Characterization of Three Cases of Primary Hypogalactia in Jalisco, Mexico.

INTRODUCTION: Human lactation should be taken into account as an important issue for the international agenda. Despite advances in lactation information and knowledge, insufficient milk production is still a concern for mothers and health practitioners, including International Board Certified Lactation Consultants and others. Primary hypogalactia, or insufficient milk production is uncommon, but should be considered when there is poor weight gain and decreased urine output in infants despite good latch-on and suckling, or anatomic differences in the physical exam of the lactating breast. MAIN ISSUE: This case series presents three cases illustrating insufficient milk production resulting in infants who experienced significant dehydration and poor weight gain. MANAGEMENT: Primary hypoplasia was diagnosed by means of a thorough interview and physical examination that entailed a consultation with a physician who was also an International Board Certified Lactation Consultant. CONCLUSION: Awareness of an infant's feeding needs and proper evaluation of a child's health status is paramount if health care providers are to identify the important factors contributing to breastfeeding problems. In some instances, breastfeeding goals cannot be achieved, and then the provider's role becomes support in coming to terms with persistent insufficient milk production, and coordinating appropriate supplementation to meet each baby's nutritional needs.

Exploring physiotherapists' clinical definition and diagnosis of inflammatory conditions of the lactating breast in Australia: a mixed methods study.

BACKGROUND: Differences in physiotherapy intervention practices for mastitis have been shown across Australian regions and facilities and it is unknown if this is associated with physiotherapists' definition and diagnosis of Inflammatory Conditions of the Lactating Breast (ICLB). The aims were to determine how Australian physiotherapists' define and diagnose ICLB and if there are regional or facility differences in their ICLB definition and diagnosis. METHOD: A cross-sectional mixed methods design was used to investigate how physiotherapists construct a definition and diagnosis of ICLB, via online qualitative and quantitative questions. Participants included 63 Australian physiotherapists who treated at least one woman with ICLB per month, over the last year. Thematic analysis and descriptive statistics were used to analyse qualitative and quantitative responses, respectively. RESULTS: ICLB definition varied among physiotherapists (n = 63) with generated themes including definitions based on pathophysiology (57%), combination of local and systemic symptoms (38%), conditions (32%), local symptoms (25%) and breast function (16%). Overall, quantitative data supported these findings, as some physiotherapists considered blocked ducts an ICLB (83%), but some did not (17%), and some considered abscess and engorgement an ICLB (65%) and some did not (35%). For ICLB diagnosis, the main theme generated was lack of consensus between physiotherapists (n = 39) on the number or combination of local or systemic symptoms required. Quantitative data confirmed these themes, as 63% of physiotherapists (n = 63) indicated that more than one symptom was necessary to clinically diagnose ICLB, but 27% required only one symptom. For region and type of facility, consistency across the themes for region and facility was evident. Overall, quantitative data confirmed these findings, with no regional or facility differences, except physiotherapists from the Australian state of Victoria (96%) were more likely to consider blocked ducts as an ICLB, compared to those from the states of NSW (71%) or WA (71%) (n = 58; χ2 = 6.49, p = 0.04). CONCLUSION: Australian physiotherapists have varied definitions of ICLB and the required ICLB symptoms for clinical diagnosis. These results may prompt physiotherapists, who treat ICLB, to engage in explicit communication when discussing an ICLB in patient care, when delivering information in training courses and in developing treatment guidelines.

ABM Clinical Protocol #32: Management of Hyperlactation.

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breast-feeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Self-Resolving Vulvar Breast Tissue Arising in the Post-Partum Setting: A Case Report and Review of Literature.

INTRODUCTION: During the postpartum period, breast engorgement in preparation for lactation may trigger the onset of vulvar labial nodules that present with pain and discomfort. These labial nodules may originate from ectopic breast tissue and can rarely present in women during the postpartum period in the labia majora. MAIN ISSUE: A 37-year-old African American female, gravida 1 para 1, presented to the Loma Linda University Medical Center with complaints of new onset labial swelling worsening 6 days following her full term spontaneous vaginal delivery. Additionally, our respondent complained of difficulty breastfeeding due to intermittent lack of milk production. She reported bilateral breast engorgement with tenderness, despite frequent attempts at breastfeeding. The respondent's presentation did not meet the criteria for other common differentials due to the physical characteristics of the nodules. The location of the nodules along the milk line led physicians to believe that the respondent was presenting with engorged extra-mammary breast tissue in the labia majora. MANAGEMENT: The participant was told to observe her course over the next few days as she began to have milk production and ejection. The respondent was seen in clinic for her 6-week postpartum visit, and was no longer complaining of difficulty with breastfeeding. The labial nodules had resolved spontaneously. CONCLUSION: A literature search yielded no case reports that described a case of an extra-mammary vulvar mass that self-resolved with resolution of breast engorgement. The infrequent presentation of extra-mammary vulvar tissue makes it difficult to conclude a guideline for diagnosis and management.

Lactational phlegmon: A distinct clinical entity affecting breastfeeding women within the mastitis-abscess spectrum.

We aimed to describe the presentation and treatment of lactational phlegmon, a unique complication of mastitis in breastfeeding women that may require surgical management. We retrospectively analyzed medical charts of breastfeeding women treated by a single breast surgeon for lactational phlegmon or the related conditions of abscess or uncomplicated mastitis (UM) from July 2016 to October 2018. Demographic variables and treatment details were analyzed using ANOVA and Pearson's Chi-square test. Ten women with lactational phlegmon (19.2%), 15 women with abscess (28.8%), and 27 women with UM (51.9%) were identified. Phlegmon presented as a tender, erythematous, and nonfluctuant mass in a ductal distribution. Ultrasonography demonstrated an ill-defined, complex fluid collection. Epidemiologically, women with phlegmon were similar to patients with abscess and UM. Women with phlegmon reported more intense deep breast massage than patients in the other two groups, but significantly lower rates of breast pump use than women with abscess (30.0% vs 80.0%, P < .05). Relative to women with UM, patients with complicated mastitis (CM, defined as phlegmon or abscess) reported greater utilization of nipple shields (36.0% vs 11.1%, P < .05). Treatment of phlegmon entailed effective milk removal, antibiotics (range 10-30 days), and close follow-up until both clinical and radiographic resolution (range 8 days to >3 months), with biopsy of persistent masses. Antibiotic duration was significantly longer for patients with phlegmon compared to those with UM (mean 15.0 days vs 9.7 days, P < .05). Two phlegmons coalesced into abscesses within 1 week of diagnosis. Lactational phlegmon is a complication of mastitis in breastfeeding women that is distinct from abscess and UM. Optimal treatment consists of an extended course of antibiotics and close follow-up to monitor for coalescence into a drainable fluid collection and/or persistence of mass requiring biopsy.

European Network of Pregnancy Registers in Rheumatology (EuNeP)-an overview of procedures and data collection.

BACKGROUND: The collaborative initiative of the European Network of Pregnancy Registers in Rheumatology (EuNeP) aims to combine data available in nationwide pregnancy registers to increase knowledge on pregnancy outcomes in women with inflammatory rheumatic diseases (IRD) and on drug safety during pregnancy and lactation. The objective of this study was to describe the similarities and differences of the member registers. METHODS: From all registers, information about their structure and design was collected, as well as which parameters regarding demographics, maternal outcomes, treatment, course and outcome of pregnancy, and development of the child were available in the respective datasets. Furthermore, the current recruitment status was reported. RESULTS: The four registers (EGR2 (France), RePreg (Switzerland), RevNatus (Norway), and Rhekiss (Germany)) collect information prospectively and nationwide. Patients can be enrolled before conception or during pregnancy. To date, more than 3500 patients in total have been included, and data on 2200 pregnancies with an outcome are available. The distribution of diagnoses in the respective registers varies considerably, and only three entities (rheumatoid arthritis, psoriatic arthritis, and spondyloarthritis) are captured by all the registers. Broad consistency was found in non-disease-specific data items, but differences regarding instruments and categories as well as frequency of data collection were revealed. Disease-specific data items are less homogeneously collected. CONCLUSION: Although the registers in this collaboration have similar designs, we found numerous differences in the variables collected. This survey of the status quo of current pregnancy registers is the first step towards identifying data collected uniformly across registers in order to facilitate joint analyses. TRIAL REGISTRATION: Not applicable.

Postdelivery Emergencies.

This article covers a high-risk time in a woman's life, the period just after delivery of her baby. There are large variations in complication rates across various groups in the United States. Many women seek care in the emergency department for routine and more serious postpartum pathologies. Emergency physicians should be well versed in common and life-threatening complications of delivery. The specific pathologies discussed in this article include lactation in the emergency department, postpartum hemorrhage, amniotic fluid embolism, endometritis, and mastitis.

Selected serum acute-phase proteins in peripartum sows and evaluation of their diagnostic usefulness.

Lactation impairment in sows is a frequent and significant clinical problem. Due to a complex aetiopathogenesis, early diagnosis of postpartum dysgalactia syndrome (PDS) is difficult and so far has usually been based on physical examination performed in the first days after farrowing. To date no data have been provided on the diagnostic usefulness of acute phase proteins (APP) in early diagnosis of peripartum disorders, including lactation disorders in sows. This study aimed at measuring the serum concentration of selected APP (C-reactive protein (CRP), haptoglobin (Hp), serum amyloid A (SAA) and pig major acute phase protein (Pig-MAP)) in sows with physiological and pathological course of the peripartum period and at evaluating the possibility of utilising the studied markers in the early diagnosis of lactation disorders. Also, the correlation between the studied APP serum concentration and production parameters was assessed. To the best of the authors' knowledge, the present study is the first such performed on sows. The experiment was conducted on 139 sows divided into three experimental groups based on the course of peripartum period: HEALTHY (n = 58) - clinically healthy sows, PDS (n = 45) - sows with milk production disorders, and OTHERS (n = 36) - sows which had experienced difficult parturitions, inflammations not connected with mammary glands (abscesses, hooves infections), or lameness. Thirteen serum samples from each sow were analysed, samples being taken on days -28 (-30 to -25), -14 (-16 to -11), -7 (-8 to -6), -5, -3, -1, 0 (parturition day), +1, +3, +5, +7, +14 and +28 (prior to or post farrowing). In order to measure the level of serum APP, commercial, quantitative ELISA tests were used. The results of the study indicate that the diagnosis made on the basis of the assessment of SAA levels on day 7 before the farrowing was not statistically different from the diagnosis made on the basis of the physical examination in the first days after the farrowing, that is the so-called "gold standard". The achieved results indicate that SAA may be a useful early marker of lactation impairments in sows, which allows detection of which sows are susceptible to lactation disorders with high probability even as early as one week before parturition.

Delivery mode and breastfeeding outcomes among new mothers in Nicaragua.

Breastfeeding has been shown to benefit infants and mothers. Women who have caesarean deliveries (C-sections) are expected to be less likely to initiate and continue breastfeeding than those who have vaginal deliveries. Given the high rate of C-sections in Nicaragua, the importance of breastfeeding, and the centrality of culture in choices about breastfeeding, this study sought to examine if mode of delivery relates with breastfeeding initiation and exclusivity in Nicaragua. Two hundred fifty mothers were surveyed about birth experiences and breastfeeding behaviour in 3 public clinics in León, Nicaragua, between June and August 2015. Logistic regression analyses were performed to examine the association of mode of delivery with initiation of breastfeeding within 1 hr of birth (early initiation) and exclusive breastfeeding for 6 months post-partum. The rate of early initiation was 68.8% and that of exclusively breastfeeding for 6 months was 12.7%. Mode of delivery was not significantly associated with early initiation (p = .383) or exclusive breastfeeding (p = .518). Early initiation was negatively associated with prelacteal feeding, AOR = 0.30, 95% CI [0.16, 0.58]; p = .001. Mothers who had perceived their infants as large at birth were significantly less likely to exclusively breastfeed for 6 months, AOR (95%CI) = 0.25 (0.06-0.97); p = 0.046. Mode of delivery was not significantly associated with optimal breastfeeding initiation and exclusivity among mothers in Nicaragua. The 2 risk factors identified for delayed initiation of breastfeeding and lack of exclusive breastfeeding were prelacteal feeding and maternal perception of a large infant at birth, respectively.

[Pregnancy and lactation-associated osteoporosis]. / Schwangerschaftsassoziierte Osteoporose.

Pregnancy and lactation-associated osteoporosis (PLO) is a rare form of osteoporosis, which occurs in the last trimester or postpartum. So far 100 cases have been published. The leading symptoms are severe low back pain or less frequently hip pain. Many patients develop postpartum depression due to inability to care for the baby and vertebral fractures. The therapeutic decision has to be made individually but teriparatid and bisphosphonates seem to be the best option. We report the clinical course (16 years) of a 37-year-old patient with PLO, who suffered 6 vertebral fractures. There were severe physical limitations and mental problems caused by the disease. The patient was treated by multimodal therapy including physiotherapy and psychotherapy and bisphosphonates were given. The time between the onset of symptoms and diagnosis was 5 months. No further fractures occurred in the following 16 years. The physical and mental condition significantly improved.

Implementation of an education package on breast engorgement aimed at lactation consultants and midwives to prevent conflicting information for postnatal mothers.

AIM: The aim of this evidence-based practice project was to improve local practice in the treatment of breast engorgement in postnatal mothers and to ensure the treatment of engorgement in postnatal mothers is performed according to the best available evidence. METHODS: This evidence-based practice project took place in a 28-bed postnatal ward in a large metropolitan tertiary hospital. Twenty midwives and 20 in-patients were recruited for the project. The project utilized an audit and feedback design. Midwives were asked a series of questions to test their knowledge on engorgement, and mothers were asked questions relating to the breastfeeding and engorgement care they received. The project was conducted in three phases: preparation for quality audit, implementation of best practice and postimplementation audit. RESULTS: Comparison of Audit 1 (preimplementation) and Audit 2 (postimplementation) results shows significant improvements in all eight audit criteria. An increase of 80% was achieved for the criteria 'midwives received formal education on engorgement' on completion of the project. A 20% increase in 'consistency of education regarding latch' was reported by the mothers, and there was a 30% increase in 'information given to mothers on prevention and signs of engorgement'. Sixty-five percent of midwives were able to correctly identify and manage engorgement, a significant improvement from 5% at baseline. CONCLUSION: This evidence-based practice project successfully identified and utilized best practice in the management of breast engorgement care in mothers in our clinical setting. With effective breast engorgement interventions in place, mothers could continue to successfully breastfeed their babies. The major challenges identified during the conduct of the project included: time constraints on the midwives to attend education sessions and to educate mothers on prevention. At the completion of this project, a closer relationship was forged between the lactation consultant team and the midwives in the project setting. This increased the satisfaction and productivity of the midwives, and motivated them to deliver high-quality care, which contributed to an improvement in mother's confidence and reduction in conflicting information.

ABM Clinical Protocol #20: Engorgement, Revised 2016.

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Reliability of Lactation Assessment Tools Applied to Overweight and Obese Women.

BACKGROUND: The interrater reliability of lactation assessment tools has not been evaluated in overweight/obese women. OBJECTIVE: This study aimed to compare the interrater reliability of 4 lactation assessment tools in this population. METHODS: A convenience sample of 45 women (body mass index > 27.0) was videotaped while breastfeeding (twice daily on days 2, 4, and 7 postpartum). Three International Board Certified Lactation Consultants independently rated each videotaped session using 4 tools (Infant Breastfeeding Assessment Tool [IBFAT], modified LATCH [mLATCH], modified Via Christi [mVC], and Riordan's Tool [RT]). For each day and tool, we evaluated interrater reliability with 1-way repeated-measures analyses of variance, intraclass correlation coefficients (ICCs), and percentage absolute agreement between raters. RESULTS: Analyses of variance showed significant differences between raters' scores on day 2 (all scales) and day 7 (RT). Intraclass correlation coefficient values reflected good (mLATCH) to excellent reliability (IBFAT, mVC, and RT) on days 2 and 7. All day 4 ICCs reflected good reliability. The ICC for mLATCH was significantly lower than all others on day 2 and was significantly lower than IBFAT (day 7). Percentage absolute interrater agreement for scale components ranged from 31% (day 2: observable swallowing, RT) to 92% (day 7: IBFAT, fixing; and mVC, latch time). Swallowing scores on all scales had the lowest levels of interrater agreement (31%-64%). CONCLUSION: We demonstrated differences in the interrater reliability of 4 lactation assessment tools when applied to overweight/obese women, with the lowest values observed on day 4. Swallowing assessment was particularly unreliable. Researchers and clinicians using these scales should be aware of the differences in their psychometric behavior.

Sheehan's syndrome in Xinjiang: Clinical characteristics and laboratory evaluation of 97 patients.

OBJECTIVE: To evaluate the clinical and hormonal characteristics of patients with Sheehan's syndrome in Xinjiang, China. METHODS: 97 cases diagnosed as Sheehan's syndrome in our hospital from 1999 to 2013 were retrospectively reviewed. The medical history, physical examination findings and hormonal profiles were documented and analyzed. RESULTS: The mean age at diagnosis was 43.7±12.4 years, with a mean diagnostic delay of 9.1±9.5 years (range, 1 month-35 years). 10 of our patients (10.3%) had a home birth. 96 of our patients (99.0%) had a history of obstetric hemorrhage. The most common clinical presentation included amenorrhea (80/97, 82.5%), agalactia (2/97, 74.2%) and loss of axillary or pubic hair (83/97, 85.6%). Seventy two of our patients (74.2%) failed to lactate and 80 of our patients (82.5%) failed to resume menstruation. Hypothalamic dysfunction included the hypothalamic-pituitary-gonadal axis (HPG) (LH deficiency: 77/83 patients, 92.8%; FSH deficiency: 73/83 patients, 88%; E2 deficiency: 62 of 82 patients,75.6%), the hypothalamic-pituitary-thyroid (HPT) axis (TSH deficiency: 77/93 patients, 82.8%, TT3 deficiency: 70/ 87 patients, 80.5%, TT4 deficiency: 72/87 patients, 82.8%) and the hypothalamus-pituitary-adrenal (HPA) axis (ACTH deficiency: 19/37 patients, 51.4%, cortisol deficiency: 49/64, 76.6%). CONCLUSIONS: Sheehan's syndrome is still common in Xinjiang, especially in rural areas. Long diagnosis delay in most of the patients indicates that women might be lacking correct diagnosis and treatment. Physicians need to be aware of the most important clues for diagnosis such as lack of lactation in the postpartum period and failure to resume menstruation.

Rusty pipe syndrome, a cause of bloody nipple discharge: case report.

Breastfeeding has universally known advantages to the mother and child that include nutritional and immunological benefits but also involve reasons of ecological and economic order. Initiation and maintenance of breastfeeding can be associated with common problems. The beginning of milk production may course with bloody nipple discharge, which, after exclusion of pathological entities, concerns a self-resolving physiological syndrome called rusty pipe. We present a case of rusty pipe syndrome and discuss the implications.