Reproduced from 'HOT TOPIC'
Number 11 November 2002
Exclusively for Lactation Resource Centre subscribers

Elisabeth Speller BA(Hons), IBCLC, Kate Mortensen Grad Dip(Counselling), IBCLC, ABA Counsellor, Kathryn Wood BSc.

INTRODUCTION

A number of conditions which women experience in the postnatal period have often been attributed to breastfeeding. Some of these have no clear cause and more research is required to determine the exact cause. In a study by Gjerdingen et at (1993) it is interesting to note that of women who were not breastfeeding 28% reported breast discomfort, and 6% reported nipple irritation at 1 month postpartum. This would tend to indicate that the changes during pregnancy and birth are contributing factors as much as breastfeeding. It would also be interesting to have more studies conducted on the symptoms experienced by new mothers who breastfeed compared with those who do not, to determine the actual effect of breastfeeding. Current knowledge about a selection of conditions follows.

ACNE

In a study of 436 women acne was increased during the postnatal period, probably related to hormonal changes (Gjerdingen et al 1993). The authors proposed that the increase in acne may be related to hormonal changes following delivery. There was no correlation between breastfeeding and acne although the authors did identify that acne occurred more often in women who had given birth by caesarean section.

ALOPOECIA (HAIR LOSS)

Normal hair growth consists of alternating active growth (anagen) and resting (telogen) phases, with a short transition (catagen) stage between the two. At any one time about 13% of adult scalp hairs are in the telogen phase and 1% in the catagen phase. During pregnancy there is a decrease in the conversion of hair from active growth to resting phase, resulting in a greater percentage of hairs in active growth. As a result many women notice that their hair is thicker. One explanation for postpartum hair loss is the stress of childbirth. The stress of giving birth causes the hair to enter the resting phase prematurely and this results in an excessive shedding of normal club hairs, called telogen effluvium (Gjerdingen et al 1993). The time between the event causing stress and the resulting hair loss is usually three to four months (Aldridge 1984; Parkinson 1992). An alternative explanation for postpartum hair loss involves hormonal changes. During pregnancy placental hormones stimulate active growth. After the birth placental hormones rapidly decline and the stimulus for this growth is withdrawn. The hair follicles enter the resting phase for two or three months. When the active growth stage begins again, the follicles start to produce new hairs which push out the old ones all at once. The amount of hair loss varies between individual and may be influenced by hereditary tendencies. (Department of Dermatology, St. Vincent's Hospital Melbourne 2002)

Hair loss can also occur as the result of illness or reaction to drugs (Parkinson 1992). These factors must be excluded in women experiencing postnatal hair loss. Normal hair loss is about 100 hairs per day. There are no unique characteristics of postnatal hair loss that can be diagnosed by laboratory tests - it is a normal reaction to pregnancy and birth in some women.

In a study of the health of 436 women in the year after their babies were born, hair loss increased after the first month, with a peak at 6 months (Gjerdingen et al 1993). Twenty percent of women in this study experienced hair loss subsequent to the birth of a child. Other research has indicated that this shedding usually begins about 2-3 months postpartum and continues for an average of 2-3 months but can continue for a year or longer (Department of Dermatology, St. Vincent's Hospital Melbourne 2002). Postpartum alopoecia is usually resolved within 18 months, though about 50% of these women report that their hair is not as thick as prior to the pregnancy (Parkinson 1992).

ANAPHYLAXIS

An anaphylactic reaction associated with breastfeeding has been recorded in two women (Mullins et al 1991; MacDonnell 1998). Several causes of the reaction were investigated in each of the cases. The first recorded case was of a 29 year old woman who experienced generalized urticaria 30 minutes after the first breastfeeding of her first-born baby. The authors conclude that the episodes were triggered by breastfeeding or milk let down and, at least in the first occurrence, by paracetamol and aspirin. The second recorded case had similarities, but differed in that the first episode was not the first breastfeed but 48 hours after the birth (MacDonnell 1998).

CARPAL TUNNEL SYNDROME

Approximately 3% of women will develop carpal tunnel syndrome in the postpartum period (Gjerdingen et al 1993). In the Gjerdingen (1993) study there was no relationship between hand numbness (a typical carpal tunnel syndrome symptom) and breastfeeding.

Some mothers have experienced hand numbness and pain because of the pressure of the baby's head on their forearm whilst feeding. Having the arm well supported and modifying the position slightly may help with this (Shaywitz & Shaywitz 1972).

HEADACHES

Headaches in relation to lactation were first reported in 1989 (Askmark & Lundberg 1989). There has been little further research on this phenomenon with a small number of cases reported in the literature (Thorley 1997a; Thorley 1997b; Thorley 1997c; Thorley 2000; Wall 1992).

When women experience headaches during lactation it is important to rule out any underlying causes. Good history taking is important. If necessary, mothers can be advised to ask for a referral to a neurologist or endocrinologist, or to see an opthalmologist or dentist (Thorley 2000). Most headaches that occur in the early postpartum days resolve in a short period of time - usually peaking 3-6 days after the birth (Lawrence & Lawrence 1999).

Headaches occurring during lactation, where there is no other apparent physiological cause, can usually be categorized under three general headings: those related to hormonal changes or other lactation-related triggers (deemed to be true lactational headaches); those no different from headaches experienced by the general population and not influenced by lactation; those triggered by a combination of factors (Thorley 2000).

Thorley (2000) identifies two main types of lactational headaches. Type 1 appears to be linked to the surge of oxytocin at let down. Some women experience this headache during the feed rather than at the beginning, and this may be linked to let downs which occur throughout the feed. Type 2 headaches are different in that the let down brings relief, the pain appearing to be caused by overfull breasts. This type of headache may, however, be the precursor of mastitis.

Diary keeping may be helpful in identifying and avoiding triggering factors for lactational headaches. Such information as the date, time and duration of the headache, and any other identifying factors, could be helpful (Thorley 2000).

Non-pharmacological treatments such as physiotherapy and breathing and relaxation exercises may be recommended. Some mothers have successfully used techniques such as chiropractic and lymphatic drainage, though these treatments have not been assessed (Thorley 2000).

Over-the-counter medications, such as ibuprofen, paracetamol and panadeine may be used to treat these headaches. Where stronger medications are required the effects on the breastfed baby need to be taken into consideration. In some, very rare cases, these headaches are so debilitating that the medication necessary for pain relief is not suitable while breastfeeding (Askmark & Lundberg 1989).

NAUSEA

Nausea during the let down does appear in the published breastfeeding literature though most of the information is from case histories and unpublished anecdotal information (Lactation Resource Centre 2002). From unpublished information it appears to be related to the following: medications particularly anti-depressant medication; excessive fluid intake; not enough fluid intake; low blood sugar: low blood pressure; thrush in gastrointestinal tract; low grade urinary tract infection; eating disorder; tiredness; abuse memories; hunger.

Of all these causes hunger is the one backed up by research. This research shows increased gastrointestinal activity when the let down occurs (Widstrom et al 1988, Uvnas-Moberg 1989, Uvnas-Moberg 1989). The production of gastrin (a polypeptide hormone) occurs as part of a protective effect to ensure adequate energy supply for milk production. This subsequent increase in energy uptake can then lead to nausea. If there are other factors involved this could exacerbate the effect of the extra gastrointestinal activity. Anecdotal suggestions that may help are: high carbohydrate snack before a breastfeed (Lawrence & Lawrence 1999) and sea bands used for motion sickness. Mothers reported that the problem eased over time, varying from a few weeks to some months.

SUMMARY Some conditions that occur in the postnatal period, such as acne, have no known causes and breastfeeding is not believed to be involved. The stress of giving birth, or the rapid decline in placental hormones may trigger 'normal' hair loss. This is usually resolved within the first year. There have been two recorded cases of an anaphylactic reaction associated with breastfeeding. Carpal tunnel syndrome and hand numbness is not believed to be linked with breastfeeding. Where the weight of the baby's head on the mother's arm causes pain and numbness, good support and/or changing position may be helpful. Most headaches occurring in the first week postpartum will resolve. Underlying causes of headaches during lactation need to be ruled out. Lactation headaches may be linked to the oxytocin surge during let down or, conversely, to the breasts being overfull. Keeping a diary may help determine the causes of lactation headaches. Non-pharmacological methods of pain relief may be suggested. Over-the-counter medications are usually safe and may be effective. If stronger medications are required the breastfed baby needs to be considered. For some, very few, women the pain may be so debilitating that the medication required means that the baby should be weaned. Nausea during the let down, while predominantly anecdotal, can be caused by the activity of gastrointestinal hormones. Anecdotal suggestions include high carbohydrate snack before feeding and the use of motion sickness sea bands.

REFERENCES

• Aldridge RD 1984, Hair loss. Br Med J 289: 985-989.
• Askmark H, Lundberg PO 1989, Lactation headache - a new form of headache? Cephalalgia 9(2): 119-122.
• Department of Dermatology, St. Vincent's Hospital Melbourne 2002, Postpartum Hair Loss (information sheet).
• Gjerdingen DK, Froberg DG, Chaloner KM, McGovern PM 1993, Changes in women's physical health during the first postpartum year. Arch Fam Med 2(3): 277-283.
• Lactation Resource Centre 2002, Case History.
• Lawrence RA, Lawrence RM 1999, Breastfeeding: a guide for the medical profession. 5th Ed St Louis, Mosby.
• MacDonnell JW, Ito S 1998 Breastfeeding Anaphylaxis Case Study. J Hum Lact 14(3): 243-244.
• Mullins RJ, Russell A, McGrath GJ, Smith R, Sutherland DC 1991, Breastfeeding Anaphylaxis. Lancet 388(8777): 1279-1280.
• Parkinson RW 1992, Hair loss in women. Postgrad Med J 91(4): 417-423.
• Shaywitz BA, Shaywitz SE 1972, Nursing Neuropathy. Am J Dis Child 123(Mar):247.
• Thorley V 1997a, Lactational headaches. Breastfeeding Rev 5(1): 23-25.
• Thorley V 1997b, Lactational headache: a lactation consultant's diary. J Hum Lact 13(1): 51-53.
• Thorley V 1997c, Lactation and headaches (letter). South Dakota Journal of Medicine 50(2): 57.
• Thorley V 2000, Headaches in breastfeeding women. Birth Issues 9(3): 85-88.
• Uvnas-Moberg K 1989, The gastrointestinal tract in growth and reproduction. Sci Am Jul: 60-65.
• Uvnas-Moberg K 1989, Gastrointestinal hormones in mother and infant. Acta Paediatr Scand Suppl 351: 88-93.
• Widstrom AM, Winberg J, Werner S, Svensson K, Posloncec B, Uvnas-Moberg K 1988, Breastfeeding -induced effects on plasma gastrin and soma statin levels and their correlation with milk yield in lactating females. Early Hum Dev 16: 293-301.
• Wall VR 1992, Breastfeeding and migraine headaches. J Hum Lact 8(4): 209-212.

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