Jennifer Lind, PharmD, MPH is an Epidemic Intelligence Service Officer assigned to the Nutrition Branch in the Division of Nutrition, Physical Activity and Obesity at the CDC. Dr. Lind’s research is focused on research and surveillance issues related to infant and young child feeding practices. Before joining the CDC, Dr. Lind worked as a community pharmacist which led to her deep commitment to public health and fostered her interest in chronic diseases. Dr. Lind and her colleagues recently published a ground breaking study in the Journal of Human Lactation that demonstrates an association between use of labor pain medications and a delay in the onset of lactation (DOL) (defined as milk coming in >3 days after delivery).
Jennifer Lind, PharmD, MPH
Dr. Lind was recently interviewed by Marie Hemming, IBCLC, a member of the International Lactation Consultant Association® (ILCA®) Medialert Team.
Marie Hemming: What led you to study the effect of labor medications on the onset of lactation?
Dr. Lind: As a pharmacist, labor pain medications are of interest to me and there is very little research done on the association between labor medications and how it can potentially affect the onset of lactation. So many women (estimate of 83%) use labor pain medications and we know that a delay in the onset of lactation (DOL) can lead to shorter breastfeeding durations.
MH: Please summarize the results.
DL: Mainly, in all of the groups of labor pain medications and delivery method, we found that mothers who received labor pain medications were 2-3 times more likely to report DOL compared to mothers who did not use labor pain medications and delivered vaginally.
MH: Are there other studies that demonstrate this association?
DL: This information is relatively new. There are 2 other studies, but they are greater than 10 years old. This current study is the most recent data on the topic.
MH: What do you think are the public health implications of these study results?
DL: This research adds to the body of literature on the topic, which can help inform clinicians and women as they make decisions regarding labor and delivery.
More studies need to be done looking at this association to evaluate why this association exists.
Finally, we need to explore if by providing additional lactation support to women who receive labor pain medications, we are able to improve breastfeeding outcomes and prevent the shorter breastfeeding duration that we know exists in women who have DOL.
MH: How can these data be used by pregnant women?
DL: Women can use these data when they are talking to their health care providers about labor pain medications as part of the decision making process. The research can help them make an informed decision with the knowledge that there may be a risk of experiencing breastfeeding difficulties if they use labor pain medications. Women can also be prepared with appropriate community support mechanisms in case they do experience a delay in the onset of lactation after they are discharged from the hospital. Everyone is very excited about the information because it addresses a gap in this field which is great for clinicians who work in labor and delivery and help mothers enhance natural breast feeding.
MH: Studies show it can take up to 17 years to translate research into practice. How do you think we can disseminate this information more quickly to pregnant women and their caregivers?
DL: This study is available online at the Journal of Human Lactation now. We hope to reach as many families and clinicians as possible so that this can go into the clinical decision making process that mothers and their caregivers make.
Correlation does not equal causation.
no where does this say correlation equals causation. just that this study might be helpful when discussing choices with your doctor.
“The research can help [women] make an informed decision with the knowledge that there may be a risk of experiencing breastfeeding difficulties if they use labor pain medications”
No no no.
“… a risk of [x] if they use [y]” implies causation.
The study has merit, but any article reporting on a study such as this should make it clear that correlation is NOT causation, if they truly are trying to provide women with the knowledge to make an informed decision.
This important information needs to be shared with not only lactation consultants but all childbirth educators and their organizations. Then to Anesthesiology, Pediatric and OB groups.
Besides hospitals needing to become Mother-Friendly, better accessibility to, and insurance coverage of, professional L&D doulas is urgently needed.
My intention was to have a natural childbirth … At 12 hours I didn’t dilate past 4 and too tired to keep on top of contractions… After 3 failed epidurals and an emergency c-section for a multitude of unexpected complications my son was born… My milk came in amazingly quickly (my nurses were shocked as well) and my son was a natural … I breastfed on demand for 23 months and my son has rarely been ill… Although correlations exist the bottom line is this…if you recognize that we women are made to breadtfeed and understand the vitality of it, you will MAKE it happen…
I agree Jennifer. When I had my children, everyone was given Demerol, babies went straight to the nursery and then brought to the mother every 4 hours for about 45 – 60 minutes. There was NO breastfeeding support.
I was determined to breastfeed and I did for about 30 months each – despite lots of common problems and pain.
I am not saying that today’s mother is less determined but – as a childbirth educator, doula and lactation consultant, I do see a link between medicalized birth and breastfeeding problems. Birth without the roduction of the natural hormanal “coctail” impedes breastfeeding. It doesn’t make it impossible but can and does make it more difficult for most.
I don’t want to sound rude but I can’t agree with your comment about breast feeding I was so committed to making it work my husband had to step in and make the decision to put mine on formula I literally dried up but refused to give up I went nearly 24 hours trying to make it work with my first before hubby stepped in and only 12 with my third before he stepped in I was committed but it just wouldn’t work.
Yes, woman are meant to breastfeed, they are always designed to birth babies without medication.
Not All can, and not all are so lucky. I was, twice.I really feel blessed!
Count yourself blessed, because not everyone is as lucky as you in this regard. :/ Both myself and a dear friend who had a C-section experienced SEVERE delay of lactation with our first babies – me for 10 days, and her for almost a month. We were both dedicated to breastfeeding and went on to pump exclusively for many months for our kiddos who would no longer tolerate the breast because of the delay, but willpower and determination alone isn’t always enough to make something happen. We both saw MANY IBCLC’s, doctors, pediatricians, the list goes on and on, but something biological/physiological interfered with our abilities to do what “women are made to do.” The potential DOL is not something that is discussed or brought up as a side effect when you’re presented with the option of pain relief, and if there’s even a chance that it could be a legitimate effect, it darn well should be.
As a childbirth educator, I always brought up DOL and other breastfeeding effects/complications of routine labor interventions in my classes.
Occasionally I would get an angry call form doctors and sometimes was accused of being “biased” from students. I finally made a sign “Don’t shoot the messenger”.
Some people simply do not want to hear the facts – especially if they are in opposition to their “plan”.
It is true that, rarely, a woman will not produce enough colostrum or milk for her baby. But, we see it more often in women who really can produce – especially when they are told that a newborn only needs to be fed every 3 hours or so.
If more women were told how important it is to keep the baby skin-to-skin and frequently feed during the early days, and to use “laid-back-breastfeeding” positions early on, it is my firm belief (and experience) that we would see far fewer problems and far more successes.
Reblogged this on Eurolac! and commented:
Pijn medicatie tijdens de baring heeft meer effecten dan alleen het wegnbemen van de pijn.
One woman’s anecdote…I had to have a scheduled C-section at 40 weeks due to my doctors not wanting to risk a post-dates VBAC at my age (40). So, I went in and had the epidural and all the typical C section anaesthesia. My daughter was delivered to me, rooted, then nursed for at least 40 minutes while we were still in the operating room! The nurses had never seen that. She continues to exclusively BF at 4 months, to be a very advanced baby!
What makes her advanced? Just curious. Thank you. And it’s so lovely when the babies go to breast right away. They didn’t used to give us that opportunity. (Tell them with your next baby that 40 is not old! lol) Congratulations.
you are so lucky you got to bf in OR. I’ve had 3 C-sections and had one arm strapped down and was draped from just below neck down so I won’t have had access to my breasts. Even given that I breastfed all 3 for two years each. Agree that if you really are committed to breastfeeding (usually) it will work for you.
Rachel, this is how it CAN be…..Especially when mothers start to insist on it. https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=natural%20caesarean%20video
I had 3 pain relief free vaginal births, with my first and last babies I suffered DOL and the longest I was able to feed either was only 9wks. My middle one I have no idea as I was put in coma the day after he was born but I know they gave me medication at the time to keep me lactating. How ever as I had a long road to recovery I chose not to feed him.
I had an epidural and spinal block but I breastfed with ease for 6 months, then i chose to stop. it was also my first child so I had no prior experience with breastfeeding and the midwives were useless. Perhaps I was just luck that it me and baby found it so easy but never the less I think this needs a lot more research.
I strongly believe this is true. It also influences baby’s sucking patterns. I really wonder if this would make a difference.
I had an unmedicated vaginal birth, and my milk never came in. After 2 lactation consultants and my son being hospitalized for jaundice and not thriving I had to give formula.
What was wrong with me then? I did everything right, and I still couldn’t. This kind of information hasn’t been studied enough and can be super dangerous.
Ezada, there actually has been quite a lot of good research on the effects of some routine labor interventions’ effect on lactation since the 1970’s.
I am so sorry to hear that you were not successful in your attempts at breastfeeding. There is a very rare condition called insufficient glandular tissue that can and does affect some women and their ability to produce any/enough milk. One of the early signs is no breast changes or enlargement during pregnancy. But, again this is rare.
Some of these women have continued to feed their babies at the breast with what is called a supplemental nursing system.
I have to disagree with you that this information hasn’t been studied enough, because it actually has. What is dangerous is NOT making good studies available to the public.
I am a proponent of informed consent. In order to make informed decisions about anything, one must have adequate, correct and up-to-date information.
Good research that repeats itself over and over needs to be shared and “out there” in order to facilitate informed decision making.
It is then up to every individual to make their own decisions regarding their personal circumstances.
I would love to see research about ingesting placenta (capsules, smoothies, or cooked) and its effect on breast milk production. Also, would there be less of a delay in the mother who had labor pain meds IF she did consume her placenta …..
I couldn’t agree more! There is a lot of anecdotal information “out-there” but solid research is sorely lacking.
I am surprised that no one has brought up how the constant stream of family & friends visiting the new parents can impact DOL. many mothers aren’t comfortable nursing in front of their family or friends, no skin to skin b/c “I need/ want to see hold baby” so you have sleepy babies. You could have a labor w.out any meds or IV fluids but if this scenario happens you’ll get DOL
All this says is pain medications. I’d be interested to know what medications they are talking about because there are so many different things given. I had an epidural and my doctor gave me medicine after birth. My milk took five days to come in and because of that I had to work with my son for three weeks to get him to nurse again.
Kayla,
The medications they are referring to are narcotics. Narcotics are now commonly added to epidural anesthesia. The two most commonly used are Actiq (fentanyl) and Duramorph (morphine). Both are known to interfere with infant respiratory and neurologic functions. NEITHER are approved by the FDA for use in pregnancy, labor, delivery, or lactation (Physicians Desk Reference), The PDR is the only publication that must publish the text of an FDA approved label of a drug exactly as it appears in the drug’s package insert). http://www.aimsusa.org/ObstetricDrugs-NotApproved.htm.
If you read that link, you will find that MOST of the drugs commonly used used in labor and delivery have NOT been approved by the FDA for use in pregnancy, labor, delivery, or lactation – http://www.aimsusa.org/obstetricdrugs.htm.
Nursing mothers need access to their newborns. Having them right near you so that the baby can be nursed on demand will help bring in the milk. The more you nurse, the more milk you will have. Both of my newborns nursed anywhere between one hour to every hour and a half. I left the hospital with my second the day after delivery and my milk was in within 24 hours. No drugs for either birth. I don’t know if drugs effect a milk supply or not, but I do know that nursing very frequently and staying in a comfortable, quiet setting does help. I drank lots of water too. Kept it by my bed. I read somewhere a long time back that in one primitive culture the mother stays in a place with a few women attending her. She stays there for around a month before anyone else sees the baby. So her chances are very good that all will go well while she eases her way into mothering.
For all mothers who choose to nurse their babies I wish you the best. Take it easy and enjoy.
Linda, you are right on!
Breastfeeding is a primitive biological function that relies on the production of Prolactin (milk making hormone) and Oxytocin (a powerful neurohypophysial hormone. Oxytocin is produced by having the baby in close physical (skin-to-skin) contact and with suckling.
Natural Oxytocin is a rather “shy” hormone – responsible for orgasm for one. When a new ‘inexperienced’ mother is trying to learn the art of breastfeeding – when there are visiting onlookers passing the baby around, it makes it extremely difficult for her to produce Oxytocin! She wouldn’t be expected to experience orgasm with those same onlookers now would she!
I do not know if the 3 days until milk comes in with both my first and 2nd had to do with the epidural. I wasl already 8-9cm dilated and had no issues breastfeeding my 2nd (my first i had an issue due to work). I breastfed my 2nd for 19 months. I received the epidural again with my 3rx and my milk came in the 2nd day. So who knows but really doesn’t matter, doesnt mean you cant breastfed.
I just had my daughter a month ago, vaginally delivery and I received pain medication throughout my 26 hours if labor, as well as an epidural when I called for 3 hours before giving birth to my daughter. I had absolutely no error in producing breast milk or getting her to feed, and I still don’t.
I find articles like this extremely arrogant and biased and seem to infer we mothers who choose pain medication as being “weaker” or “less determined” and putting our own comfort ahead of our child’s needs. “Choosing” pain relief is sometimes the best choice for some mothers even to do “what women were designed to do”. Pain relief was a recommended option for me as I had three high risk pregnancies, my first being a stillborn son at 32 weeks. I still lactated perfectly every time, even when I didn’t get to see or hold my baby for over 12 hours and breastfed for as long as baby and I chose. Choosing pain relief helped keep me alive and I resent it when people act as if pain relief is a “weak” choice. In the end, having a healthy baby AND mom is the goal. I wish people wouldn’t tout their own opinions as the only valid ones to be made. The grace of God and Medical advancements such as labour pain relief, having baby in hospital under the supervision of an obstetrician and top notch pediatric experts are what helped me deliver what are now two gorgeous strong young men. Would these people who seem to infer choosing pain relief as a birth option is a “weak” or “undetermined” choice choose to have a cavity filled or tooth pulled without pain relief? Because there are risks it can freeze your face permanently. Medical advancements save lives. I would not be alive to have breastfed, nourished and watch my children grow without them. Try being a little more accepting and less judgmental about others’ choices who are different from your own, people!
I am sorry that you are angry with this research article. More importantly, I am so very sorry for the loss of your 32 week old baby.
After reading your post, I went back and re-read the article and all the comments that came after. Not once did I read a inference to “mothers who choose pain medication as being “weaker” or “less determined”. I am sorry that you feel that you read that into the information posted. I regret that you may feel that you were viewed as weak or less determined because you chose to use medical pain relief for your labors.
As a long-time childbirth and lactation educator/consultant, who keeps up with the plethora of recent research, I can tell you that the article in question is neither arrogant or biased. Good research that is replicated – is what it is – reliable research.
I couldn’t agree more with your statement – “Choosing” pain relief is sometimes the best choice for some mothers even to do “what women were designed to do”. Even if there has been no reported maternal deaths due to childbirth pain – and increased rates of mortality and morbidity due to obstetric intervention – including narcotic pain relief.
Achieving a SATISFYING birth is the most important goal for any mother regardless of her birth outcome. Because we carry our memory of birth with us for as long as we live. A satisfying birth means many different things to different mothers.
As I said above, in another post, I am a proponent of INFORMED consent. In order to make informed decisions about anything, one must have adequate, correct and up-to-date information.
Good research that repeats itself over and over needs to be shared and “out there” in order to facilitate informed decision making.
It is then up to every individual to make their own informed decisions regarding their personal circumstances.
That said, It has been well established (and researched) that non-pharmacological pain relief measures i.e. doula support, warm water (tub/shower), nutrition (eating/drinking), movement, feeling safe and respected as well as many other non medical comfort measures are not only safer but very effective for many mothers in labor.
I am not going to say there isn’t a correlation between pain meds and DOL because I really don’t know. While this information is extremely interesting I find the way it is presented judgemental. When I had my son and was determined to have him without meds, but when a trained medical professional looks at you and says “your baby is in distress and either you willingly sign the paperwork for the epidural or I’m going to get it declared medically necessary” you do what you are told. I did have some trouble feeding him but I contribute that to age (teenager) and so many people visiting I didn’t spend the time I should have working on it. The reason I say this is no two women are alike, some can breastfeed, some can’t. Some don’t need medication, some do. Every situation and childbirth is different. While I believe that all information should be shared with an expecting mother, if you have to get pain meds, you have to and you shouldn’t feel guilty about it. This article made me feel guilty and it shouldn’t have cause I didn’t have a choice!
I truly believe that if anyone should feel guilty about all this, it is the medical/obstetrical system that is currently being practiced. NOT the mothers!! Currently, LAWS have to be passed to force hospitals, doctors and nurses to provide Baby-Friendly care that promotes and supports breastfeeding! To top it off, our current system of obstetrical care is neither evidence-based nor cost effective. The US has some of the poorest birth and breastfeeding outcomes for mothers and babies in the world!
The [medically] well known “Cascade of Intervention” http://www.childbirthconnection.org/article.asp?ck=10182#cascade is not communicated to expectant parents by thier caregivers and all too often, not even by their childbirth educators teaching in a hospital based program.
Most women think that non invasive/non pharmacological pain relief is just “breathing” and “relaxation” techniques but it is so much more than that! See:
http://www.childbirthconnection.org/pdfs/comfort-in-labor-simkin.pdf
When comparing the differences in cost, efficacy and risks between invasive (medical) pain relief and non-invasive pain relief measures it was found that medical pain relief was far less safe and far more expensive. In that same study, it was found that mothers rated a “bath” (submersion in warm water) to be equal to (as effective) as mothers who rated their epidural. And thirteen other non-invasive techniques with “no side effects” were rated more effective than narcotics. https://www.pennysimkin.com/shop/simkins-ratings-of-comfort-measures-for-childbirth/
In a paper entitled – Reducing Pain and Enhancing Progress in labor:A Guide to Non-pharmacologic Methods for Maternity Caregivers, the conclusion was:
“Nurses and other maternity caregivers can employ a broad range of effective and simple non-pharmacologic techniques to promote the laboring woman’s physical comfort, psychological well-being, and labor progress. Unfortunately, training and practice in the use of these
measures are not included in the education of most maternity caregivers, nor are they a part of most orientation programs for new maternity nurses. This lack of knowledge is at least partly responsible for today’s heavy reliance on drug management of labor pain.”
This is where a professional labor Doula comes in! Studies around the globe have shown that; “Overall, women who received continuous support were more likely to have spontaneous vaginal births and less likely to have any pain medication, epidurals, negative feelings about childbirth, vacuum or forceps-assisted births, and C-sections. In addition, their labors were shorter by about 40 minutes and their babies were less likely to have low Apgar scores at birth. For most of these outcomes, the best results occurred when woman had continuous labor support from a [professional] doula– someone who was NOT a staff member at the hospital and who was NOT part of the woman’s social network.” http://evidencebasedbirth.com/the-evidence-for-doulas/
One can’t get much better than that!