you have questions for me, call me at 919.843.4118.

Again, to share your story, click HERE.

My best,

Emily C. Taylor,  MPH, CD(DONA), Project Manager

with Miriam H. Labbok, MD, MPH, Principal Investigator

<<< AGAIN: THE LINK FOR THE SURVEY IS: http://uncodum.qualtrics.com/SE?SID=SV_eXQdDevYooF8Ya8&SVID=Prod >>>

--

Emily C. Taylor, MPH, CD(DONA)
Senior Programs Director
Carolina Breastfeeding Institute
Department of Maternal and Child Health
UNC-CH Gillings School of Global Public Health
T:  919.843.4118
F:  919.966.0458
E:  emilytaylor@unc.edu
W:  sph.unc.edu/breastfeeding

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Please read if you are interested in the events in lactation worldwide -
especially if you are not a current member of ILCA. The article on Mary
Tully includes the tribute that Mary Overfield delivered during Mary T’s
Funeral/Memorial Mass.

http://www.ilca.org/files/eGlobe/2010/022010_eGlobe.pdf

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Dear Friends and Colleagues,
It would be much-appreciated if you could forward this to physicians, nurse practitioners and physician assistants in North Carolina.  This is a world class training, offered on three more occasions, with scholarships available!

Dear Provider,

Attached is a flier for an upcoming CME training,

“What Every Provider Needs to Know about Breastfeeding.”

The Carolina Global Breastfeeding Institute in the UNC School of Public Health, funded by The Duke Endowment, is offering this training to support breastfeeding and reduce breastfeeding-related health disparities in North Carolina.

As many of you know, improved breastfeeding support skills are important for many reasons, including:

1. Breastfed infants have fewer illnesses and require significantly less hospitalization than non-breastfed infants. The decrease in risk for many illnesses continues for a life-time.
2. Women who breastfeed also decrease their own risks for several diseases that are on the rise, including breast cancer, ovarian cancer and type-2 diabetes.
3. The Joint Commission has new Neonatal Criteria going into effect in the spring of 2010 that include measuring the rate of exclusive breastfeeding at hospital discharge.
4. Adherence to The Ten Steps to Successful Breastfeeding increases rates of breastfeeding duration and exclusivity, because mothers and babies have fewer difficulties with breastfeeding.  And, patients at Baby-Friendly Hospitals and Clinics report greater satisfaction with their care, and constitute a loyal consumer base.

The faculty is made up of physicians known throughout the state, country and world for their expertise in breastfeeding and maternal and child health.

PRESENTED BY LOCAL and NATIONAL EXPERTS, INCLUDING:

Miriam Labbok, MD, MPH, FABM, IBCLC

Joan Meek, MD, MS, RD, IBCLC, FAAP, FABM

Edward Newton, MD, FABM, FACOG

Laura Sinai, MD, MSCE, FAAP

Christina Smillie, MD, IBCLC, FABM, FAAP

Alison Stuebe, MD, MSc, FACOG

• Benefits of breastfeeding
• Normal management of breastfeeding
• Clinical case studies for supporting moms and babies experiencing breastfeeding problems
• Prescribing medications to the breastfeeding mother
• The North Carolina Breastfeeding-Friendly Star Approach

Please register to attend the course at one of the following convenient dates and locations:

• Saturday, February 27, 2010: Gastonia, NC
• Saturday, April 24, 2010: Asheville, NC
• Saturday, December 4, 2010: Greenville, NC

Registration is quick and easy- just click here!  The training costs only $150 for 8 CMEs, meals and training materials.

Scholarships are available for physicians serving low-wealth populations in selected areas.  Please contact the Project Director at the Carolina Global Breastfeeding Institute
Emily Taylor
EmilyTaylor@unc.edu
919-843-4118 with any questions.

Sincerely,

Carolina Global Breastfeeding Institute

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“Formula Feeding is the longest lasting uncontrolled experiment lacking informed consent in the history of medicine.”
Frank Oski, M.D., retired editor, Journal of Pediatrics

Check out this trailer for a film called Formula Fed America.

http://www.formulafedamerica.com

Tell us what you think about it

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By Nancy Walsh, Senior Writer, MedPageToday
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.
January 26, 2010

Women taking selective serotonin reuptake inhibitor (SSRI) antidepressants may experience delays in postpartum breast milk production, researchers said.

Delayed secretory activation occurred in 87.5% of a small group of women taking SSRIs, compared with 43.5% of those not taking the drugs (RR 2, 95% CI 1.51 to 2.67, P=0.02), according to Aaron M. Marshall, PhD, of the University of Cincinnati.

The relative risk of delayed activation remained significantly higher (P<0.05) among SSRI users after adjustment for maternal age, obesity, cesarean delivery, infant gestational age, and infant breastfeeding behavior, the researchers reported online in the Journal of Clinical Endocrinology and Metabolism.

An early breastfeeding difficulty faced by many women, particularly those who are primiparous, is milk secretion delayed beyond 72 hours postpartum.

These women also are at risk of early cessation of breastfeeding. In fact, only 11% of mothers in the U.S. breastfeed exclusively for the recommended six months.

Studies in animal models and cell cultures suggested that serotonin (5-HT) is an important local regulator of lactation homeostasis, and the 5-HT transporter is expressed in mammary tissue at the apical membrane of epithelial cells.

Serotonin is controlled intracellularly by a balance between synthesis and degradation, while extracellularly its availability is controlled through recycling by the 5-HT transporter.

The 5-HT transporter also is the target for the most commonly prescribed class of antidepressants in the U.S. and other developed countries. These SSRI antidepressants are typically used to treat postpartum depression.

The investigators conducted in vitro and animal studies to establish that the 5-HT transporter is expressed in breast tissue, particularly in the apical membranes of mammary epithelial cells, and that pharmacologic inhibition of the transporter disrupts tight junctures leading to a local involution-like effect.

To examine the potential effect of SSRI inhibition on milk production in women, Marshall and colleagues enrolled 431 mothers as part of a longitudinal cohort study examining barriers to early lactation success.

All were expecting their first live-born infants, had no known absolute contraindication to breastfeeding, and were at least 19 years old.

Women taking SSRIs were more likely to have scored higher on a depressive symptom scale (as expected), and were somewhat more likely to be obese or to have had a cesarean delivery.

Participating mothers were visited between 72 and 96 hours after giving birth to assess their breastfeeding experience and to determine the timing of secretory activation, and then seen again one week later.

Delayed secretory activation was defined as initiation more than 72 hours postpartum.

Median onset of secretory activation among the SSRI-treated mothers was 85.8 hours compared with 69.1 hours in mothers not using the drugs (P=0.004).

Eight women reported regular use of an SSRI medication. Seven experienced definite delayed secretory activation, and the eighth reported activation at 72 hours and therefore did not meet the defined cutoff for delayed activation.

All women taking SSRIs had experienced secretory activation by their second visit a week after the first interview.

The researchers noted that most studies on the effects of SSRI use during pregnancy and lactation have focused on the risks for developmental defects or whether the drugs passed into milk during lactation.

This study, they said, is the first to report data on another important aspect of SSRI use during the peripartum, the effect on milk production.

They concluded that the risk of delayed secretory activation was twice as great among primiparous women using an SSRI medication, and although the fraction of women taking the drugs was small, the risk was significant and remained so after adjustment for potential confounding factors.

Further examination of this relationship is needed in larger groups of mothers, the researchers said, and in studies to determine if there are differences among the antidepressant medications.

Action Points

• Explain to interested patients that the use of certain types of antidepressants in the postpartum period may affect the onset of mothers’ milk production.
• But note that this observation was in a study that included only a small number of women using the drugs, and further research is needed.

Primary source: Journal of Clinical Endocrinology and Metabolism
Source reference: Marshall A, et al “Serotonin transport and metabolism in the mammary gland modulates secretory activation and involution” J Clin Endocrin Metab 2009; DOI: 10.1210/jc.2009-1575.

Website source: https://rexnurse.mednewsplus.com/html/topicdetails.asp?pid=89&section_id=187&topic_id=18149&puid=11536&flag=1%22_blank%22

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