Download Suppression of Lactation or Weaning

ROYAL HOSPITAL FOR WOMEN
LOCAL OPERATING PROCEDURE
CLINICAL POLICIES, PROCEDURES & GUIDELINES
Approved by Quality & Patient Safety Committee
21/6/12
SUPPRESSION OF LACTATION OR WEANING
This LOP is developed to guide clinical practice at the Royal Hospital for Women. Individual patient
circumstances may mean that practice diverges from this LOP.
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AIM
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A woman who suppresses lactation is supported in her decision and managed appropriately
PATIENT
Newly birthed or lactating woman
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STAFF
Registered midwives
Registered nurses
Student midwives
Enrolled/Endorsed/Mothercraft nurses
Medical Officers
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EQUIPMENT (as required)
• Firm supportive bra or top
• Cool cloths or chilled clean cabbage leaves
CLINICAL PRACTICE
Discuss strategies to manage suppression that are relevant and acceptable to the woman
depending upon her circumstances
1, 2
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Provide written information appropriate to woman’s situation and discuss same
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Identify if suppression is going to occur in the immediate postpartum period or the woman has
established lactation
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Immediate suppression of lactation post birth:
• Avoid unnecessary breast stimulation
• Wear a firm supportive bra or top
• Apply cool cloths, gel packs or cabbage leaves as required
• Maintain normal fluid intake
• Allow leakage of breastmilk to occur, sufficient expression to maintain comfort may be
required
• Advise the woman regarding options for analgesia (paracetamol)
• Discuss the role and the potential side effects of pharmacological suppression of lactation with
the woman
• Administer medication if requested by woman and ordered by a medical officer
• Do not breastfeed/give baby any expressed breastmilk once pharmacological treatment
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initiated
…./2
2.
ROYAL HOSPITAL FOR WOMEN
LOCAL OPERATING PROCEDURE
CLINICAL POLICIES, PROCEDURES & GUIDELINES
Approved by Quality & Patient Safety Committee
21/6/12
SUPPRESSION OF LACTATION OR WEANING cont’d
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Cabergoline (Dostinex) is registered for use to suppress lactation . It does however have side
effects, interactions and contra-indications for use. In the immediate postpartum period the following
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regimen is recommended :
Dosage
1mg Cabergoline
orally during the
first day but
preferably within the
first 12 hours of
birth (single dose of
2 x 0.5mg tablets)
Side Effects
Headache,
dizziness, fatigue,
orthostatic
hypotension, nose
bleed
Drug Interactions
Contraindications/Precautions
Interaction is more
common with antiemetics commonly
used in the
postpartum period.
Do not use with other
dopamine
antagonists such as
metoclopramide, the
phenothiazines,
butyrophenones and
thioxanthines as
these may reduce the
prolactin lowering
effects.
Contraindications:
Hypersensitivity to the drug,
other ergot alkaloids or to any of
the excipients, pre-eclampsia or
postpartum hypertension.
Precautions:
Renal disease, Raynaud
syndrome, liver disease,
pulmonary or cardiac fibrotic
disorders, gastrointestinal
bleeding, history of psychosis,
hypotension
Suppression of established lactation:
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• Recommend gradual suppression of lactation to reduce risk of mastitis and breast abscess
o Gradually reduce the number of breastfeeds or breast expressions over several
days/weeks ensuring the breasts remain comfortable
o Unless contra-indicated any expressed breastmilk can be given to the baby
• Cease breastfeeding
o Express for comfort only
o Wear a supportive bra
o Apply cool cloths, gel packs or cabbage leaves as required
o Maintain normal fluid intake
o Advise the woman regarding options for analgesia (paracetamol)
o Discuss the role and the potential side effects of pharmacological suppression of
lactation with the woman
o Administer medication if requested by woman and ordered by a medical officer
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DOCUMENTATION
• Integrated clinical notes
• ObstetriX
• Maternal medication chart
…./3
3.
ROYAL HOSPITAL FOR WOMEN
LOCAL OPERATING PROCEDURE
CLINICAL POLICIES, PROCEDURES & GUIDELINES
Approved by Quality & Patient Safety Committee
21/6/12
SUPPRESSION OF LACTATION OR WEANING cont’d
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EDUCATIONAL NOTES
• As a baby friendly accredited facility RHW supports every woman’s right to make an informed
infant feeding decision in accordance with the implementation standards of “The Ten Steps to
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Successful Breastfeeding” .
• The woman suppressing lactation in the early postpartum period is at risk of pain and
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engorgement in addition to potential stress or grief over her decision not to breastfeed .
Appropriate management will diminish the milk supply with as little discomfort as possible and
minimisation of any complications.
• Depending on the reason for suppressing lactation the woman may require additional
psychological support and be referred to social work or perinatal mental health services.
• There are no recent high quality studies to recommend one form of treatment over another
when suppressing lactation in the immediate postpartum period, although pharmacological
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and non-pharmacological measures appear to be better than no treatment at all .
• Pharmacological or non-pharmacological suppression should be offered to all women
according to their preference; however there is limited evidence that this is effective after the
immediate postpartum period.
• Bromocriptine has been implicated in serious puerperal complications such as cerebral
accident and myocardial infarction and thromboemblic complications. In 1989, the United
States Food and Drug Administration recommended against the routine use of bromocriptine
for suppression of postpartum lactation, noting that while there was no clear proof of adverse
effects, there were also no proven health benefits. Cabergoline appears to have fewer side
effects than bromocriptine, although there is limited data re adverse events from randomised
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controlled trials.
• Some women with a stillbirth/neonatal death choose to lactate then suppress gradually as it
helps with their grieving process, other women do not wish to experience lactation at all.
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Washed cabbage leaves have been documented as a treatment for engorgement . There is
however currently insufficient evidence to recommend the widespread use of any particular
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treatment . The application of cold therapy may be soothing, is unlikely to cause harm, and
cabbage leaves are readily available.
• With regards to pharmacological analgesia, evidence for engorgement suggests NSAIDs are
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effective if not contraindicated.
• Cabergoline is a dopamine ergoline derivative, with potent and long-lasting prolactin-lowering
3,4
activity . The prolactin lowering effect is dose-related both in terms of degree of effect and
duration of action.
• Potential side effects are to be clearly explained when ordering the medication and discussion
points appropriately documented in the woman’s integrated notes.
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• Rebound lactation has been documented within one to two weeks after initial treatment i.e.
resumption of milk supply as demonstrated by filling of the breasts and possible leakage of
milk. The woman needs to be informed of this possibility.
• The woman with an established supply will benefit from gradual weaning, it is important for the
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physical and emotional wellbeing of both the mother and child . Abruptly suppressing an
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established supply increases the risk of blocked ducts, mastitis and breast abscess . Gradual
weaning allows the fat tissue to replace glandular tissue. The levels of protective factors in
breastmilk increase during the weaning period providing a final boost to the baby’s immune
system.
• There are currently no studies to clearly identify a pharmacological regime for suppressing
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established lactation. The following regime for Cabergoline (Dostinex) has been suggested :
0.25mg Cabergoline orally every 12 hours for 2 days for a total of 1.0mg (i.e. 4 doses of ½
tablet or 0.25mg). It should be noted that this is an unlicensed indication, not based on
randomised controlled trial evidence.
…./4
4.
ROYAL HOSPITAL FOR WOMEN
LOCAL OPERATING PROCEDURE
CLINICAL POLICIES, PROCEDURES & GUIDELINES
Approved by Quality & Patient Safety Committee
21/6/12
SUPPRESSION OF LACTATION OR WEANING cont’d
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RELATED POLICIES / PROCEDURES / CLINICAL PRACTICE LOP
• Breastfeeding – protection, promotion and support
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REFERENCES
1. SESIAHS Handout 2009 “Weaning or Suppressing Lactation” (create hyperlink)
2. SESIAHS Handout 2009 “Breast care when your baby has died” (create hyperlink)
3. MIMS Full Prescribing Information 2009 Cabergoline (Dostinex)
http://www.ciap.health.nsw.gov.au or
http://proxy36.use.hcn.com.au/Search?print.aspx?xmlDoc=2987.xml&XSLKey=PIxsl_pdf&Pat
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hKey=FullPIxmlPath Accessed 25 April 2012
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4. Hale TW 2010 Medications and Mothers Milk (14 Edition) Hale Publishing: Amarillo, Texas
5. Academy of Breastfeeding Medicine Clinical Protocol #4: Mastitis 2008 Breastfeeding
Medicine 3; 3:177-180
6. BFHI (2009) (unpublished) The Global Criteria for Baby Friendly Hospitals in Australia Booklet
1 Standards for Implementation of the Ten Steps to Successful Breastfeeding
rd
7. Day J (Ed) 2011 Breastfeeding…naturally (3 Edition) Australian Breastfeeding Association:
Vic
8. Oladapo OT, Fawole B. Treatments for suppression of lactation. Cochrane Database of
Systematic Reviews 2009, Issue 1 Art. No.: CD005937.
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9. Riordan J & Wambach K (2010) (Eds) Breastfeeding and Human Lactation. (4 Edition) Jones
& Bartlett: Mass, USA
10. Mangesi L & Dowsell T (2010) Treatments for breast engorgement during lactation. Cochrane
Database of Systematic Reviews. Issue 9
11. LactMed: US Library of Medicine “Cabergoline” (Latest revision 2011)
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http://www.toxnet.nlm.nih.gov/ Accessed 25 April 2012
Acknowledgement: GE2010_006 Suppression of Lactation - NSCCAHS
REVISION & APPROVAL HISTORY
Approved Quality & Patient Safety Committee 21/6/12
Reviewed Obstetric LOPs Committee May 2012
Reviewed 2007/08
Approved Quality Council 20/9/04
Reviewed by Lactation CNC July 2004
Approved RHW Council 25/6/01