Lactancia materna y tratamiento con litio: Caso clínico / Lithium while breastfeeding: Case report

El tratamiento con litio forma parte de la terapia habitual en las personas que sufren el trastorno bipolar. Habitualmente, aquellas madres que desean dar el pecho a sus hijos son sometidas a la disyuntiva entre modificar el tratamiento o bien administrar lactancia artificial. La administración de litio durante la lactancia materna se ha asociado con diversos efectos adversos en el lactante, tales como alteraciones tiroideas, hipotermia o hipotonía, entre otros. Son pocas las publicaciones en las que no se observan dichas anomalías en los lactantes. A continuación, se presenta el caso de un lactante amamantado por su madre en tratamiento con litio que no presentó alteraciones renales ni tiroideas.

Lithium therapy is currently a cornerstone of treatment for mothers who suffer bipolar disorders. Those who wish to breastfeed their children are often told they have to decide whether modifying the treatment for their disorder or even avoiding lactation. Lithium administration during breastfeeding has been described to produce certain side effects such as thyroid disorders, hypothermia and hypotonia. To our knowledge, there are few publications where infants have no laboratory abnormalities. Here we present the case of an infant without renal or thyroid alteration while he was breastfed.

[Lithium while breastfeeding: Case report]. / Lactancia materna y tratamiento con litio: Caso clínico.

Lithium therapy is currently a cornerstone of treatment for mothers who suffer bipolar disorders. Those who wish to breastfeed their children are often told they have to decide whether modifying the treatment for their disorder or even avoiding lactation. Lithium administration during breastfeeding has been described to produce certain side effects such as thyroid disorders, hypothermia and hypotonia. To our knowledge, there are few publications where infants have no laboratory abnormalities. Here we present the case of an infant without renal or thyroid alteration while he was breastfed.

El tratamiento con litio forma parte de la terapia habitual en las personas que sufren el trastorno bipolar. Habitualmente, aquellas madres que desean dar el pecho a sus hijos son sometidas a la disyuntiva entre modificar el tratamiento o bien administrar lactancia artificial. La administración de litio durante la lactancia materna se ha asociado con diversos efectos adversos en el lactante, tales como alteraciones tiroideas, hipotermia o hipotonía, entre otros. Son pocas las publicaciones en las que no se observan dichas anomalías en los lactantes. A continuación, se presenta el caso de un lactante amamantado por su madre en tratamiento con litio que no presentó alteraciones renales ni tiroideas.

Differences in mother-to-infant bonding according to type of C-section: Elective versus unplanned.

Aim To compare the mother-to-infant bond of mothers who gave birth by elective C-section versus urgent C-section in the first 48-72h of life and 10-12weeks after delivery. METHODS: This is a cohort prospective study of women giving birth by C-section. 48-72h after delivery, sociodemographic variables were collected, Mother-to-Infant Bonding Scale and newborn's response to separation test were performed. 10-12weeks after delivery Mother-to-Infant Bonding Scale and questions about baby's feeding were completed. RESULTS: A total of 116 dyads were recruited, 58 in each group. No significant differences between the two C-sections in bonding, newborn response to separation or type of feeding were observed at any time points. However, those dyads presenting with an abnormal bond at time 1 had more frequently an abnormal bond at time 2 (50% versus 8.1%, p=0.000). CONCLUSIONS: No differences in mother-to-infant bond were found according to type of C-section.

The Relationship of the Administration of Intrapartum Synthetic Oxytocin and Breastfeeding Initiation and Duration Rates.

AIM: The consequences that intrapartum administration of hormones can have on breastfeeding are unclear. The aim of the study is to determine if synthetic intrapartum oxytocin, used routinely for induction/stimulation, has a relationship to initiation/duration of breastfeeding. PATIENTS AND METHODS: We conducted a cohort study that was carried out in a tertiary university hospital distinguished by WHO-UNICEF as a BFHI (Baby-Friendly Hospital Initiative). A group of 53 mother and newborn dyads who had been exposed to intrapartum synthetic oxytocin were compared with 45 nonexposed dyads. A breastfeeding questionnaire was administered by a midwife blind to patient group through phone calls 3 and 6 months after delivery. RESULTS: No statistically significant differences were observed between the two groups in the rates of mothers exclusively breastfeeding (EBF) or nonexclusively breastfeeding. The percentage of those who were EBF when discharged was 97.3% in the oxytocin-nonexposed group and 87.1% in the oxytocin-exposed group (p = 0.14). At 3 months, the group rates of exclusive breastfeeding were 72.5% in the nonoxytocin-exposed group versus 65.9% in the oxytocin-exposed group (p = 0.71). At 6 months, rates of breastfeeding were 31.4% versus 27.9% (p = 0.53) in the oxytocin-nonexposed and oxytocin-exposed groups, respectively. CONCLUSIONS: In this study, no statistically significant effect of intrapartum synthetic oxytocin administration was observed pertaining to the initiation or duration of breastfeeding.

Intrapartum synthetic oxytocin reduce the expression of primitive reflexes associated with breastfeeding.

AIM: Several synthetic peptide manipulations during the time surrounding birth can alter the specific neurohormonal status in the newborn brain. This study is aimed at assessing whether intrapartum oxytocin administration has any effect on primitive neonatal reflexes and determining whether such an effect is dose-dependent. MATERIALS AND METHODS: A cohort prospective study was conducted at a tertiary hospital. Mother-infant dyads who received intrapartum oxytocin (n=53) were compared with mother-infant dyads who did not receive intrapartum oxytocin (n=45). Primitive neonatal reflexes (endogenous, antigravity, motor, and rhythmic reflexes) were quantified by analyzing videotaped breastfeeding sessions in a biological nurturing position. Two observers blind to the group assignment and the oxytocin dose analyzed the videotapes and assesed the newborn's state of consciousness according to the Brazelton scale. RESULTS: The release of all rhythmic reflexes (p=0.01), the antigravity reflex (p=0.04), and total primitive neonatal reflexes (p=0.02) in the group exposed to oxytocin was lower than in the group not exposed to oxytocin. No correlations were observed between the dose of oxytocin administered and the percentage of primitive neonatal reflexes released (r=0.03; p=0.82). CONCLUSIONS: Intrapartum oxytocin administration might inhibit the expression of several primitive neonatal reflexes associated with breastfeeding. This correlation does not seem to be dose-dependent.

Neuroendocrinology of childbirth and mother-child attachment: the basis of an etiopathogenic model of perinatal neurobiological disorders.

This review focuses on the neuroendocrine mechanisms in the mother and the newborn that are involved in the generation and consolidation of mother-child attachment. The role that different hormones and neurotransmitters play on the regulation of these mechanisms during parturition, the immediate postpartum period and lactation is discussed. Interferences in the initiation of mother-child attachment may have potential long-term effects for the behavior and affection of the newborn. Therefore, the possible consequences of alterations in the physiological neuroendocrine mechanisms of attachment, caused by elective Cesarean section, intrapartum hormonal manipulations, preterm delivery, mother-infant postpartum separation and bottle-feeding instead of breastfeeding are also discussed.

Guía de práctica clínica de atención en el embarazo y puerperio / Clinical practice guide for pregnancy and puerperal care

El objetivo de esta guía es establecer un conjunto de recomendaciones basadas en la evidencia científica de mayor calidad disponible para mejorar la salud de las mujeres embarazadas y puérperas, así como la salud de los y las recién nacidos.

Mode of delivery may influence neonatal responsiveness to maternal separation.

INTRODUCTION: Maternal-infant separation (MIS) is a highly stressful situation for the neonate. MATERIALS AND METHODS: A study was conducted to observe and describe the reactions of term neonates to brief maternal separation and restoration of skin contact within the first 48 h of life, and to assess whether the mode of delivery influences neonatal responsiveness. A brief maternal-infant separation situation was videotaped to observe the reactions of the newborns within the first 12-48 h of life. Characteristics observed in the newborns were: the Moro reflex, spreading out arms and feet, looking at the mother, presence/lack of crying, and some dichotomous variables (present or lacking); in mothers: adult speech, "motherese" speech, speaking to another adult present in the room, singing, clicking, tapping on the diaper, rocking, kissing the baby, touching toes, touching hands, changing position, making loving comments, calling the newborn by his/her name and touching his/her back. Crying on restoration of contact was measured. RESULTS: Ten neonates born by planned C-section and 21 neonates born by oxytocin-induced vaginal delivery were included. No behavioral differences were observed according to the mode of delivery. Neonates born by vaginal delivery took longer (64.8±8.6 s) to calm down than those born by C-section (0.9±1.4 s) (p=0.004). A correlation was observed between cortisol concentrations at birth and the time required to calm the baby down (r=0.41; p=0.02). CONCLUSION: Neonates born by a planned C-section cried much less on maternal separation, which might indicate an altered attachment behavior and altered response to stress. Further studies are needed to determine the potential long-term implications of variations in mother-infant attachment during the first days of life.

Trichotillomania, bipolar disorder and white matter hyperintensities in a six-year old girl.

A six-year-old girl was referred to our child psychiatry outpatient clinic by the Pediatric Neurology Unit with a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) and trichotillomania. She had neither eyebrows nor eyelashes. The clinical picture was of irritability, frequent tantrums, and aggressive behaviour. During the following year she presented several brief episodes of intense mood changes, which typically started with night-time onset trichotillomania and sleep disturbance. The episodes lasted no longer than five days and recurred within one or two months. A diagnosis of pediatric bipolar disorder (BD) was made after the first months of clinical follow-up. An MRI showed focal white matter hyperintensities (WMH) in T2.

Newborn feeding behaviour depressed by intrapartum oxytocin: a pilot study.

AIM: To investigate the effect intrapartum oxytocin administration can have on Primitive Neonatal Reflexes. The secondary objective was to observe the influence of intrapartum oxytocin may have on breastfeeding. METHODS: Twenty healthy primiparae with a single gestation at term were included. To assess Primitive Neonatal Reflexes, video film was taken during an experimental situation designed to elicit Primitive Neonatal Reflexes. Three independent observers blinded to the oxytocin dose that had been administered coded the Primitive Neonatal Reflexes. Data regarding breastfeeding were collected by telephone at 3 months. RESULTS: Medium oxytocin dose was 1931.9 ± 1754.4 mUI. A Kappa index >0.75 was obtained for four Primitive Neonatal Reflexes: swallow, jaw jerk, suck and gazing. A negative association was found between oxytocin dose and sucking (p = 0.03). At 3 months of life, women exclusively breastfeeding (63.1%) had received a significantly lower average dose of oxytocin than those not exclusively breastfeeding (36.8%) (p = 0.04). CONCLUSION: In this pilot study, intrapartum exogenous oxytocin seems to disturb sucking and breastfeeding duration. Further studies are required to confirm these results and to ascertain whether there could be other effects of intrapartum oxytocin on newborn behaviour.

Breastfeeding following emergency peripartum hysterectomy.

Emergency peripartum hysterectomy (EPH) is usually performed in cases of intractable obstetric hemorrhage unresponsive to conservative treatment. EPH is associated with a high incidence of maternal morbidity and mortality. Most of these women do not have the opportunity to even start breastfeeding. We report a case where breastfeeding was attempted after EPH. The mother spent 6 days in the intensive care unit and suffered several medical and surgical complications. On day 7 she was reunited with her baby. One month later, a diagnosis of post-traumatic stress disorder was made. Breastfeeding became very important, with the patient frequently expressing that this was the most healing aspect in her recovery from the traumatic EPH. At 3 months, five daily feeds were supplemented with formula. Breastfeeding, principally nocturnal, continued 6 months after childbirth, with the baby being weaned at 7 months. Women who undergo EPH need psychological support. The option of breastfeeding should be considered even days or weeks after the surgical intervention as it can be a healing experience for some women who are grieving the loss of their fertility. Professional specialized breastfeeding support should be offered in these cases, and the possibility of reuniting mother and infant even when the mother is in the intensive care unit should be considered.

Lactancia para psiquiatras: recomendaciones sobre el empleo de psicofármacos en madres lactantes / Breastfeeding for psychiatrists: considerations before prescribing to nursing mother

El tratamiento de los trastornos mentales maternos durante la lactancia presenta una complejidad añadida: el posible paso del psicofármaco a la leche y su efecto en el lactante. En la práctica clínica, la decisión de iniciar tratamiento psicofarmacológico a menudo conlleva el destete temprano, privando a la madre y al bebé de los efectos beneficiosos de la lactancia. Entre otros, la lactancia puede ser un instrumento facilitador de la recuperación psíquica y del establecimiento del vínculo maternofilial. Un mejor conocimiento de la farmacocinética en la lactancia y de los psicofármacos que pueden ser utilizados permitiría mantener la lactancia incluso cuando la madre precisa tratamiento farmacológico. En el presente trabajo se revisan y comentan los estudios más recientes publicados sobre el uso de psicofármacos en lactancia. El objetivo es establecer pautas que puedan orientar a los psiquiatras a la hora de establecer un plan de tratamiento que permita continuar con la lactancia. Se presta especial atención a la utilización de antidepresivos, ansiolíticos y estabilizadores del ánimo, puesto que son los psicofármacos que con mayor frecuencia se prescriben en madres puérperas. La decisión de iniciar tratamiento psicofarmacológico en madres lactantes debería ser tomada siempre por un equipo multidisciplinar (formado por médicos psiquiatras y pediatras y otros profesionales de enfermería y salud mental) que garantice el seguimiento de la díada madre-hijo y el tratamiento psicoterapéutico indicado. En cualquier caso, la utilización de psicofármacos no debería ser nunca el único abordaje terapéutico de los trastornos mentales del puerperio (AU)

Treatment of maternal psychopathology during the postpartum period poses the clinical dilemma of having to choose the psychotropic drugs that are compatible with breastfeeding. The decision to initiate pharmacological treatment often involves weaning, depriving the mother and the baby of the beneficial effects of lactation. Breastfeeding can be a therapeutic tool to facilitate psychological recovery and establishment of mother-child bond. In this paper we present a review and discuss the most recent studies concerning the use of psychoactive drugs by nursing women. The aim is to establish guidelines that can guide psychiatrists when planning a treatment that will support breastfeeding. Special attention is given to the use of antidepressants, anxiolytics and mood stabilizers, the psychotropic drugs most frequently prescribed in postpartum mothers. Treatment of nursing mothers should always include a multidisciplinary team (consisting of psychiatrists and pediatricians and other nursing and mental health professionals) to ensure close monitoring and psychotherapeutic treatment. The use of psychotropic drugs should never be the only therapeutic approach in the treatment of puerperal mental disorders (AU)

Oxytocin and autism: a hypothesis to research. Can perinatal oxitocinergic manipulation facilitate autism?

The study of the neurohormonal and behavioral processes and neural mechanisms involved in the development of attachment between the infant and the mother has received increased attention over the last years. Oxytocin has been shown to play a central role in the regulation of affiliate social behavior, including sexual behavior, mother infant bonding and social memory and recognition. Following normal physiological vaginal birth highest levels plasmatic endogenous oxytocin are achieved, which has been related to the presence of a sensitive period which seems to facilitate bonding and initial mother and newborn attachment. Perinatal manipulation of peptidic hormones like oxytocin can have life long lasting effects on social and sexual behaviors in animal models. Disregulation of oxytocinergic system has been observed in individuals with autistic disorders. A review of the possible effects of oxytocinergic perinatal manipulation in human newborns is discussed in the present review article. The hypothesis of the possible effect of perinatal oxytocin manipulation on the ethiology of autism is discussed.