Introduction
Methods
Review
Factors impacting early breastfeeding
Mechanical factors/edema
Delayed onset of lactogenesis II
Factors impacting longer breastfeeding duration and exclusivity in obese women
Androgens
Thyroid dysfunction
Psychosocial factors
Mammary hypoplasia/insufficient glandular tissue
Interventions to increase breastfeeding in obese women
Authors, year of publication, country | Study population | Intervention | Control | Breastfeeding outcomes | Child health outcomes |
---|---|---|---|---|---|
Rasmussen et al. 2011 [88] Rural New York, USA (BIBS1) | BMI > 29 carrying singleton infants recruited at ≤ 35 weeks gestation, delivering at ≥ 37 wks gestation in Rural Bassett Hospital | 3 telephone calls by one of 3 IBCLCs. One call prenatally and then at 48 and 72 h to educate, assist with and encourage breastfeeding. | 1 prenatal telephone call (less detailed) | EBF median: support 3.4wks (25th–75th % 0.7–8.4) control 8.1wks (2.1–13.1) | Not assessed |
Any BF median: support 8.6wks (3.9–13.0), control 12.6wks (9.1–13.5) | |||||
n = 40 | |||||
Rasmussen et al. 2011 [88] Rural New York, USA (BIBS2) | BMI > 29 carrying singleton infants recruited at ≥ 35 weeks gestation, delivering at ≥ 37 wks gestation in Rural Bassett Hospital | Mothers given manual or multiuser electric breastpump and instructed to pump for 10 min after each of 5 breastfeeding sessions each 24 h for 5 days or until their milk came in. | Usual care. No breastpump or instructions given | EBF median: manual pump 2.3wks (0.4–4.4), electric pump 0.7wks (0.1–2.7), control 4.4wks (1.1–9.4) | Not assessed |
Any BF median: manual pump 13.4wks (2.1–36.0), electric pump 4wks (2.4–8.4), control 26.6wks (9.4–44.6) p < 0.004 for pumping groups | |||||
n = 39 | |||||
Chapman et al. 2013 [89] Connecticut, USA | BMI ≥ 27 carrying singleton infants recruited at ≤ 36 weeks gestation, from prenatal Baby Friendly Hospital clinic, income < 185 % of the federal poverty level with telephone access. Infants ≥ 36 weeks’ gestation, birth weight ≥2.5 kg and ≤ 3.9 kg, 1 and 5 min Apgar scores of ≥ 6, and no NICU admission. | 3 prenatal visits, daily in-hospital support, phone access, up to 11 postpartum home visits from specialized obesity-trained breastfeeding peer counselors. Home visits tentatively scheduled 3 per week in 1st week, 2 per week in weeks 2–4, 1 per week in weeks 5 and 6. Phone call between 2 and 3 months. Large breastfeeding sling, single electric breastpump if separated for work/school. Mothers had work phone number of peer counselors. | 3 prenatal visits, daily in hospital support and up to 7 home visits from Breastfeeding Heritage peer counselors. Mothers had work phone number of peer counselors. | Any BF at 2 weeks: AOR 3.76 (95 % CI: 1.07, 13.22) | Odds of hospitalization in first 6 months after birth: AOR 0.24 (95 % CI: 0.07, 0.86) |
≥50 % of feedings as breast milk at 2 weeks: AOR 4.47 (95 % CI: 1.38, 14.5) | |||||
N = 206 | |||||
Carlsen et al. 2013 [90] Denmark | BMI ≥ 30 delivering healthy singleton infants at term participating in prenatal weight gain reduction (TOPS) study in Denmark recruited at < 48 h postpartum | Minimum of 9 telephone consultations by a single IBCLC if continuing to breastfeed. First call in first week postpartum, 2 more calls in first month, every 2 weeks until 8 weeks, and monthly until 6 months. Extra calls for specific difficulties, mothers had study IBCLC phone number | Usual care, including contact with a breastfeeding supportive pediatric nurse within 1 week of birth, and standard breastfeeding support at study hospital | EBF median: Support 120d (14-142d) | Days of exclusive breastfeeding inversely associated with: |
Control 41d (3-133d) p = 0.003 | Infant weight at 6 months | ||||
Any BF median: Support 184d (92–185d) Control 108d (16–185d) p = 0.002 | β = 4.39 g/day, (95 % CI: −0.66, −8.11 p = 0.021) | ||||
n = 207 | |||||
EBF 3 months: AOR 2.45 (95 % CI: 1.36, 4.41 p = 0.003) | Infant length at 6 months | ||||
Any BF 6 months: AOR 2.25 (95 % CI: 1.24, 4.08 p = 0.008) | β = 0.012 cm/day (95 % CI: −0.004, 0.02 p = 0.004) |
Clinical considerations
Prenatal | |
Obese mothers may benefit from | Rationale |
Strategies to limit weight gain in pregnancy | Reduce the risk of preeclampsia, gestational diabetes, LGA baby, and cesarean birth [5]. |
Discussion of strategies such as doula care and non-pharmacological pain management to reduce the need for labor interventions. | |
Intrapartum | |
Obese mothers may benefit from | Rationale |
Careful evaluation of adequate time to labor | First stage of active labor increases with increasing BMI. Research indicates a need to reevaluate normal labor progression in obese women to establish new guidelines to prevent unnecessary augmentation and surgical intervention [52]. |
Assistance with non-pharmacological pain management techniques | |
Judicious use of pitocin/ IV fluids | Reduce risk of DOL due to postpartum edema [101]. |
Constant support while laboring | Obese pregnant women have been shown to have higher levels of anxiety and stress, which may contribute to excessive catecholamine levels and reduced uterine contractibility [52]. |
Early Postpartum | |
Obese mothers may benefit from | Rationale |
Guidance on how to know baby is getting enough milk | Perception of insufficient milk is the most common reason mothers do not breastfeed as long as desired. This is even more common in obese mothers [81]. |
Demonstration of multiple feeding positions such as: | Pain is cited as second most common cause of breastfeeding discontinuation. This is even more common in obese mothers [81]. Demonstrating multiple options for positioning allow for better tailoring to mother’s needs, and reduced nipple stress. |
Laid-back breastfeeding positions | |
Side-lying | |
Cradle/cross cradle hold | |
Clutch/football/underarm hold | Breastfeeding positions that utilize semi-reclined maternal posture may work particularly well for obese mothers as they utilize mother’s torso to support baby, obviating the need for pillows and breast support. Side-lying positions also provide additional support for breast and baby [102]. |
Assistance to support large breasts and to better visualize latch | Mothers with large breasts may need additional assistance to visualize latch and breastfeed comfortably [103]. A rolled towel or breast sling to elevate the breast and/or a mirror to visualize nipple and latch may be helpful. |
Demonstration of reverse pressure softening around areola to enable deeper latch | Obese mothers are more likely to experience significant postpartum edema, which can temporarily flatten nipples, making latch difficult. Reverse pressure softening, accomplished by holding gentle reverse pressure around the areola toward the chest wall, can be useful in reducing peri-areolar edema [12, 101]. |
Specific Guidance to supplement only when medically necessary. | Early supplementation is associated with reduced breastfeeding duration and exclusivity, and risk is elevated in children of obese mothers [81]. |
Use Academy of Breastfeeding Medicine Protocol #3 to verify medical need for supplementation [104] | |
Continued support postpartum | Phone support by an IBCLC may increase breastfeeding duration and exclusivity in some populations of obese mothers [90]. Regular phone support, referral to breastfeeding support groups, and skilled in-person care should be a priority in this at-risk population. |