Not just the “rushers”
This year, among the invited experts participating in the debate were: Prof. Justyna Kowalska, MD, PhD, from the Department of Infectious Diseases for Adults MUW, Prof. Piotr Gałecki, MD, PhD, national consultant in psychiatry, Magdalena Nehring-Gugulska, MD, PhD, President of the Creative Women's Foundation and the Center for Lactation Science, Aleksandra Wesołowska, PhD, President of the Human Milk Bank Foundation, Head of the Laboratory of Research on Human Milk and Lactation, Joanna Kozakiewicz, lactation consultant (IBCLC), doula, as well as Justyna Mieszalska, President of the Medical Center MUW and Malgorzata Perl, President of the Excersice is Medicine Poland Foundation, who acted as moderators.
The discussion began with Małgorzata Perl noting that the group we first think of as children at risk of not being breastfed are premature babies, which is almost one in eight children in Poland. For them, however, breast milk is more than food...
- Indeed, in their case it is almost a cure. Based on research, we know that babies born prematurely fed naturally get good therapeutic results faster than their peers fed artificially. This is due to the composition of breast milk, in which, in addition to the most important nutrients, we also find immunomodulating components. For this reason, in the absence or scarcity of biological mother's milk, the first choice should be to supplement the baby's diet with another mother's milk from a milk bank - Dr. Wesołowska explained.
The expert also noted that it is difficult to estimate how many mothers of premature babies have impaired lactation due to the lack of data monitoring the diet of babies born prematurely in Poland.
- In fact, since Prof. Krystyna Mikiel-Kostyra's research, i.e. since 1997, we have no nationwide epidemiological studies on breastfeeding in Poland collected according to World Health Organization (WHO) guidelines. On exclusive breastmilk feeding, we have only data from local studies, albeit methodologically correct, and the conclusions are sad... Although most mothers start breastfeeding after birth, the percentage of children fed artificially in hospitals is high, ranging from 50 to 70 percent. - Dr. Nehring-Gugulska commented.
Although the list of beneficiaries of milk from a milk bank, in addition to premature and long-treated children, includes other groups of children deprived of access to mother's milk due to fortuitous reasons, such as orphaned children, children of mothers after mastectomy or children of HIV-infected mothers, milk from a milk bank is not reimbursed for them. Therefore, even with significant milk bank supplies, they rarely get the chance to use milk from a milk bank, and it is always an individual decision of the particular milk bank. This should be changed by expanding reimbursement to special groups that are at risk of not being breastfed.
- Unfortunately, procedural and financial problems stand in the way of expanding the groups of children who could benefit from milk banks. I personally feel that two groups should get access to milk bank feeding as soon as possible. The first is the children of mothers with oncological diseases, and the second is the children of HIV-positive mothers - Dr. Wesołowska stressed.
Referring to milk banks, Justyna Mieszalska recalled that they have been operating in the world for more than 100 years. The first ones opened in Vienna (1909) and Boston (1919), while we had to wait until 2012 for our Polish one. Exactly a few months earlier, the first daughter of Joanna Kozakiewicz, a lactation consultant (IBCLC), doula and, above all, mother, was born.
- I must admit that my “milk road” was bumpy. I wanted to give birth to my first daughter at home, it happened otherwise... I ended up in the hospital, where they tried to control my developing HELLP syndrome. In the 32nd week of pregnancy, due to the immediate threat to life, a cesarean section was performed under general anesthesia. I spent the next month in a 10-bed room with mothers who had their babies with them. My daughter lay in the NICU. Attaching the baby to the breast was not an option, the medical staff rarely agreed to kangarooing, and the medications I was taking, namely Dopeyt and Metocard, were considered incompatible with lactation, so I could only pump. It wasn't until later that I learned that both preparations could be safely used while breastfeeding. I remember that one mom wanted to share her milk with my daughter. Unfortunately, the neonatologist laughed at us, saying that the “institution of the mamma” ceased to exist in the early 20th century. - she commented.
Ukrainian-Polish lactation
Another group of children at risk of not breastfeeding that experts discussed were refugee children and victims of crises.
- War always entails severe stress, which affects not only our quality of life and health, but also the course of lactation. Extreme stress in the mother after childbirth may or may not have an inhibitory effect on lactation, after all, it develops mainly due to high levels of prolactin after childbirth. Thus, in the first month of lactation, stress has less of an impact than in the following months, when prolactin is no longer so important, and milk is produced on a supply and demand basis. The flow of milk from the breast depends on oxytocin, and severe stress can disrupt its secretion - Dr. Nehring-Gugulska explained.
Dr. Wesołowska also commented on lactation problems of Ukrainian refugee women introducing the goals of the project “Supporting mothers in proper nutrition of children in crisis” implemented by the Human Milk Bank Foundation thanks to funding from the UNICEF Office for Emergency Response in Poland.
- The project focused on developing and implementing the principles of infant and young child nutrition in crisis situations in Poland. In cooperation with 11 hospitals in the country, we were able to provide mothers who found themselves in a difficult perinatal situation with the opportunity for free lactation, neurological, physiotherapeutic and psychological counseling. Interestingly, Ukrainian women were much more willing to receive lactation support than psychological support, that is, they primarily tried to take care of the needs of their child and themselves. However, very often it turned out that it was psychological advice that allowed to solve the lactation problem. This shows how important a holistic approach and interdisciplinary teams are for the well-being of lactation. Our Foundation also carried out another project, which consisted of collecting qualitative interviews with mothers from Ukraine. My thoughts: there were wet wipes, diapers and artificial mixtures waiting at the reception points. There was a lack of trained people who could give them lactation support.
Primarily, “let's level the playing field”
The second part of the debate was devoted to the children of HIV-positive moms and the children of moms requiring drug treatment after childbirth.
As Prof. Kowalska pointed out, due to the risk of virus transmission in most highly developed countries, including Poland, breastfeeding is not a recommended method of nutrition. On the other hand, if the mother is receiving antiretroviral treatment then HIV infection is not an absolute contraindication.
- In mothers on effective treatment, the risk of viral transmission is very low - less than 1 percent. Despite this, in my clinical experience, and as an infectious disease specialist I have been working with people living with HIV for 25 years, most HIV-positive mothers choose not to breastfeed. Which is also understandable given that the quality of artificial milk and the purity of its administration are incomparable to Africa, where the safer natural method, the breast, is chosen for sanitary reasons. However, I think that what is lacking in Poland, and what I discovered thanks to Dr Wesołowska, is a lack of information. That is, we routinely do not inform HIV-positive women that their children can be breastfed as long as certain conditions are met. What's more, their children could get their milk if we decided to give them a form of support such as pasteurization. Personally, I think that just as important as the “one health” strategy is the “people first” strategy, where the patient is the decision-maker and our job is to support them in making the most informed decisions possible.
Finally, Justyna Mieszalska raised the topic of drug use and breastfeeding. As she noted, although according to Prof. Hale's classification most medicinal substances can be safely used during breastfeeding, in the Characteristics of Medicinal Products (SmPC) most manufacturers include information that they should not be used, which causes confusion for mothers.
- Indeed, although there are few drugs in the L5 category, i.e. contraindicated in lactation, many mothers hear that they cannot breastfeed during pharmacotherapy, and even according to our survey “Observance of the rights of breastfeeding women in Poland,” almost half of mothers are denied some kind of service because of breastfeeding, mainly the administration of a drug, but also a dental procedure, immunization or imaging test. And yet Prof. Hale's world-renowned lexicon, who devoted 25 years of his professional life to analyzing available clinical trials of drugs during lactation, is widely available and updated every two years. Patients can also use it, for example in the online database Lactmed or e-lactancia, as well as the Polish Lactation Drug Lexicon. Knowing the pharmokinetic parameters of a drug, we can choose the safest drug from a given group, in the case of drugs administered with caution, choose the time of feeding so as not to feed the baby at the time of peak concentration in the milk, choose the optimal route of administration of the drug and provide guidance to the mother on feeding the baby - Dr. Nehring-Gugulska stressed.
The safety of pharmacotherapy during pregnancy and lactation was also addressed by Prof. Gałecki.
- In psychiatry, both pregnancy and lactation have always been seen as contraindications to pharmacotherapy, which, from the perspective of modern knowledge, was a deprivation of access to treatment. Being a young doctor myself, I often felt helpless when dealing with patients suffering from anxiety or depressive disorders, who were not being helped. This experience led me to convince the Polish Psychiatric Association to address this topic when I became a national consultant in psychiatry, and now every specialty exam will include a question on the treatment of pregnant and breastfeeding women. On the other hand, it is worth returning to the history and clinical observations that have provided us with knowledge about the effects of drugs on the body of a woman and her child. Before the advent of atypical neuroleptics in schizophrenic patients, we used classical neuroleptics, which led to disorders of prolactin secretion, which manifested as menstrual disorders or galactorrhea. And naturally, our patients being sexually active did not get pregnant. The appearance on the market of second-generation psychotic drugs, i.e. atypical neuroleptics, most of which are devoid of the negative effect associated with hyperprolactinemia, resulted in unplanned pregnancies, which gave birth to healthy children! The same was the case with antidepressants - it is usually the case that a woman finds out about pregnancy 4-6 weeks after conception, and if she is taking antidepressants then even after withdrawal they are still biologically active in her body for about 2 weeks. In practice, this means that a slight delay in the diagnosis of pregnancy means that when we stop the drug for the entire first trimester she is under the influence of the active substance, and this is the period associated with the greatest teratogenic risk. And also retrospective studies have shown that the risk is none, moreover, the development of children of mothers who were clinically depressed and took the drug is better than the development of children of mothers who were depressed and did not take the drug.
At the end of the debate, each participant expressed his or her dream related to protecting and supporting breastfeeding. Ours remains the same: let's stop talking about lactation terror and simply support moms who want to breastfeed.