Ross Konno procedure

The Ross–Konno procedure is a last resort heart procedure for patients with complex multilevel left ventricular outflow tract obstruction often having other cardiovascular anomalies such as severe annular hypoplasia and a dysplastic aortic valve ¹⁾. Recently, the Ross-Konno procedure has found application as the initial procedure in patients with an interrupted aortic arch or after primary repair in patients with a severely restricted subaortic area, hypoplastic aortic annulus, and bicuspid valve ²⁾. The Ross–Konno procedure consists of using the patients’ pulmonary valve as a neoaortic autograft (Ross procedure), combined with the opening of a narrowed left ventricular outflow tract (LVOT) by incising the outflow septum. Patients in need of a Ross–Konno procedure often have accompanying congenital anomalies, such as coarctation of the aorta, an interrupted aortic arch and ventricular septal defects (VSDs). Careful patient selection is important in predicting the success of the Ross–Konno procedure, especially in patients with a borderline left ventricle (LV) and/or endocardial fibroelastosis. The capability of the autograft to grow with the child is one of the main advantages of the Ross–Konno procedure in infants and children. Downsides of the Ross–Konno operation are the need for reoperations for the right ventricle to pulmonary artery (RV–PA) conduit and possible dilatation of the autograft root ³⁾.

The Ross-Konno procedure increases our therapeutic choices for neonates or infants with critical aortic stenosis who show unacceptable results following open valvotomy or balloon valvotomy ⁴⁾. Some newborns with critical aortic stenosis, a hypoplastic aortic annulus, and significant endocardial fibroelastosis can be effectively treated with the Ross-Konno procedure and resection of endocardial fibroelastosis, thus avoiding single ventricular palliation.

The Ross-Konno procedure allows easy access to the left ventricular myocardium for resection of endocardial fibroelastosis, normalizing the left ventricular outflow tract and the long axis of the left ventricle ⁵⁾. It can be performed earlier in life, thus avoiding repeated surgical reinterventions, which may provide only short-term palliation and potentially exacerbate ventricular function ⁶⁾.

It is unclear whether the use of the Ross-Konno procedure at an earlier age alters the natural history of complex left ventricular outflow tract disease. It is also not known whether the risk of late reoperation on the neoaortic valve is higher if performed in the neonate, infant, or child, due to aortic root sinus dilation and valve distortion over time. Based on experience from arterial switch operations for transposition of the great arteries, the neonatal pulmonary valve might be able to adapt rapidly to the aortic position. Long-term changes in left ventricular mechanics await further study. Despite the technically demanding nature of the operation, the Ross-Konno procedure is the method of choice for the multilevel type of left ventricle outflow tract obstruction, especially in newborns and infants ⁷⁾.

The Ross–Konno procedure remains a high-risk procedure. In a case series ⁸⁾, the early mortality rate was 12.5%. This is consistent with a recent report by Vergnat et al. ⁹⁾, reporting an early mortality rate of 10.2%. Adriaan et el ¹⁰⁾ found preoperative poor LV function to be a risk factor for early mortality, which was also found by Vergnat et al ¹¹⁾. Others have reported more positive early mortality outcomes. Aszyk et al. ¹²⁾ described their experience with 16 patients under the age of 1 year undergoing the Ross–Konno procedure. They reported no early mortality ¹³⁾. Maeda et al. ¹⁴⁾. reported 1 early death in 24 patients operated under the age of 1 year.

Ross-Konno procedure can be performed early in life, thus avoiding repeated surgical reinterventions, which may provide only short-term palliation and potentially exacerbate ventricular function. The Ross-Konno procedure increases the therapeutic choices for neonates or infants with critical aortic stenosis who show unacceptable results following open valvotomy or balloon valvotomy. The pulmonary autograft demonstrates durability without the likelihood of developing aortic stenosis or progressive dilatation and a low incidence of developing aortic insufficiency.

Complex, multilevel left ventricular outflow tract obstruction (LVOTO) consists of a combination of a hypoplastic aortic annulus with or without a dysplastic aortic valve and diffuse subaortic narrowing, as frequently seen in Shone complex (a developmental complex of “parachute mitral valve,” supravalvular ring of left atrium, subaortic stenosis, and coarctation of aorta) ¹⁵⁾, after primary repair of an interrupted aortic arch or in congenital aortic valve stenosis. Initial palliation aims to relieve the critical level of obstruction. This may involve open/balloon aortic valvotomy, and/or subaortic membrane and muscle resection ¹⁶⁾. Often this initial approach might avoid a more extensive operation in the first days of life, thus achieving clinical improvement with some degree of residual stenosis or insufficiency. However, the recurrence rate of severe left ventricular outflow tract obstruction and progression of acquired aortic regurgitation is high. If relief of multilevel left ventricular outflow tract obstruction and aortic valve replacement is indicated, the Ross-Konno operation should be considered as a method of choice.

Figure 1. Ross–Konno procedure

Footnote: (A) Preoperative view showing the incisions for the performance of the Ross–Konno procedure. (B) Intraoperative view showing the replacement of the mechanical aortic valve with the pulmonary autograft, the Konno incision in the left ventricular outflow tract (LVOT) and the right and left coronary buttons after separation from the aortic wall. (C) Postoperative view after completion of the Ross–Konno procedure.

[Source ¹⁷⁾ ]

Ross-Konno surgical technique

In children, a technique of complete root replacement with anterior aortoventriculoplasty is used ¹⁸⁾. The standard technique of cardiopulmonary bypass, including bicaval cannulation and moderate hypothermia, are used. Myocardial protection is preferentially provided by retrograde cardioplegia. A left ventricular vent is inserted through the entrance of the right pulmonary veins.

After aortic cross-clamping, the aorta is partially transected and the feasibility of valve repair is assessed. The main pulmonary artery is transected just proximal to the bifurcation of the pulmonary artery. In the case of severe abnormalities or bicuspid anatomy, one should consider abandoning the Ross-Konno operation and perform the Konno operation with a mechanical valve.

After complete transection of the aorta, the right and left coronary buttons are formed and dissected for maximal mobilization.

The aortic cusps and sinus wall are removed, leaving an approximately 3–5 mm cuff of the aortic wall annulus in place.

The pulmonary autograft is harvested, along with an extension of the infundibular free wall muscle attached to it. This extra tissue is used for patching the ventriculoplasty incision.

Great care is taken to avoid injury to the left coronary artery, the pulmonary artery valves, and septal perforator of the left coronary artery.

After harvesting the pulmonary valve, cardioplegia is delivered and any bleeding points from the area of the previous dissection are controlled, either by diathermy or by over-sewing with a shallow suture.

The interventricular septum is incised to the left of the right coronary artery. The length of the incision depends on the morphology of the obstruction. If only an annular enlargement is necessary, the septal incision is limited, extending about 5–10 mm into the septum. In patients with long-segment subaortic stenosis, the septal incision is extended beyond the obstruction.

Resection of any endocardial fibroelastosis or ventricular myectomy is performed, if necessary. The goal is to remove any fibrous tissue, which could obstruct the left ventricular outflow tract and limit the movement of the left ventricle cavity.

The pulmonary autograft is implanted in the left ventricular outflow tract (LVOT) using a running suture technique. Natural alignment of the autograft is preferable. The left semilunar cusp of the pulmonary autograft should occupy the area of the previous left coronary cusp. Therefore, the anterior semilunar cusp of pulmonary valve (autograft) is orientated anteriorly and the anterior lip of the retained infundibular free wall is used to patch the triangular area of the incised interventricular septum.

The suture line is subannular so that the autograft is plugged into the left ventricular outflow tract, thus having the fibromuscular support of the outflow tract.

The second running adventitial suture over the remnant of the aortic wall reinforces the first one and decreases the risk of inaccessible bleeding, especially from the posterior aspect of the anastomosis. It is important to reinforce the patching of the ventriculoplasty incision with infundibular free wall muscle and pledgeted interrupted mattress sutures to minimize the risk of bleeding or aneurysm formation.

The left coronary artery button is implanted into the circular opening made in the pulmonary artery wall, avoiding rotation, tension, or kinking.

The neoaortic reconstruction is completed by proximal anastomosis with the ascending aorta using a continuous suture. After completing the distal anastomosis, the neoaortic root is expanded with a dose of cardioplegia and the appropriate position for implantation of the right coronary artery is determined. A circular opening is made in the pulmonary artery wall, staying away from the valve commissure, and the coronary is implanted.

The right ventricular outflow tract is reconstructed with the homograft. The homograft is sutured directly to the right ventricular infundibular muscle without the use of any additional patching material.

An echocardiogram should be routinely performed after the patient has been weaned from bypass.

Ross Konno procedure disadvantages

There are disadvantages of the Ross-Konno procedure as well. The nature of the operation places two valves at risk for single valve disease. However, many pediatric patients are not candidates for a Konno operation because of anatomic considerations and the lack of readily available, appropriately sized prostheses ¹⁹⁾. Particularly in the growing pediatric patient the need for pulmonary conduit replacement is high. Replacement of a pulmonary conduit is, however, less difficult than repeated aortic root replacement. Other concerns regarding the use of the Ross-Konno procedure in children include the uncertain long-term outcome of the pulmonary autograft in the aortic position. The pulmonary autograft demonstrates durability without developing aortic stenosis or progressive dilatation, and there is a low incidence of aortic insufficiency development. Enlargement of the aortic annulus parallels somatic growth in the majority of cases ²⁰⁾. Patching the ventriculoplasty incision by infundibular free-wall muscle optimizes the geometry of the neoaortic root and left ventricular outflow tract. It allows regular, proportional growth of neoaortic root. The ventriculoplasty incision could be reconstructed with a separate prosthetic patch as well. The drawbacks are increased complexity of reconstruction of the left ventricular outflow tract and unpredictable growth of the anterior segment of neoaortic root ‘immobilized’ by a rigid patch.

Ross Konno procedure complications

The Ross-Konno procedure can be accomplished with a mortality of <5% and a low morbidity rate. Early complications are especially related to malignant arrhythmias (nonsustained ventricular tachycardia, nonsustained supraventricular tachycardia, etc.) ²¹⁾. The incidence of complete heart block varies from 0% to 6%. The freedom from autograft reoperation is above 90% at 10 years of follow-up ²²⁾. The freedom from homograft reoperation is between 70% and 94% at 5 years, being less favorable for small children due to earlier homograft failure ²³⁾. The choice of conduit appears to impact the need for replacement. The aortic homograft rather than pulmonary homograft and smaller homograft size are factors adversely affecting homograft longevity. The policy is to place the largest pulmonary homograft possible at the time of procedure ²⁴⁾.

What is DIPG

DIPG is short for “diffuse intrinsic pontine glioma”, a rare fast-growing tumor that forms in cells called glial cells in a part of the brain stem called the pons. The pons controls vital life functions including balance, breathing, bladder control, heart rate, and blood pressure. Nerves that control vision, hearing, speech, swallowing, and movement also pass through this part of the brain. DIPG tends to be a high-grade tumor and is the most aggressive primary pediatric brain tumor with <10% of children surviving 2 years ¹⁾. Diffuse intrinsic pontine gliomas or DIPG tend to spread to nearby tissue and other parts of the brain stem with little notable mass effect ²⁾ and are hard to treat and have a poor prognosis (outcome).

DIPG is a diffuse tumor, meaning that the tumor is not well-defined or contained. The tumor extends finger-like projections into healthy tissue. Because of the location in the brainstem and spread out nature of the tumor, surgery cannot safely remove DIPG.

DIPG is almost exclusively seen in children, with a median age at diagnosis of 6 to 7 years ³⁾. Approximately 300 to 400 pediatric brain stem tumors are diagnosed each year in the United States. DIPG accounts for approximately 75% to 80% of pediatric brain stem tumors ⁴⁾. There are about 200-300 new cases of DIPG every year in the United States. Most children with DIPG are diagnosed between the ages of 5 and 10 years. DIPG is rare in adults.

Radiation therapy delivered over a 6-week period remains the mainstay of DIPG treatment ⁵⁾, but there is a great clinical need for improvements and advancements in treatment strategies ⁶⁾. Although radiation temporarily improves symptoms in most patients, it is not a cure. Upfront radiation appears to only provide transient relief of symptoms while offering minimal survival advantage ⁷⁾. Studies examining the role of alternative fractionation regimens and/or addition of radiosensitizers have failed to demonstrate a survival benefit ⁸⁾.

In the recently revised World Health Organization (WHO) classification of central nervous system (CNS) tumors, the majority of DIPG has neuropathologically been reclassified within a novel tumor entity: diffuse midline glioma, H3-K27 mutant (DMG H3-K27M). This entity is defined as an infiltrative high-grade glioma, located in the brain midline, i.e. usually brainstem, spinal cord, cerebellum or thalamus, with astrocytic differentiation and K27M mutation in either H3F3A or HIST1H3B/C ⁹⁾. Up to 85% of the DIPGs harbor this mutation ¹⁰⁾. Wild-type H3-K27 DIPGs have not yet been separately classified within the revised WHO classification, but show similar survival as H3-K27M DIPGs ¹¹⁾.

Figure 1. Brain anatomy

DIPG causes

Researchers do not yet know what causes DIPG. However, researchers are learning more about gene changes associated with these tumors. Having certain genetic disorders, including neurofibromatosis type 1 (NF1), may increase the risk of a brainstem glioma. There is no evidence that indicates DIPG is caused by environmental factors (exposure to chemicals or radiation).

Diffuse intrinsic pontine glioma symptoms

DIPG tumors grow quickly, and symptoms usually develop in a short period of time (often about 1 month before diagnosis). There is a rapid onset and fast progression of problems. Children with DIPG may present with the following classic triad of cerebellar signs, long tract signs, and cranial nerve palsies; however, children may present with only one or two of these symptoms at diagnosis:

1. Cranial neuropathies, particularly abducens paresis. Facial weakness or drooping or abnormal eye movement due to problems with nerves that control the muscles and sensation of the head, face, and eyes (cranial nerve disorders or neuropathies)
   • Cranial nerves are 12 pairs of nerves that arise in the brain. Cranial nerves 5, 6 and 7, which arise in the pons, can be affected in DIPG. Specific problems can be related to each of these nerves:
     • Cranial Nerve 5: Loss of sensation or numbness over the face and parts of the mouth.
     • Cranial Nerve 6: Abnormal eye movements such as not being able to look to the side or crossing of the eye so that it is pulled in towards the nose.
     • Cranial Nerve 7: Weakness over the face, particularly over the mouth and the eyelids.
     • Problems with cranial nerves 6 and 7 are most common in DIPG. Sometimes other cranial nerves can be injured. If the tumor spreads to an area above the pons (midbrain), patients can develop additional problems with eye movements. If the tumor spreads to area below the pons (medulla), problems with swallowing, and changes in voice can occur.
2. Weakness in the arms and legs, jerking movements, and abnormal reflexes (long tract signs).
3. Problems with balance and coordination (ataxia)

Signs and symptoms of DIPG may include:

• Loss of balance or problems walking
• Eye problems such as blurred vision, double vision, drooping eyelids, uncontrolled eye movements, not being able to fully close the eye, eyes don’t look the same direction together or appear crossed (strabismus)
• Facial weakness or drooping, usually on one side
• Drooling or problems swallowing
• Weakness in the legs and arms, usually on one side
• Irregular or jerking movements
• Abnormal reflexes
• In very young children, a failure to thrive

Less common symptoms may include:

• Nausea and vomiting
• Headache, especially in the morning and often gets better after vomiting
• Behavioral changes, school problems, irritability, or night laughter

Obstructive hydrocephalus caused by expansion of the pons can also be a presenting symptom. Nonspecific symptoms may also occur, including behavioral changes and decreased school performance.

Why does DIPG cause weight gain and face swelling?

This is a common question. However, most often, this is not due to the tumor itself. Weight gain, face swelling, and puffiness are mainly due to high doses of corticosteroid medications given to help manage symptoms of DIPG. Brain tumors can cause fluid and pressure to build up. This pressure (hydrocephalus) causes symptoms such as headaches, nausea, weakness, and problems walking. Steroid medicines like dexamethasone decrease brain swelling and pressure. But they also have side effects, especially when given in high doses or for a long time.

Corticosteroids can increase appetite and cause patients to eat more and gain weight. They can make it hard for the body to get rid of fluids, causing swelling. The body may also store fat differently, leading to puffy cheeks or “moon face.” Rapid weight gain sometimes causes stretch marks on the skin. The change in appearance due to corticosteroids can be very distressing to patients and families. Other side effects of steroid treatment include mood swings, irritability, and muscle weakness. Despite the side effects, these medicines are an important part of supportive care and quality of life for many brain tumor patients. Families should talk to their care team about side effects and goals of care.

Diffuse intrinsic pontine glioma diagnosis

Of pediatric brain tumors, about 10-20% are found in the brainstem. When a tumor develops in the brainstem, it is usually DIPG. However, about 20% of brainstem tumors are low-grade astrocytomas and are not considered DIPG.

Doctors test for DIPG in several ways. These tests include:

• A physical exam and medical history help doctors learn about the type and time course of symptoms, general health, past illness, and risk factors.
• A neurological exam measures different aspects of brain function including memory, vision, hearing, muscle strength, balance, coordination, and reflexes.
• Imaging tests are used to help identify the tumor, see how big the tumor is, and find out what brain areas may be affected. Magnetic resonance imaging (MRI) is the main imaging technique that is used to diagnose DIPG.

Doctors look for key features of the tumor on the MRI to diagnose DIPG:

1. The tumor is located in the pons.
2. It usually involves and expands most of the pons (intrinsic).
3. The tumor does not have well-defined borders. It infiltrates healthy tissue (diffuse).

The diagnosis is typically made using a combination of clinical signs and symptoms of short latency (<3-6 months) and characteristic radiographic findings, either on magnetic resonance imaging (MRI) or computed tomography (CT scan). Findings on MRI include an intrinsic, centrally located tumor involving >50% to 66% of the pons ¹²⁾ with hypointensity on T1 images ¹³⁾, hyperintensity on T2 images ¹⁴⁾ with indistinct tumor margins and engulfment of the basilar artery and absence of cystic or exophytic components ¹⁵⁾.

Role of biopsy in DIPG diagnosis

A biopsy is sometimes used to diagnose DIPG. Historically, biopsy has not been routinely performed as the standard of care unless a tissue analysis is required to identify a potential pharmacologic target. Although biopsy has not been shown to alter treatment outcomes,10 recent advances in stereotactic neurosurgery have enabled surgeons to obtain reliable tissue for histologic and genomic analyses with morbidity of <4% ¹⁶⁾. Complete surgical resection of DIPG is hindered by the location and infiltrative nature of the tumor ¹⁷⁾. However, it is becoming more common. Reasons for not doing a biopsy include:

• DIPG frequently has specific features on both MRI and clinical evaluation, so it can often be diagnosed without any additional tests.
• There is risk of causing harm by doing a biopsy because of the location of the tumor.
• A biopsy may not change treatment plans or influence outcomes.

With better surgical techniques and advances in the understanding of the biology of DIPG, the recommendation for a biopsy has become more common. After a biopsy, a pathologist will look at the tissue sample under a microscope to identify the specific type and grade of tumor. The tumor will also be tested for genetic changes or markers. Understanding tumor histology and molecular features may one day offer better treatments for DIPG such as targeted therapy and immunotherapy.

Staging and Grading of DIPG

There is no standard staging system for DIPG. Treatment recommendations are based on two main factors:

1. Whether DIPG is found only in the brainstem or if it has spread to other distant areas in the brain or spinal cord (metastatic disease)
2. Whether DIPG is newly diagnosed or has come back after initial treatment (recurrent disease)

Gliomas are grouped by how they look under the microscope. The more abnormal cells look, the higher the assigned grade. Grade I and II tumors are considered low grade gliomas. The cells look more like normal cells and grow more slowly. Grade III and IV tumors are considered high grade gliomas. They are aggressive and grow quickly and can spread throughout the brain. DIPG tumors are usually high grade. More rarely DIPG may appear as a low grade tumor (grade II).

H3 K27M Mutation in DIPG

A specific mutation, or change in the DNA, is found in most (about 80%) DIPG tumors. This mutation is known as H3 K27M. It is found in tumors located deep within the middle part of the brain and spine that show diffuse or infiltrative growth. This finding has led to a new diagnosis based on pathology called diffuse midline glioma, H3 K27M-mutant. These tumors most often occur in the pons, but they may also be found in the thalamus, spinal cord, and other sites in the midline of the brain.

Even without a biopsy, it is thought that most DIPG tumors have the H3 K27M mutation. These are aggressive tumors. Tumors that have an H3 K27M mutation usually have a poor outcome no matter the grade or how they appear under the microscope.

DIPG treatment

DIPG is a very aggressive cancer. There is no cure at this time. The current standard of care is based on radiation therapy. Much of DIPG patient care is focused on controlling symptoms and supporting quality of life as much as possible. Corticosteroid medications such as dexamethasone (Decadron) can help reduce some of the symptoms caused by the tumor by decreasing the swelling associated with the tumor. They are usually used at diagnosis and at tumor progression to help manage neurologic symptoms. Corticosteroid medications can cause side effects including increased moodiness, agitation, weight gain, increased appetite and high blood pressure and blood sugar. These last two side effects can be controlled with medication, if they become severe.

A number of clinical trials are exploring therapies that may improve outcomes for patients with DIPG. Many patients with DIPG receive care through a clinical trial. Clinical trials are available for patients at the time of diagnosis, after completion of radiation therapy but before progression, or after tumor progression.

Radiation therapy

Radiation therapy is the main treatment for DIPG. In most cases, radiation provides a temporary response to slow or shrink the tumor. However, radiation therapy does not provide a long-term cure. It may provide a temporary easing of symptoms lasting an average of 6 months and may extend life by an average of 3 months.

At most treatment centers in the US, the standard recommendation is local radiation therapy with a dose range of 54-60 Gy for a period of 6 to 7 weeks. Newer studies suggest that hypofractionated radiation therapy may offer similar benefits with less burden on the patient and family. This hypofractionated approach gives larger doses of radiation over a shorter time (usually 3 weeks).

Radiation upfront is usually helpful in stalling disease progression for a time. Recent studies have shown that repeat radiation to the DIPG tumor can be done safely; however, when the disease recurs, the tumor has become more resistant to radiation, and the benefits of radiation are more limited. When radiation is given a second time, it is usually done over 2 to 3 weeks.

There is often a time after initial radiation therapy where the tumor shrinks temporarily. Symptoms improve, and patients are able to go home to their usual activities. This is sometimes known as the “honeymoon period.” This phase is hard to predict. Some children are almost back to normal during this time. Some children do not improve at all. Families may use the time to be together or do something special as a family.

Chemotherapy

Chemotherapy may be used in addition to radiation therapy to see if better outcomes can be achieved. However, chemotherapy has not been found to increase length of life or overall survival in DIPG. As a result, chemotherapy is generally not offered as part of standard care for DIPG.

With new insights into the underlying genetic changes in DIPG, more tumor-specific treatment protocols are being tested through clinical trials. These include different combinations of drugs and new methods of administration.

The blood-brain barrier can limit the effectiveness of chemotherapy for some brain tumors. This protective barrier acts to prevent substances in the blood from getting into the brain. This can limit how much medicine reaches a brain tumor. New drug delivery techniques are being explored to overcome this problem. One of these methods is Convection-Enhanced Delivery (CED). It involves placing a catheter into the region of the DIPG tumor by precise surgery. This allows the drug to reach the tumor directly in a more controlled way.

Surgery

Surgery is not used to treat DIPG due to the location of the tumor. The pons, the region of the brain where the tumor occurs, is responsible for vital life functions. Therefore, the tumor cannot be removed by surgery.

Surgery may be used to help treat hydrocephalus. As the pons expands due to tumor, it can block cerebrospinal fluid surrounding the brain and spinal cord. This can cause increased pressure on the brain. Some children with hydrocephalus due to DIPG may have a shunt placed to drain fluid from the brain.

In some cases, surgery may be used to remove parts of the bone at the base of the skull (decompression) to relieve pressure on the brainstem and spinal cord.

Targeted therapy

Targeted therapies work by acting on, or targeting, specific features of the tumor such as genes and proteins. Some targeted therapies being studied as part of clinical trials in DIPG include targeting:

• Cell surface receptors thought to be enriched or active in DIPG
• Intracellular proteins that regulate cell growth and survival of tumor cells
• Proteins that repair DNA damage that might be altered in DIPG, making cancer cells more resistant to radiation and chemotherapy
• Proteins that regulate gene expression related to the specific mutation, H3 K27M

Immunotherapy

Immunotherapy is a type of treatment that uses the body’s own immune system to recognize and attack cancer cells. More recently, various types of immunotherapy are being explored in patients with DIPG. These include antibodies that may activate the patient’s immune system to fight against the DIPG tumor. Scientists are also studying whether a vaccine may be able to target DIPG tumor cells that have a specific type of H3 K27M mutation.

Supportive care for children with DIPG

DIPG is progressive, and symptoms get worse over time. Supportive care helps maintain quality of life as much as possible for as long as possible. Families should talk to their care team about what problems to expect and ways to help manage them.

Common symptoms of late stage DIPG

When DIPG comes back, symptoms can progress rapidly. However, symptoms and their course and severity can vary. Some signs and symptoms of late stage DIPG include:

• Loss of balance and motor control, often leading to inability to walk and the need for a wheelchair
• Progressive weakness and paralysis, often on one side of the body
• Difficulty swallowing, with problems related to aspiration pneumonia and not being able to eat normally and requiring a feeding tube
• Weight gain and face swelling or puffiness as a result of corticosteroid medications such as dexamethasone
• Problems speaking or communicating
• Anxiety, irritability, or agitation
• Depression and feelings of sadness
• Fatigue or drowsiness
• Sleep problems
• Changes in vision
• Headache
• Nausea and vomiting
• Constipation
• Decrease in urine, urinary retention
• Problems breathing
• Problems with heart rate and blood pressure
• Seizures
• Confusion, delirium
• Loss of consciousness

Medicines can help control pain, nausea and vomiting, anxiety and depression, and medical problems that develop as the tumor grows. Art therapy, music therapy, and other complementary therapies can also help patients and families manage symptoms.

Hydrocephalus causes symptoms such as headaches, nausea, weakness, and problems walking. Steroid medicines decrease brain swelling and pressure, but they also have side effects. Weight gain, face swelling, and puffiness are mainly due to high doses of corticosteroid medications to treat hydrocephalus.

DIPG prognosis

Unfortunately, there is no cure for DIPG at this time. Less than 10% of children survive more than 2 years after diagnosis. In a recent study ¹⁸⁾ of an international DIPG registry, the median overall survival was 11 months from diagnosis. The time to tumor progression was 7 months from diagnosis. Only 10% of patients lived more than 2 years with DIPG, and the survival rate was less than 2% at 5 years.

In most patients, radiation therapy helps to stop or slow the symptoms of DIPG. But this improvement is only temporary. Radiation may shrink the tumor, but it starts to grow again within months. Once DIPG comes back after initial treatment, the disease usually progresses quickly and does not respond to further treatment. Death often occurs within a few months.

DIPG can sometimes spread outside of the brainstem before treatment. About 20% of patients with DIPG have spread of disease to distant areas of the brain or spine or the meninges at diagnosis. This latter type of spread of disease is called leptomeningeal metastases. DIPG can also spread to other areas of the brain and spinal cord or the meninges as the disease progresses after treatment. About 20% of patients have spread to distant regions at tumor progression.

A somewhat better outcome may be seen in very young patients (3 years of age or younger) and patients with a longer duration of symptoms leading to diagnosis. Diffuse brainstem tumors in patients with neurofibromatosis type 1 (NF1) may also live longer with the disease. However, long-term survival in DIPG is generally thought to be associated with atypical features or misdiagnosis (the tumor was not actually DIPG).

DIPG survival

Despite advancements in radiation and systemic strategies as well as developments in oncologic research, survival outcomes for children with DIPG have not changed significantly over the past 20 years. Children suffering from diffuse intrinsic pontine glioma (DIPG) face a dismal prognosis with a median overall survival of approximately 11 months, and a 2 year survival rate of 10% ¹⁹⁾. The median overall survival for diffuse intrinsic pontine glioma patient population remains approximately 10 months ²⁰⁾. Due to the delicate location of the diffuse intrinsic pontine glioma tumor, surgical resection is not possible. To date, radiotherapy remains standard of care at diagnosis and confers a survival benefit of approximately 3 months ²¹⁾. Chemotherapy has not proven to be effective thus far ²²⁾.

Sedation dentistry

Sedation dentistry uses a combination of techniques, ranging from nitrous oxide (NO₂) also called “laughing gas” or “happy gas” to general anesthesia, to relax a patient during surgeries or otherwise uncomfortable appointments. Nitrous oxide gas, delivered with oxygen acts as an NMDA receptor antagonist. Before and during dental work, patients breathe the odorless and tasteless nitrous oxide gas (“laughing gas” or “happy gas”) in through a mask, which can help to relax them. Nitrous oxide gas has a rapid anxiolytic/sedative/analgesic effect and is delivered by inhalation. Nitrous oxide gas doses may be titrated to achieve target effect. Afterwards, the effects usually disappear within five to ten minutes.

Sedation is a state of depressed consciousness. There are depths or levels of sedation that range from minor to major depression of consciousness. Whereas depression of consciousness is a continuum, with no clear boundaries between levels, three levels of sedation have been defined and are in common use: minimal, moderate and deep sedation. The target level of sedation is the level that is intended for the patient. The level of sedation can vary according to the drug, the dose, the patient and the stimulus of the procedure. The level of sedation varies over time due to two main factors: the change in the concentration of the sedation drug within the patient and the variation in the stimulation that opposes sedation.

Although most dentists are qualified to administer nitrous oxide (NO₂), other types of sedation require additional training, equipment and emergency supplies. And because a relevant qualification is required to perform these techniques, not every dental clinic will provide the service you’d like. For this reason, some may choose to contract qualified doctors or dentists to come to their office to perform sedation for their patients. It is essential you find a qualified professional(s) who is qualified and familiar with dental sedation guidelines.

Types of dental sedation

Nitrous oxide (NO₂) or Laughing Gas

Probably the most common form of sedation in the dental office is nitrous oxide or “laughing gas” / “happy gas”. Also called inhalation analgesia and used to alleviate pain when giving birth, according to the National Institutes of Health – nitrous oxide does not put you to sleep, and is effective at reducing your anxiety about a dental procedure. It is very safe and provided in most dental offices. Local injections of anesthesia, which are still used in combination with nitrous oxide, now see consistent effectiveness, and some are practically painless. Nonetheless, the nitrous oxide gas can be administered by a machine to further reduce the discomfort of the injection.

Nitrous oxide (NO₂) or Laughing Gas is safe as it is a combination of Nitrogen and Oxygen which are present in the air we breathe. Happy Gas never goes past 70% Nitrogen, of which there is 80% in normal air.

You can’t overdose on the nitrous oxide gas, as the mixture quickly leaves your body if you breathe in one or two breaths of ordinary air. There are no after-effects either, and you can drive a car after about 15 minutes. This is the most frequently used and safest sedation method used in dentistry.

Advantages of nitrous oxide inhalation sedation:

• Safe
• Rapid Onset
• Flexible duration can be used for any appointment length
• Absolute Control. It is easy to quickly control the level of sedation
• People recover quickly
• Very few side effects
• There is an analgesic effect (pain-free)
• You can return to normal activities immediately after the appointment

Enteral sedation

The next type of sedation comes in the form of a pill or liquid that you take orally. This is called enteral sedation. Like local anesthetics, oftentimes it is used in combination with nitrous oxide. You may still be awake, but not nervous about the dental work.

Twilight anesthesia or IV sedation

Twilight sleep anesthesia also known as a twilight anesthesia, “I.V. sedation”, “conscious sedation” or “zombie state,” is an anesthetic technique wherein the dental sedation drugs are directly injected into a vein, is characterized by insensibility to pain without loss of consciousness, induced by an injections of scopolamine–morphine mixture. Twilight sleep anesthesia allows patients to be sedated without completely losing consciousness. This technique will allow the dentist to provide a deeper sedation, although you will still be awake but less aware of the procedure. The process requires recovery time after you leave the office. You must have someone take you home after the procedure. During surgery or other medical procedures, the patient is under what is known as a “twilight state”, where the patient is relaxed and “sleepy”, able to follow simple directions by the doctor, and is responsive. Generally, twilight anesthesia causes the patient to forget the surgery and the time right after. It is used for a variety of surgical procedures and for various reasons. Just like regular anesthesia, twilight anesthesia is designed to help a patient feel more comfortable and to minimize pain associated with the procedure being performed and to allow the medical practitioner to practice without interruptions. Twilight sleep anesthesia is safe and effective for people who need minor surgery or a procedure to diagnose a condition.

There are four levels of sedation by anesthesia. Twilight anesthesia is level 2, also known as moderate sedation/analgesia or conscious sedation, a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied with light physical stimulation. Breathing tubes are not required for this type of anesthesia. Some of the same drugs used in general anesthesia are also used for twilight anesthesia, except in smaller doses and in a bolus interval (a concentrated mass of a substance administered intravenously for diagnostic or therapeutic purposes). These drugs can be administered via gases, such as nitrous oxide (laughing gas), or intravenously, with drugs such as ketamine (pediatrics primarily, and infrequently in adults), propofol, and midazolam. Twilight anesthesia alone is not used to provide relief from surgical pain, therefore, it is always given in conjunction with a local or regional anesthetic. Additionally, IV sedation is frequently administered as a concoction of several agents including those previously mentioned for induction and maintenance of anesthesia, as well as a benzodiazepine (usually midazolam, but temazepam or flunitrazepam are also used via the oral route) and a narcotic/systemic analgesic such as demerol or fentanyl. As discussed in the levels of sedation by anesthesia, assistance with breathing tubes (endotracheal tube or laryngeal mask airway) are not generally used for this type of anesthesia.

Patients under twilight anesthesia are carefully maintained in a state of drowsy relaxation during their surgical procedure. It is common for patients to fall into a light sleep during this type of anesthesia. The medication for sedation is delivered intravenously, while the surgeon or anesthesiologist injects the area to be operated on with a local anesthetic (ie. numbing medicine) for pain. It is completely normal for people to remember being in the operating room while under twilight anesthesia, or to remember people talking to them while the procedure is occurring. It is also possible to have vivid dreams, and to recall them after the procedure. These are all normal with twilight anesthesia, yet many people remember nothing at all. You should not feel pain, however, during twilight anesthesia, because the area to be operated on will always be numbed by the surgeon. These numbing medications last anywhere from 1-6 hours.

As with any anesthetic, all of the patient’s vital signs are continuously monitored throughout the procedure, but a breathing tube is not required Conscious Sedation because the patient is responsive enough to continue breathing. The recovery period for twilight anesthesia is usually very brief, and many patients feel better after this type of sedation than with general anesthesia.

IV Sedation indication

Patients that are suitable for IV sedation include those who:

• are anxious or have a fear/phobia of dental procedures
• have had bad experiences in the past
• require complex dental treatments
• have difficulty getting numb with local anesthetic
• have a strong gag reflex
• have a needle phobia

Types of procedures (under IV sedation)

• Dental fillings
• Cleans
• Extractions (including complex surgical extractions)
• Wisdom Teeth Extractions
• Dental Implants
• Veneers/Crowns
• Emergency Procedures
• Pain Relief

IV Sedation contraindications

There are some relative contraindications where we won’t be able to provide IV sedation.

These include:

• Pregnant patients
• Age below 15
• Diagnosed Obstructive Sleep Apnea
• BMI (body mass index) greater than 40
• Unstable medical conditions

IV Sedation side effects

IV sedation or twilight sleep anesthesia is usually safe. A very small minority of patients have dream-like recollections of the experience but these are not distressing. IV sedation is generally well tolerated, with transient side-effects which can include dizziness and nausea. However, if you are given too much of the medicine, problems with your breathing may occur. A doctor will be watching you during the whole procedure.

Your doctors always have special equipment to help you with your breathing, if needed. Only certain qualified health professionals can provide twilight sleep anesthesia.

Some common side effects of twilight sleep anesthesia may last for a few hours after the procedure, including:

• drowsiness.
• feelings of heaviness or sluggishness.
• loss of memory of what happened during the procedure (amnesia)
• slow reflexes.
• low blood pressure.
• headache.
• feeling sick.

General anesthesia

General anesthesia is a form of sedation by which you will be asleep for the entire procedure. It is practiced using drugs that are directly injected into a vein, along with the possible inhalation of a gaseous anesthetic. A thorough recovery time in the office may be required before leaving.

When you come in for your dental procedure, it usually takes about 20 minutes for an anesthetist or trained dentist to put in the IV line and administer sedation. Anesthetic cream can also be used beforehand on your skin to reduce the sensation of the IV line being put in.

During the dental procedure, professionals constantly monitor blood pressure and measure your pulse and oxygen. If you’re having several different procedures, the sedation may be adjusted, with more being used during extraction and less being used for a dental filling.

After a short period of recovery, you’ll be awake and can get up and walk around. But if you sit down or rest, you could very quickly fall asleep again. For this reason, patients shouldn’t drive or use heavy equipment after twilight sedation and should have someone with them at home after the procedure.

General anesthesia indications

Most of dental procedures can be performed under local anesthesia which is safe in nature. Decisions regarding general anesthesia can only be made according to each patient’s condition, but its use in dentistry should be restricted to ¹⁾:

1. Acute infection such as acute dento-alveolar abscess and severe pulpitis, which preclude to achieve appropriate local anesthesia, and pain relief during dental treatment. Meanwhile, in these circumstances medications or drainage procedures are failed due to local change in pH and a risk of spreading infection;
2. Small children who may not tolerate dental procedures under local anesthesia or those who experienced failures of previous attempts using local anesthesia constitute a majority of outpatient general anesthesia in dentistry. It is recommended that administration of general anesthesia to very young children be accomplished only by pediatric anesthetists;
3. Mentally compromised patients are unlikely to allow safe completion of treatment under local anesthesia because of problems related to physical/mental disability; therefore they might need general anesthesia;
4. Dental phobia: patients suffering from long-term dental phobia are best managed under general anesthesia in the first visit with the aim of gradual shift to local anesthesia, conscious sedation and behavior management techniques respectively;
5. Allergy to local anesthetic ingredients mostly the preservative methyl paraben can cause allergic reactions, which should be differentiated with vasovagal attacks;
6. Extensive dentistry and maxillofacial surgery: local anesthesia is unable to provide pain relief in an alert patient during extensive procedures ²⁾.

General anesthesia complications

D’Eramo et al. ³⁾, in studies demonstrated that the most common complication related to dental anesthesia was syncope (up to 80%) followed by laryngospasm, phlebitis, dysrhythmia, bronchospasm, and hypotension. Death was one of the most crucial side effects of anesthesia in dentistry most commonly caused by hypoxia according to Tomlin PJ ⁴⁾. Hypoxia can mimic a syncope attack with a low blood pressure, and a low cardiac output state with severe bradycardia ⁵⁾. According to review of the literature, the mortality rate associated with dental office anesthesia has been estimated to be between 1:1639 to 1: 1,733,000 ⁶⁾.

Periventricular leucomalacia

Periventricular leukomalacia is a type of brain injury that affects premature infants. Periventricular leukomalacia is characterized by the death or damage and softening of the white matter around fluid-filled areas called ventricles, the inner part of the brain that transmits information between the nerve cells and the spinal cord, as well as from one part of the brain to another. The damage creates “holes” in the brain. “Leuko” refers to the brain’s white matter. “Periventricular” refers to the area around the ventricles, the spaces in the brain containing the cerebrospinal fluid.

• Periventricular means around or near the ventricles
• Leuko means white
• Malacia means softening

Periventricular leucomalacia may occur alone or in addition to intraventricular hemorrhage (bleeding inside the brain).

Periventricular leukomalacia is the second most common central nervous system (CNS) complication in preterm infants, after periventricular hemorrhage. Periventricular leucomalacia is caused by ischemia in the watershed territory of the preterm infant ¹⁾. Periventricular leukomalacia occurs most commonly in premature infants born at less than 32 weeks’ gestation who have a birth weight of less than 1500 g. Many of these infants have a history of maternal chorioamnionitis. Most affected infants experience cardiorespiratory problems, such as respiratory distress syndrome or pneumonia, in association with hypotension or patent ductus arteriosus during their first days of life. Bacterial infection at birth also appears to be a risk factor.

The incidence of periventricular leukomalacia ranges from 4-26% in premature infants in neonatal intensive care units (NICUs) ²⁾. The incidence of periventricular leukomalacia is much higher in reports from autopsy studies of premature infants. As many as 75% of premature infants have evidence of periventricular leukomalacia on postmortem examination.

With periventricular leucomalacia, the area of damaged brain tissue can affect the nerve cells that control motor movements. As the baby grows, the damaged nerve cells cause the muscles to become spastic, or tight, and resistant to movement. Infants with periventricular leukomalacia are at risk for development of neurodevelopmental deficits ³⁾. Babies with periventricular leucomalacia have a higher risk of developing cerebral palsy (a group of disorders that prevent the child from controlling their muscles normally), and may have intellectual impairment, learning difficulties or visual disturbances.

Mild periventricular leukomalacia is often associated with spastic diplegia. Severe periventricular leukomalacia is associated with quadriplegia. Severe periventricular leukomalacia is also associated with a higher incidence of intelligence deficiencies and visual disturbances.

Periventricular leukomalacia tends to be suspected in babies born prematurely or at low birthweight, so they may be checked soon after birth before any symptoms start to show. They may have a cranial ultrasound scan – this is similar to the ultrasound scans carried out in pregnancy but the probe is held over the soft spot on the top of the head (fontanelle). Another imaging scan that might be suggested is an MRI scan – this shows the characteristic appearance of the condition.

Although there is no treatment for periventricular leucomalacia, doctors may recommend other types of care for your child, such as:

• Physical therapy
• Occupational therapy
• Speech-language therapy
• Vision therapy

Most of these therapies are provided through Early Intervention programs in your community.

Figure 1. Brain anatomy

Figure 2. Brain ventricles

Periventricular leucomalacia causes

Periventricular leucomalacia is much more common in premature infants whose brain tissues are fragile than in full-term infants. Mechanically ventilated premature infants born at less than 32 weeks’ gestation are at greatest risk for periventricular leukomalacia. It is not clear why periventricular leucomalacia occurs. Hypotension (low blood pressure), hypoxemia (abnormally low level of oxygen in the blood) and acidosis (a build-up of acid in the bloodstream) may result in ischemic brain injury and periventricular leukomalacia. Marked hypocarbia also known as hypocapnia (a decrease in alveolar and blood carbon dioxide (CO2) levels) in ventilated premature infants has been associated with increased risk of developing periventricular leukomalacia.

Other associated risk factors include the following:

• Placental vascular anastomoses, twin gestation, antepartum hemorrhage
• Chorioamnionitis and funisitis
• Sepsis
• Maternal cocaine abuse

Periventricular leucomalacia may happen when the brain receives too little oxygen. A major cause is thought to be changes in blood flow to the area around the ventricles of the brain. This area is fragile and prone to injury, especially before 32 weeks of gestation. Most babies who develop periventricular leucomalacia are premature, especially those born before 30 weeks gestation. However, it is not clear when the trigger for periventricular leucomalacia occurs–before, during, or after birth.

Infection around the time of delivery may also play a role in causing periventricular leucomalacia. The risk for periventricular leucomalacia is higher for babies who are more premature and more unstable at birth.

Premature babies who have intraventricular hemorrhage are also at increased risk for developing this condition.

Other factors that may be associated with periventricular leucomalacia include early rupture of membranes (amniotic sac) and infection inside the uterus.

Periventricular leucomalacia pathophysiology

The pathophysiology of periventricular leukomalacia is a complex process. Periventricular leukomalacia occurs because of ischemia induced injury to oligodendrocytes in the periventricular area of the developing brain. Cytokine-induced damage following maternal or fetal infection may play a role.

Periventricular leukomalacia is a white matter lesion in premature infants that results from hypotension, ischemia, and coagulation necrosis at the border or watershed zones of deep penetrating arteries of the middle cerebral artery.

Several factors related to vascular development make the periventricular region of the preterm brain uniquely sensitive to ischemic injury. First, early in development, the deep penetrating arteries that supply the watershed zone of the periventricular white matter lack the vascular anastomoses that help maintain perfusion during periods of hypotension. As the fetus matures, the number of anastomoses between the deep penetrating arteries increases, and the periventricular white matter becomes less susceptible to small decreases in blood pressure.

The second vascular developmental factor that plays a role in periventricular leukomalacia is related to cerebral autoregulation. Premature infants have impaired cerebrovascular blood flow autoregulation, increasing their susceptibility to periventricular leukomalacia and intracranial hemorrhage. Decreased blood flow affects the white matter at the superolateral borders of the lateral ventricles. The site of injury affects the descending corticospinal tracts, visual radiations, and acoustic radiations.

Maternal infection, placental inflammation, and vasculitis are also important in the pathogenesis of periventricular leukomalacia. A link between maternal infection, preterm birth, and central nervous system (brain and spinal cord) injury has been established by epidemiological studies ⁴⁾. A role for infection and cytokine-induced injury in periventricular leukomalacia is strengthened by studies that demonstrate the presence of tumor necrosis factor in periventricular leukomalacia lesions ⁵⁾ and in the cerebrospinal fluid (CSF) of infants with cerebral white matter injury ⁶⁾.

After the initial insult, either ischemia or inflammation, injury to the immature premyelinating oligodendrocytes occurs by either free radical attack or by excitotoxicity. The preterm infant is particularly sensitive to oxygen free radical attack because of delayed development of superoxide dismutase and catalase ⁷⁾.

In a 2014 report, Inomata et al ⁸⁾ suggested that combined elevations in serum levels of interleukin (IL) 6 and C-reactive protein (CRP) at birth are predictive of white matter injury in preterm infants with a fetal inflammatory response.

Injury to the premyelinating oligodendrocytes results in astrogliosis and microgliosis. This results in a deficit of mature, myelin-producing oligodendrocytes, which leads to cerebral hypomyelination ⁹⁾.

Premature infants on mechanical ventilation may develop hypocarbia. Several studies have linked hypocarbia, particularly in the first few days of life, with the development of periventricular leukomalacia ¹⁰⁾. Cumulative exposure during the first 7 days of life has been shown to independently increase the risk of periventricular leukomalacia in low birth weight infants ¹¹⁾.

Periventricular leucomalacia prevention

Prevention of premature birth is the most important means of preventing periventricular leukomalacia.

Prior to birth, diagnosing and managing chorioamnionitis may prevent periventricular leukomalacia. In 1999, Baud et al ¹²⁾, ¹³⁾ reported that betamethasone administered to mothers at 24-31 weeks’ gestation, before delivery, significantly reduced the risk of periventricular leukomalacia, suggesting the possible effect of steroids on fetal inflammatory response.

Avoiding maternal cocaine abuse and avoiding maternal-fetal blood flow alterations has been suggested to minimize periventricular leukomalacia.

Following delivery of a premature infant, attempts to minimize blood pressure swings and hypotension may also be beneficial in preventing periventricular leukomalacia.

Avoidance of prolonged hypocarbia in the mechanically ventilated premature infant may be useful in the prevention of periventricular leukomalacia.

Periventricular leucomalacia signs and symptoms

Initially, most premature infants are asymptomatic. Periventricular leucomalacia may not be apparent until later months. Each baby may experience symptoms differently. If symptoms occur, they are usually subtle. The most common symptom of periventricular leucomalacia is spastic diplegia, a form of cerebral palsy (a condition that affects coordination and movement) characterized by tight, contracted muscles, especially in the legs. Cerebral palsy is a very variable condition – some children may only have minor movement problems but others may have severe disabilities. Children with periventricular leukomalacia may also have visual problems and/or learning disabilities. The symptoms of periventricular leucomalacia may resemble other conditions or medical problems. Always consult your baby’s doctor for a diagnosis.

Periventricular leucomalacia symptoms may include the following:

• Decreased tone in lower extremities
• Increased tone in neck extensors
• Trouble with vision and with eye movements
• Apnea and bradycardia events
• Irritability
• Pseudobulbar palsy with poor feeding
• Clinical seizures (may occur in 10-30% of infants)
• Trouble with movement, and tight muscles
• Developmental delay that is increasingly apparent over time

Periventricular leucomalacia diagnosis

In addition to a complete medical history and physical examination, diagnostic procedures for periventricular leucomalacia may include:

• Cranial ultrasound. A painless test that uses sound waves to view the baby’s brain through the fontanelles, the soft openings between the skull bones. With periventricular leucomalacia, the ultrasound shows cysts or hollow places in the brain tissue. The timing of initial cranial ultrasonography can be useful in determining the timing of the insult. Cystic periventricular leukomalacia has been identified on cranial sonograms on the first day of life, indicating that the event was prenatal rather than perinatal or postnatal.
• Magnetic resonance imaging (MRI). This test uses a combination of a large magnet, radio frequencies, and a computer to produce detailed images of internal structures. MRI may show some of the early changes in the brain tissue that occur with periventricular leucomalacia.

Cranial ultrasound

Cranial ultrasonography is the modality of choice for the initial evaluation of hypoxic-ischemic damage of the central nervous system in premature infants. Ultrasonography may be performed in the NICU without the need to transport fragile infants.

The earliest ultrasonographic appearance of periventricular leukomalacia is abnormal increased echotexture in the periventricular white matter. This is a nonspecific finding that must be differentiated from the normal periventricular halo and mild periventricular edema that may not result in permanent injury.

The abnormal periventricular echotexture of periventricular leukomalacia usually disappears at 2-3 weeks. Approximately 15% of infants experiencing periventricular leukomalacia demonstrate periventricular cysts first appearing at 2-3 weeks after the initial increased echodensities.

The severity of periventricular leukomalacia is related to the size and distribution of these cysts. Initial cranial ultrasonographic findings may be normal in patients who go on to develop clinical and delayed imaging findings of periventricular leukomalacia.

Magnetic resonance imaging

As with CT scanning, MRI does not play a major role in the early evaluation of periventricular leukomalacia. MRI is most helpful in detecting infants with non-cystic periventricular leukomalacia or evaluating infants who develop clinical signs suggestive of periventricular leukomalacia ¹⁴⁾.

MRI demonstrates the loss of white matter, abnormal signal intensity of the deep white matter, and ventriculomegaly; it also reveals thinning of the posterior body and splenium of the corpus callosum in severe cases of periventricular leukomalacia.

In a study of MRIs at term-equivalent age from 3 cohorts of 325 very preterm infants, Kidokoro et al found 33% (n=107) had some grade of brain injury (eg, periventricular leukomalacia, intraventricular/cerebellar hemorrhage) and 10% (n=33) had severe brain injury ¹⁵⁾. The investigators noted severe brain injury and impaired growth patterns were independently associated with perinatal risk factors and delayed cognitive development ¹⁶⁾.

Volumetric MRI scanning is also helpful in determining the extent of injury to the descending corticospinal tracts.

A relationship between the degree of injury to the descending corticospinal tracts as assessed by MRI and the severity of diplegia has been reported.

Other studies

Obtain electroencephalography (EEG) studies in preterm infants for early detection of periventricular leukomalacia. Changes in hypoxic-ischemic encephalopathy and EEG wave patterns may change over time and indicate the severity of the brain injury ¹⁷⁾. EEG abnormalities may be apparent before anomalies seen on ultrasonography.

Spectral-domain optical coherence tomography (SD-OCT) shows promise in the evaluation of prematurity on early optic nerve development and of central nervous system development and anomalies ¹⁸⁾.

On histologic examination, periventricular leukomalacia lesions demonstrate widespread loss of oligodendrocytes and an increase in astrocytes.

Periventricular leucomalacia treatment

Currently there are no treatments for periventricular leucomalacia. Management of the problems that can result from periventricular leucomalacia will be determined by your baby’s doctor based on:

• Your baby’s gestational age, overall health, and medical history
• Extent of the condition
• Your baby’s tolerance for specific medications, procedures, or therapies
• Expectations for the course of the condition
• Your opinion or preference

Babies at risk for periventricular leucomalacia may need special care and close neurodevelopmental follow-up after discharge from the hospital. Follow-up may include physical therapy, occupational therapy, and speech therapy.

Developmental follow-up: Premature infants with evidence of periventricular leukomalacia require close developmental follow-up because of the high association with cerebral palsy (CP).

Early intervention strategies carried out by occupational therapists or physical therapists may decrease symptoms and may increase the infant’s motor function.

Free radical scavengers are being investigated to determine if they have a role in preventing oligodendrocyte injury in periventricular leukomalacia.

Periventricular leucomalacia prognosis

The long-term outlook for babies with periventricular leucomalacia depends upon the severity of the initial brain damage. The types of symptoms vary widely and can range from a child who has minimal problems to a child who has severe delays and problems with movement.

Periventricular leukomalacia occurs most commonly in premature infants born at less than 32 weeks’ gestation. Many infants with periventricular leukomalacia later develop signs of cerebral palsy (CP). Spastic diplegia is the most common form of CP following mild periventricular leukomalacia. Severe periventricular leukomalacia is frequently associated with quadriplegia.

Varying degrees of intellectual impairment, developmental impairment, or both have been reported in association with periventricular leukomalacia. Fixation difficulties, nystagmus, strabismus, and blindness have been associated with periventricular leukomalacia. Some cases of visual dysfunction in association with periventricular leukomalacia occur in the absence of retinopathy of prematurity, suggesting damage to optic radiations as causation.

Extended breastfeeding facts

Extended breastfeeding in the United States is breastfeeding beyond 1 year of age. How long to continue breastfeeding for is a personal decision for each family to make. The American Academy of Pediatrics recommends breastfeeding as the sole source of nutrition for your baby for about 6 months and can be continued for as long as both mother and baby desire it. The World Health Organization (WHO) recommends exclusive breastfeeding (i.e. no other fluids or solids) for six months and then continued breastfeeding combined with solid foods for 2 years or as long as mother and baby desire. In the United States, most new moms (about 80 percent) start breastfeeding. More than half (about 58 percent) of moms breastfeed for 6 months. About one-third of new moms (36 percent) breastfeed for 12 months.

Your baby’s first tooth probably will appear after six months, though some babies are born with one or more teeth and in other cases teeth don’t appear until the child is almost a year old. Many mothers decide that it’s time to stop breastfeeding when they first notice a tooth. Usually this is because the baby has nipped the breast at the end of a feeding session or because the mother fears she will be bitten. Yet many babies with teeth (or those who are teething) never bite when breastfeeding. An actively nursing baby will not bite, because her tongue covers her lower teeth. A baby who nips the breast as he starts to pull away near the end of a feeding can be taught to stop. If your baby has sprouted a tooth and you are concerned that she may nip you as a feeding ends: Keep your finger ready to break the suction and remove your breast as soon as her rhythmic suckling stops (and before she starts to drift off or feel playful). If she has already bitten: Say no firmly and then remove her from your breast. Try to keep this action as bland and matter-of-fact as possible. Too much anger or even amusement may interest her enough to make her want to repeat the experiment again. Once she realizes that biting means no more breast, she will learn to stifle the impulse. (Meanwhile, don’t forget to offer her a one-piece teething ring when she is not nursing.)

If your child weans when she is ready, you can feel confident that you have met your baby’s physical and emotional needs in a very normal, healthy way. In cultures where there is no pressure to wean, children tend to breastfeed for at least 2 years. The World Health Organization and UNICEF strongly encourage breastfeeding through toddlerhood: ‘Breastmilk is an important source of energy and protein, and helps to protect against disease during the child’s second year of life.’ Human biology seems geared to a weaning age of between 2 and a half and 7 years. It makes sense to build your child’s bones from the breast milk that was designed for them. Your breast milk provides nutrients, anti-infective factors and other protective substances as long as your child continues breastfeeding. Mothers who breastfeed long- term have a still lower risk of developing breast cancer. Breastfeeding is a parenting factor which has been associated with child emotional development – in particular the attachment between children and their mothers. Breastfeeding eases both of you through the tears, tantrums and tumbles that come with early childhood. It helps ensure that any illnesses are milder and easier to deal with. It’s an all-purpose mothering tool you won’t want to be without. Don’t worry that your child will breastfeed forever. All children stop on their own, no matter what you do, and there are more breastfeeding youngsters around than you might guess.

Whether you breastfeed for a day or for several years, the decision to breastfeed your child is one you will never regret. And whenever weaning takes place, remember that it is a big step for both of you.

If you breastfeed your baby for just a few days, he will have received your colostrum, or early milk. By providing anti-infective factors (eg antibodies) and the food his brand-new body expects, breastfeeding gives your baby his first — and easiest — ‘immunization’ and helps get his digestive system working smoothly. Breastfeeding is how your baby expects to start and he is born with the instincts to help guide this process. It also helps your own body recover from the birth. Given how little it takes to offer it, and how very much your baby stands to gain, it makes good sense to breastfeed for at least a day or two, even if you plan to bottle-feed after that.

If you breastfeed your baby for 4 to 6 weeks, you will have eased him through the most critical part of his infancy. Newborns who are not breastfed are much more likely to get sick or be hospitalized, and have an increased risk of SIDS than breastfed babies. After 4–6 weeks, you’ll probably have worked through any early breastfeeding concerns, too. Make a serious goal of breastfeeding for a month, call the Breastfeeding Helpline or an international board certified lactation consultant (IBCLC) if you have any questions and you’ll be in a better position to decide whether continued breastfeeding is for you.

If you breastfeed your baby for 3–4 months, her digestive system will have matured a great deal, and she will be much better able to tolerate the foreign substances in formula. Giving nothing but your breastmilk for the first 6 months helps to protect against infections (eg ear, respiratory and gastrointestinal).

If you breastfeed your baby for 6 months without adding any other food or drink, you will help ensure good health throughout your baby’s first year of life, reduce your little one’s risk of infection, and reduce your own risk of breast cancer. Exclusive, frequent breastfeeding during the first 6 months, if your periods have not returned, provides 98% effective contraception. The National Health and Medical Research Council and the World Health Organization recommend waiting until about 6 months to start solids.

If you breastfeed your baby for 9 months, you will have nourished him through the period of his fastest and most important brain and body development on the food that was designed for him — your milk. Weaning may be fairly easy at this age … but then, so is breastfeeding! If you want to avoid weaning this early, be sure that, from the start, you breastfeed willingly to provide comfort, not just to provide food.

If you breastfeed your baby for 12 months, you can avoid the expense of formula. A one-year-old body can probably handle most of the family foods your family enjoys. Many of the health benefits this year of breastfeeding has given your child will last her whole life. She will be less likely to need orthodontic treatment and have a reduced risk of some childhood cancers such as leukemia. The National Health and Medical Research Council recommends breastfeeding for a year, or for as long as mother and baby desire, because it helps ensure normal nutrition and health for your baby.

How to prevent baby-bottle tooth decay

Once your baby’s teeth have begun to come in, it is important to keep in mind that even breastfeeding babies are sometimes susceptible to baby-bottle tooth decay, a major cause of dental cavities in infants that can also cause serious damage to permanent teeth later on. Baby-bottle tooth decay results from teeth being coated in almost any liquid other than water for long periods, and occurs most commonly among babies who are put to bed with a bottle of formula or juice.

Research shows that human milk by itself does not promote tooth decay. But breastfeeding infants who fall asleep while nursing with unswallowed milk in their mouths are also vulnerable to tooth decay. Beyond the first year, dental caries—tooth decay—can occur in toddlers who receive sugary liquids in a bottle or who are nursing and eating foods with sugar and carbohydrates. Make a point of removing your breast from your baby’s mouth once she has fallen asleep.

Tips to promote dental health from the start

Your pediatrician will check your baby’s teeth as part of the well-child visits during the first year of life and beyond.

• To stimulate healthy gums and good oral hygiene: Wipe the gums at least once a day, beginning at birth, even before any teeth have erupted in your child’s mouth.
• After teeth erupt: Wiping her gums and teeth with a piece of gauze or a damp cloth after feedings and before bedtime will help maintain good oral hygiene.
• Once you are able brushing: Start using a smear (grain of rice sized) amount of fluoridated toothpaste and a soft bristled, child-sized toothbrush for daily cleaning (two times per day).
  • Fluoride is an important way to protect your child’s teeth from cavities. Your pediatrician or dentist can help guide you on the optimal amount of fluoride for your child. It is important to use fluoridated toothpaste in the appropriate amounts for age, drink water with fluoride (most tap water), and have your child’s pediatrician or dentist apply fluoride varnish as needed.
• Try to take your baby to the dentist by age 1: You can form a relationship with your dentist to help keep your baby’s mouth healthy.

Benefits of extended breastfeeding

If you are still breastfeeding your child through his first birthday, you can congratulate yourself on having provided him with the best nutrition he could possibly receive. Now that he is consuming a wide variety of solid foods, your breast milk has become somewhat less critical from a nutritional perspective. Some toddlers continue to consume a moderate amount of breast milk (and thus the nutrients it contains), while others “graze” and ingest smaller quantities, getting most of their nutrition elsewhere. Certainly there is no known point at which breast milk becomes nutritionally negligible. What scientists do know is that as your child moves from babyhood toward toddlerhood, breastfeeding continues to act as a source of profound comfort and security, laying the groundwork for a confident, happy, and healthy future. For this reason, as well as the continued nutritional and immunologic benefits of breastfeeding, the American Academy of Pediatrics advises mothers to continue nursing beyond the first year for as long as mutually desired by mother and child ¹⁾.

If you breastfeed your baby for 18 months, you will have continued to provide nutrition, comfort, and illness protection for your baby, at a time when illness is common in weaned babies. Your baby is probably well established on family foods, too. He has had time to form a solid bond with you — a healthy starting point for his growing independence. He is now old enough that you and he can work together on the weaning process, at a pace that he can handle.

Benefits of breastfeeding for your baby

Breast milk is the best food for babies in the first year of life. It helps them grow healthy and strong and protects them from infections and illness. For example:

• Breast milk has hormones and the right amount of protein, sugar, fat and most vitamins to help your baby grow and develop.
• Breast milk has antibodies that help protect your baby from many illnesses. Antibodies are cells in the body that fight off infection. Breastfed babies have fewer health problems than babies who aren’t breastfed. For example, breastfed babies don’t have as many ear, lung or urinary tract infections. And later in life they’re less likely to be overweight or have asthma, certain cancers and diabetes (having too much sugar in the blood).
• Breast milk has fatty acids, like DHA (docosahexaenoic acid), that may help your baby’s brain and eyes develop.
• Breastfeeding can reduce your baby’s risk for sudden infant death syndrome (also called SIDS). SIDS is the unexplained death of a baby younger than 1 year old.
• Breast milk is easy to digest. A breastfed baby may have less gas and belly pain than a baby who is fed formula. Formula is a man-made product that you buy and feed your baby.
• Breast milk changes as your baby grows so he gets exactly what he needs at the right time. For example, for the first few days after giving birth, your breasts make a thick, sticky, early form of
• breast milk called colostrum. Colostrum has nutrients and antibodies that your baby needs in the first few days of life. It changes to breast milk in 3 to 4 days.
• Breast milk is always ready when your baby wants to eat. The more you breastfeed, the more milk you make.

Breastfeeding benefits your baby’s immune system

Human milk provides virtually all the protein, sugar, and fat your baby needs to be healthy, and it also contains many substances that benefit your baby’s immune system, including antibodies, immune factors, enzymes, and white blood cells. These substances protect your baby against a wide variety of diseases and infections not only while he is breastfeeding but in some cases long after he has weaned. Formula cannot offer this protection.

If you develop a cold while breastfeeding, for example, you are likely to pass the cold germs on to your baby—but the antibodies your body produces to fight that cold also will be passed on through your milk. These antibodies will help your infant conquer the cold germs quickly and effectively and possibly avoid developing the cold altogether.

This defense against illnesses significantly decreases the chances that your breastfeeding baby will suffer from ear infections, vomiting, diarrhea, pneumonia, urinary tract infections, or certain types of spinal meningitis. Infants under the age of one who breastfed exclusively for at least four months, for instance, were less likely to be hospitalized for a lower respiratory tract infection, such as croup, bronchiolitis, or pneumonia, than were their formula-fed counterparts. Even infants in group child care programs, who tend to catch more germs due to their close proximity, are less likely to become ill if they are breastfed or fed their mothers’ milk in a bottle.

All humans have a very large number of bacteria that normally reside in their intestines. Some of the bacteria serve normal and healthy functions, and some can cause disease such as diarrhea. Human milk encourages the growth of healthy bacteria in the intestinal tract of the breastfed baby. It does this by promoting a generally healthy environment and, in part, through substances called prebiotics, which are found in human milk. Since human milk stimulates the growth of these “friendly” strains of bacteria, other bacteria such as E. coli, which are more likely to cause disease, are inhibited from growing, multiplying, and attaching to the lining of the intestine, where they can cause infection. It has been well established that formula-fed infants have much higher rates of diarrheal diseases which may require visits to the doctor or sometimes to the hospital for intravenous fluids.

Breastfeeding and allergies

Breastfeeding is recommended for many reasons. With regard to allergy prevention, there is some evidence that breastfeeding protects babies born to families with a history of allergies, compared to those babies who are fed either a standard cow’s milk based formula or a soy formula. In these “at risk” families, breastfed babies generally had a lower risk of milk allergy, atopic dermatitis (commonly known as eczema), and wheezing early in life, if they were exclusively breastfed for at least four months. It is presumed that immune components in maternal milk provide protection against these allergic diseases. Although the long-term benefits of breastfeeding on allergies remains unclear and studies have not carefully evaluated the impact on families without a history of allergy, exclusive breastfeeding is recommended as the feeding of choice for all infants.

Other illnesses

Transfer of the human milk antibodies and other immunologic substances may also explain why children who breastfeed for more than six months are less likely to develop childhood acute leukemia and lymphoma than those who receive formula. In addition, studies have demonstrated a 36 percent reduction (some studies show this reduction to be as high as 50 percent) in risk of sudden infant death syndrome (SIDS) among babies who breastfeed compared to those who did not, though the reasons for this are not fully understood. Recent research even indicates that breastfed infants are less likely to be obese in adolescence and adulthood. They are also less vulnerable to developing both type 1 and type 2 diabetes.

Benefits of breastfeeding for mom

Release of good hormones

Many mothers feel fulfillment and joy from the physical and emotional communion they experience with their child while nursing. These feelings are augmented by the release of hormones, such as:

• Prolactin: Produces a peaceful, nurturing sensation that allows you to relax and focus on your child.
• Oxytocin: Promotes a strong sense of love and attachment between the two of you.

​These pleasant feelings may be one of the reasons so many women who have breastfed their first child choose to breastfeed the children who follow.

Health benefits

Breastfeeding provides health benefits for mothers beyond emotional satisfaction.

• Mothers who breastfeed recover from childbirth more quickly and easily. The hormone oxytocin, released during breastfeeding, acts to return the uterus to its regular size more quickly and can reduce postpartum bleeding.
• Studies show that women who have breastfed experience reduced rates of breast and ovarian cancer later in life.
• Some studies have found that breastfeeding may reduce the risk of developing type 2 diabetes, rheumatoid arthritis, and cardiovascular disease, including high blood pressure and high cholesterol.
• Exclusive breastfeeding delays the return of the mother’s menstrual period, which can help extend the time between pregnancies.

Note: Exclusive breastfeeding can provide a natural form of contraception if the mother’s menses have not returned, the baby is breastfeeding day and night, and the baby is less than six months old.

Maternal fulfillment

As welcome as all of these benefits are, though, most mothers put the feeling of maternal fulfillment at the top of their list of reasons for breastfeeding. Breastfeeding provides a unique emotional experience for the nursing mother and the baby. Breastfeeding is the one parenting behavior that only the mother can do for her baby, creating a unique and powerful physical and emotional connection. Your partner, the baby’s siblings, and other relatives can all appreciate the new member of the family being welcomed in such a loving way.​

Practical added bonuses

There are quite a few practical advantages to breastfeeding as well— bonuses the entire family can appreciate.

• Human milk is much less expensive than formula. During nursing you will need, at most, an extra 400 to 500 calories daily to produce sufficient milk for your baby, while formula can cost between $4 and $10 per day, depending upon the brand, type (powdered versus liquid), and amount consumed.
• At night, putting a baby to your breast is much simpler and faster than getting up to prepare or warm a bottle of formula. (Your partner can make night feedings even easier by changing the baby and bringing her to you for nursing.)
• It’s wonderful, too, to be able to pick up the baby and go out—whether around town or on longer trips—without having to carry a bag full of feeding equipment.
• Breastfeeding is also good for the environment, since there are no bottles to wash or formula cans to throw away.

Breastfeeding your toddler

Breastfeeding your toddler can provide ²⁾:

• 29% of his daily energy needs
• 43% of protein requirements
• 75% of Vitamin A requirements
• 60% of Vitamin C requirements.

How many breastfeeds?

Many new mothers wonder about how many times they should breastfeed their baby each day.

The answer is that babies vary a lot in terms of the number of breastfeeds they need in a 24-hour period. While it is common for babies to breastfeed 8 to 12 times in a 24-hour period, some babies may need fewer feeds and some more. A ‘breastfeed’ could be the baby feeding from one or both breasts, or from each breast more than once. Regardless of how many feeds a baby has in a 24-hour period, what is important to know are the signs of adequate milk intake.

The only true way to know how many feeds your own individual baby needs is to feed them when they need to feed. That is, by watching out for and responding to their feeding cues. The number of feeds in a 24-hour period depends on many factors. For example:

• The age of the baby. Younger babies tend to feed more frequently than older babies.
• A mother’s breast storage volume. This is the volume of milk a mother’s breasts can hold in between feeds. A mother may have a small storage volume, which means that her baby feeds more frequently than a baby whose mother has a large storage volume. However, this is only one factor as some babies of mothers with large storage volumes still need to feed frequently.
• The weather. In hot weather a thirsty baby may want to breastfeed more frequently but for shorter periods. This means they are getting more fluid.
• Babies may need comfort, reassurance and ‘connection’ with their mother, as well as breastmilk. Breastfeeding is much more than just the transfer of food.

Cutting newborn nails

You don’t need to cut baby nails very often. In newborns, nails are soft and wear down by themselves through contact with your baby’s clothing. Older babies wear down their nails while playing and interacting with their surroundings.

Baby nails do grow quite fast, though, so you can trim fingernails and toenails as needed. You can use special baby nail scissors or nail clippers. You can also file nails using an emery board. This means just rounding off the nails so they’re smooth.

Young babies tend to scratch themselves accidentally because they don’t have a lot of control over their hands and legs. You can stop babies from scratching by covering their hands with a pair of soft cotton mittens or socks. But make sure your baby has some mitten-free time to explore and play with their hands.

Baby nail problems

It’s quite common for young babies to get a small infection (called paronychia) around a fingernail or toenail. This often clears up without needing treatment. But you might need to put a small amount of antiseptic cream or liquid on the nail.

Sometimes this infection can spread further into the skin of the finger or toe, causing the area to become swollen and red.

If you notice this, see your doctor. Your baby might need an antibiotic to help clear the infection. If you do put on cream to treat the infection, make sure that you put mittens or socks on your baby afterwards. This means baby can’t put their hands or feet directly into their mouth.

Best way to cut baby nails

Try to cut baby nails when your newborn is asleep, very calm or drowsy. For older children, you can use a high chair or car seat where you can strap your child in.

These tips for cutting nails can make things easier:

• Make sure you have plenty of light, so you can see well.
• Work with someone else if it helps – one holds your baby as the other trims the nails.
• Gently pull your baby’s finger pad away from the nail to avoid cutting the skin.
• Trim toenails straight across to prevent ingrown nails.

And here are some tips to keep your baby happy as you cut nails:

• Talk calmly or sing to your baby.
• Try distracting your baby with a toy or activity. This often works well with older babies.
• Involve your baby in the activity by making a game of it.
• Praise your baby for helping you finish. This can help you both feel good about getting the job done.

If you accidentally cut your baby’s skin and it bleeds, gently press a soft cloth pad onto the cut until the bleeding stops. Don’t put on a dressing because your baby might suck it off.

If you’re worried about the cut, bring your baby to see your doctor.

Baby refuses to breastfeed

Baby refusing to breastfeed is also known as baby’s breast refusal, baby nursing strike or breastfeeding strike, is a baby’s refusal to suck at the breast is a most distressing problem and worrying problem for breastfeeding mothers ¹⁾. Some mothers might take nursing strike personally and believe her child is refusing her and not the breast milk. She might also think that there is something missing from her milk and it’s insufficient for her child ²⁾. In fact a common reason for cessation of nursing is infant’s refusal to breastfeed. But this problem can often be overcome ³⁾. A baby may refuse the breast at some or all feedings, at any age, and his reasons for doing so will vary with his stage of development or even his health at the time. He may suck for a few minutes, then break away with signs of distress and refuse to continue. He may refuse even to begin sucking although he is obviously hungry.

Most breast refusal is temporary and in most cases it should not be too long before your baby is again breastfeeding happily. Sometimes you may never discover why he did refuse. However, there are some babies who cannot be persuaded to return to the breast. If that is the case for you, it is important to remember that your baby is not rejecting you and that you will soon find other ways of relating to each other.

Sometimes, a baby does not actually refuse but is very fussy and difficult to feed. He may be the kind of baby who seems to be very unwilling to start sucking and takes a long time to get going, but once he has started, feeds well. A fussy baby can seem to receive little satisfaction from feeding. He sucks for a short while and then breaks away, finishing his feed after a series of stops and starts. He may be easily distracted and restless during the feed, perhaps pushing away from his mother with his fists or his feet. He stops as soon as his hunger is satisfied and may remain restless and fidgety afterwards.

When managing a picky feeder or a baby who is refusing to breastfeed, it is important to remain calm and patient, handling your baby gently. If you are both on edge, try taking deep breathes similar to that which you may have used during labor or when trying to calm or meditate. The deep breathing helps slow your own breathing and make it more regular which can help calm everyone, concentrate on staying relaxed, use soothing music, rock your baby gently or carry him around. This relaxation will help your milk flow readily so your baby will get milk once he latches on.

If your baby is quite unsettled, cross or crying or if you are feeling angry and upset, you may find it helps to try again when you are both feeling calmer. In the meantime a cuddle or a game may distract your baby or a walk outside may relax you both. This is the time when your partner (or a friend or relative) may be able to step in and give you both a break.

Normal nursing strike is defined as a baby who is contented and healthy and getting sufficient breastmilk for her/his needs. However, if you are still worried, you may find it comforting to have your baby checked thoroughly by your doctor.

Mother-to-mother breastfeeding support

Search the internet for a breastfeeding center near you. These centers may offer support groups. Some resources include:

• Nursing Mothers Advisory Council (https://nursingmoms.net)
• Breastfeeding USA (https://breastfeedingusa.org)
• La Leche League International (https://www.llli.org) to find a local La Leche League International support group.
• International Board Certified Lactation Consultants (https://ilca.org). International Board Certified Lactation Consultants are certified breastfeeding professionals with the highest level of knowledge and skill in breastfeeding support. International Board Certified Lactation Consultants help with a wide range of breastfeeding concerns. To earn the International Board Certified Lactation Consultant certification, candidates must have a medical or health-related education and breastfeeding-specific education and experience. They must also pass a challenging exam.

Baby is refusing to nurse causes

Now and then a baby will refuse the breast. Breast refusal is often just a passing phase, which can be caused by one or more of the following:

• Your baby has a cold.
• Your baby is uncomfortable or in pain.
• Your baby is having trouble attaching.
• Your baby is overstimulated, overtired or distracted, which is normal in older babies.
• Your milk tastes different, possibly because you are taking medication, are experiencing hormonal changes (you might be about to have a period again), or have eaten something unusual.
• Your milk flow is faster or slower to let down than usual.
• Your baby might have a strong preference for one breast.

Most of these causes of breast refusal will either go away on their own or can be sorted out with a few simple changes to your routine. None of them means you have to give up breastfeeding.

How many feeds does my baby need in 24 hours?

The number of feeds your baby needs changes as she/he grows older. A very young baby commonly needs eight to twelve breastfeeds in 24 hours, but there is a wide variation in the number of feeds an older baby needs. There is a big difference between a four-month-old who refuses one or two feeds in eight, and a baby of the same age who refuses four out of five feeds.

Regardless of the number of feeds she has, signs that your baby is getting enough breastmilk include if she has, over 24 hours, regular soft bowel motions, at least six to eight pale, very wet cloth nappies, or at least five heavy wet disposable nappies with pale, odorless urine. Check with your medical adviser if your baby’s urine is dark and has a strong smell. She is being adequately nourished if she is reasonably contented, looks alert, has bright eyes and good skin color and muscle tone and has some weight gains.

How do I know if my baby is getting enough breastmilk?

If your baby shows the following signs then it is likely that you do have enough milk:

• At least 6 very wet cloth nappies or at least 5 very wet disposable nappies in 24 hours. The urine should be odorless and clear/very pale in color. Strong, dark urine suggest that the baby needs more breastmilk and you should seek medical advice.
• A young baby will usually have 3 or more soft or runny bowel movements each day for several weeks. An older baby is likely to have fewer bowel movements than this. Formed bowel motions suggest that the baby needs more breastmilk and you should seek medical advice.
• Some weight gain and growth in length and head circumference.
• Good skin color and muscle tone. Does she look like she fits her skin? If you gently ‘pinch’ her skin, it should spring back into place.
• Your baby is alert and reasonably contented and does not want to feed constantly. It is however normal for babies to have times when they feed more frequently. It is also normal for babies to wake for night feeds. Some babies sleep through the night at an early age while others wake during the night for some time.

A newborn’s nappies

Wide variation exists in what is seen in a newborn’s nappies. The following gives a general guide as to what might be seen.

The first bowel motions a baby has are black and sticky. This is from the meconium present in the baby’s digestive tract before birth. By day 2, the bowel motions should be softer but still dark in colour. Over the next few days, the bowel motions change to a greenish-brown and then to a mustard-yellow. As the colour changes they become less sticky and larger in volume.

A baby should have at least 1 wet nappy on day one, at least 2 on day two, at least 3 on day three, at least 4 on day four and at least 5 on day five. From day 5 onwards, the information above is relevant.

Over the first few days, salts of uric acid in your baby’s wee may leave a rusty, orange-red stain on the nappy. This is normal during this time. If you see this after day 4, consult your doctor.

My baby is suddenly refusing to nurse. Does that mean it’s time to wean?

A baby who is truly ready to wean will almost always do so gradually, over a period of weeks or months. If your baby or toddler has been breastfeeding well and suddenly refuses to nurse, it is probably what is called a “nursing strike,” rather than a signal that it’s time to wean. Nursing strikes can be frightening and upsetting to both you and your baby, but they are almost always temporary. Most nursing strikes are over, with the baby back to breastfeeding, within two to four days.

First thing to remember is to feed the baby. The other important thing is to protect your supply.

Nursing strikes happen for many reasons. They are almost always a temporary reaction to an external factor, although sometimes their cause is never determined. Here are some of the most common triggers of nursing strikes:

• You changed your deodorant, soap, perfume, lotion, etc. and you smell “different” to your baby.
• You have been under stress (such as having extra company, returning to work, traveling, moving, dealing with a family crisis).
• Your baby or toddler has an illness or injury that makes nursing uncomfortable (an ear infection, a stuffy nose, thrush, a cut in the mouth).
• Your baby has sore gums from teething.
• You recently changed your nursing patterns (started a new job, left the baby with a sitter more than usual, put off nursing because of being busy, etc.).
• You reacted strongly when your baby bit you, and the baby was frightened.
• You are newly pregnant and your milk supply may be reduced.
• You are ovulating and your milk supply may be temporarily reduced.
• You have been pumping less time or with less frequency when away from baby.
• You have been sick and/or taking a medication (including some methods of birth control), which can have a negative impact on your supply.

One additional consideration is a strong or overactive letdown, where your milk comes in so fast and sprays hard that baby can’t control it well and closes his mouth, refusing the breast.

Only you know for certain which, if any, of the above factors apply in your current situation. No matter what the cause, a nursing strike is upsetting for everyone. The baby may be difficult to calm and unhappy. You might feel frustrated and upset. Remember your baby isn’t rejecting you. Breastfeeding will almost always get back to normal with a little time.

Getting over the nursing strike and getting your baby back to the breast takes patience and persistence. Get medical attention if an illness or injury seems to have caused the strike. See if you can get some extra help with your household chores and any older children so that you can spent lots of time with the baby.

Try to relax and concentrate on making breastfeeding a pleasant experience. Stop and comfort your baby if he or she gets upset when you try to nurse. Extra cuddling, stroking, and skin-to-skin contact with the baby can help you re-establish closeness.

Additionally, these time-tested suggestions have helped many nursing parents overcome a nursing strike. They are best to try before a baby’s normal feeding times, to assure that baby is not hungry and likely more resistant at the breast.

• Try not to stress about it. (So easy to say, not to do.) The baby will pick up on stress. Play calming music, lower lights in the house, go skin to skin as much as possible.
• Nurse the baby as he is asleep, just awakening, or is very drowsy. As we drift to sleep or awaken, we are in a more primitive state of mind and since breastfeeding is a survival behavior for babies, sometimes they revert to feeding well at this time.
• Vary nursing positions.
• Nurse when in motion. In this case, a sling or cloth carrier can be useful.
• Give the baby extra attention and skin to skin contact.
• Hold the baby in a sling or baby carrier between attempts to nurse to increase bonding.
• Lay in bed to play with baby while you are topless, with no pressure to nurse. Just the open invitation if baby searches for the breast.
• Nurse in a quiet, darkened room free of distractions.
• Stimulate your let-down and get your milk flowing before offering the breast so the baby gets an immediate reward.
• Take a warm bath together with lots of skin to skin snuggling and no pressure to nurse.
• Sleep together, giving baby easy access to the breast while sleeping.
• Spend time around other nursing babies and toddlers. Sometimes peer pressure can be a good thing. Playgroups or busy store nursing rooms can also be helpful.

While you are trying to persuade your baby back to the breast, you’ll want to make sure baby gets enough milk to sustain him and you keep your milk supply flowing.

You may consider feeding by cup, spoon, eyedropper, or syringe while you work on getting him back to the breast. You might feed baby by bottle, making sure to practice paced bottle feeding. Tilting a bottle or using fast-flow nipples can sometimes confuse baby and bring on a nursing strike. You may find that his need to suck will encourage him to nurse instead of “just eating” by the other methods. Try to keep in mind, this could all be over in a day or two.

While baby is refusing breast, you need to extract your milk as often as baby has been nursing. Some moms find hand expression to be effective, while others rely on pumping. Not only does this practice protect your supply, it also saves you from potential clogged ducts or mastitis.

Take one hour at a time. Be gentle with yourself.

Finally, if this strike goes on and days turn into weeks, this may signal the end of your nursing journey. Please recognize what a gift you have given your child. It can be an emotional time, especially when your “plan” was to nurse longer. Not to mention hormonal changes as your milk supply diminishes. Take care of yourself and manage the weaning carefully to avoid clogged ducts or mastitis.

Baby refusing to breastfeed causes

There are many, many reasons for babies to refuse the breast, whatever their age. Below are some of the main reasons that mothers have found for their babies’ refusal – but sometimes no reason can be found. Just as suddenly as the baby started refusing, the whole episode is over and he is happily breastfeeding again as if nothing had happened.

Baby-centered reasons

• Attachment problems
• Baby confused by bottle feeds
• Overtiredness/overstimulation
• Baby refusing one breast
• Recent immunization
• Illness, e.g. a cold or earache, sore throat
• Feeding pattern is changing
• Distractions
• Introduction of other foods
• Teething
• Biting
• Overuse of a dummy (or pacifier)
• The weather
• Discomfort associated with sucking
• Weaning
• Respiratory, infectious
• Gastro-esophageal reflux
• Nasal obstruction
• Cerebral injuries and pain ⁴⁾.

Milk supply reasons

• Fast flow
• Low supply
• Slow let-down

Mother-centered reasons

• Overtired or overstressed
• Sick or taking prescribed or over the counter medications
• Unusual food in your diet
• You smell different for some reason- e.g., different perfume, deodorant, chlorine/ salt from swimming; visit to hairdresser, smoke
• Hormonal changes
• Menstruation and pre-menstrual tension
• Ovulation
• Pregnancy
• Oral contraceptives
• Mastitis
• Drugs

Baby refusing to breastfeed treatment

Here are some things you can do to get your baby on your breast:

• Be as patient and calm as you can, even though you may be feeling frustrated or impatient. Forcing your baby to feed is likely to make the situation worse. If he has just been refusing the breast and is upset, distract him by doing something completely different – a walk outdoors, looking at toys, singing a nursery rhyme. When he has settled down he may be eased on to the breast, or he may be happier just being cuddled.
• Walk around with your baby in an upright position against your body with her head level with your nipple. Walk and feed simultaneously. You could try putting your baby in a baby sling but remember to have your bra undone so that her face is touching the skin of your breast and she can find your nipple. The sling will need to be worn lower than normal for this purpose.
• Try a completely different feeding position: your baby tucked under your arm (twin style); or lying down on a bed next to your baby with no body contact – this is especially good if it is very hot, or your baby is sensing your tension; or lying down with your baby cuddled in close next to you.
• Feeding your baby while you are both in the bath may help. You may want to have someone available to help you lift your baby in and out of the bath.
• Try breastfeeding baby after his bath when he is warm and relaxed (if he likes baths).
• You could try playing with your baby on the floor while you are bare from the waist up. After some time gradually offer your breast.
• Anticipate your baby’s waking time and lift her to feed while still sleepy – you may slip in extra night feeds this way.
• Try to soothe baby with a pacifier (dummy). Walking, singing and rocking while baby sucks the dummy may gradually soothe him so you can gently put your baby to the breast while removing the dummy. It may be necessary to start a very hungry baby sucking on a bottle with a small amount of expressed breastmilk, e.g. 30 ml, then gently replace it with the breast.
• Some mothers, whose babies have become accustomed to a bottle, have found that putting ice wrapped in a flannel on the nipple or tickling the nipple and areola makes it easier for the baby to grasp. Alternatively, you may use a nipple shield to begin a feed, slipping if off quickly and putting your baby back to the breast once the milk is flowing and she is sucking happily.
• Feed in a rocking chair.
• Express some milk into your baby’s open mouth to encourage him.
• Spend five minutes or so before the feed massaging your baby’s naked body to relax her, if she is receptive to this.
• Try singing to your baby – he probably won’t mind if it is the same few lines over and over.
• Try playing some favorite relaxing background music.
• Once you get your baby on to the breast, it may help to provide an instant milk reward. This can be done with a breastfeeding supplementer. This allows baby to receive additional milk at the breast whilst stimulating your milk supply by his sucking. If your milk supply continues to be low or your let-down slow or your baby is a ‘poor’ sucker, you may like to discuss with a Breastfeeding Association counselor the possibility of using a supplementer.

Figure 1. Breastfeeding supplementer (Supplemental Nursing System)

Breastfeeding supplementer

Breastfeeding supplementer also known as Supplemental Nursing System (SNS), is a device that allows a baby to receive extra milk at the breast rather than by bottle and teat. There are two types of breastfeeding supplementer, one the is Medela Supplemental Nursing System that uses a hard sided container for the supplement and the ‘Lactaid’ uses a soft bag to hold the supplement. Each has its own advantages and disadvantages. It is also possible to make a homemade version. Breastfeeding supplementer consists of a container that is worn on a cord around the mother’s neck. Fine tubing carries expressed breastmilk or formula from the container to the nipple. When the baby sucks at the breast, milk is drawn through the tubing into his mouth, along with any milk from the breast.

When extra milk is needed for medical reasons it is better to give it through a breastfeeding supplementer than by bottle:

• Milk given in this way rewards the baby’s efforts at sucking and he is more likely to be happy to feed from the breast and stay there for a longer time.
• Since the amount of milk a mother makes depends on how much her baby sucks and takes milk from her breasts, this extra sucking will increase her milk supply.
• Use of the mother’s own expressed breastmilk in the supplementer helps a weak or easily tired baby to get more milk with the same amount of sucking.
• The sucking action required during breastfeeding differs from that used with a bottle. Some babies find it hard to do both, or reject the breast in favor of the different bottle.
• The mother is able to provide milk at the breast and this helps with both the hormonal and physical aspects of breastfeeding.

Guide to storing fresh breastmilk for use with healthy, full-term babies

By following recommended storage and preparation techniques, nursing mothers and caretakers of breastfed infants and children can maintain the safety and quality of expressed breast milk for the health of the baby.

These are general guidelines for storing human milk at different temperatures. Various factors (milk volume, room temperature when milk is expressed, temperature fluctuations in the refrigerator and freezer, and cleanliness of the environment) can affect how long human milk can be stored safely.

Guide to storing fresh breastmilk for use with healthy, full-term babies
Place	Temperature	How long	Things to know
Countertop, table	Room temperature (up to 77 °F [25 °C])	Up to 4 hours	Containers should be covered and kept as cool as possible. Covering the container with a clean cool towel may keep milk cooler. Throw out any leftover milk within 2 hours after the baby is finished feeding.
Refrigerator	40 °F (4 °C)	Up to 4 days	Store milk in the back of the refrigerator. When at work, it’s OK to put breastmilk in a shared refrigerator. Be sure to label the container clearly.
Freezer	0°F (minus 18 °C) or colder	Within 6 months is best. Up to 12 months is acceptable.	Store milk toward the back of the freezer where the temperature is most constant. Milk stored at 0°F or colder is safe for longer durations, but the quality of the milk might not be as high.

[Source ⁵⁾ ]

When a breastfeeding supplementer might be useful

A supplementer can be a useful tool in starting and being able to maintain breastfeeding. The baby may be premature or sick and unable to suck well; some mothers have problems due to the shape of their nipples or previous breast surgery. In rare cases, mothers may not have enough milk-making tissue in their breasts to be able to make a full supply of milk for their baby. Babies and their mothers may have had a difficult birth, causing a setback to the start of breastfeeding. Other mothers who may find a breastfeeding supplementer useful include those with a very low supply that they are trying to increase, mothers who have weaned and are trying to relactate, as well as mothers who are building a milk supply for an adopted baby. They might use the supplementer for only a short while or long term. A breastfeeding supplementer allows a mother to fully breastfeed while giving her baby extra milk, which could be her own expressed breastmilk, donor human milk or formula. Breastfeeding supplementers may be fiddly to use at the start but they become easier to use with practice.

When a breastfeeding supplementer is not likely to be useful

Most mothers who have problems getting breastfeeding started will solve them without using a breastfeeding supplementer. Often all some mothers need is information and support. Talking the problem over with someone who understands and supports your wish to breastfeed and who knows a lot about breastfeeding can help you work through any problems. Often they will be able to suggest new ideas to try. Sometimes, you can solve your own problems by learning more about how breastfeeding works. It can help give you confidence if you have the support of your medical adviser, child health nurse, lactation consultant or Breastfeeding Association counselor.

It is important that the baby is able to suck well at the breast, even if he tires easily, in order for the breastfeeding supplementer to work. A baby with a poor or abnormal suck may not be able to get the milk through the tubing any better than from the breast itself.

A Breastfeeding Association counselor will be happy to talk things over with you. She will help you look at the problem and will suggest options so that you decide what you want to do about it. Every mother and baby pair is unique. Other people can give you the information you need, but only you can decide what will work in your own family situation.

Here are some ideas that you may like to think about and perhaps discuss with a counselor, a lactation consultant or your medical adviser:

• Sometimes mothers feel that their milk supply is low when it is really quite normal. An unhappy baby is not always a hungry baby — nor are low weight gains always due to low milk supply.
• If a baby breastfeeds often, looks healthy, alert and active, has plenty of wet nappies (at least 5 disposable or 6–8 cloth nappies in 24 hours), regular soft bowel motions and gains some weight, she is usually getting enough breastmilk.
• If a mother’s milk supply is low, frequent feeding over several days (perhaps 10–12 times in 24 hours) will usually increase it. Unless your medical adviser feels that there is an urgent need for your baby to have extra milk, it is worth trying extra breastfeeds for a few days before adding in any other milk. Giving extra milk will reduce your baby’s hunger and the amount she takes from the breast. This is more likely to cause a decrease in your breastmilk supply than an increase.
• Is your baby facing you and tucked in close while feeding? Is she attached well, not hurting your nipples and can you hear her swallowing milk well? A good feeding position and being able to suck well helps your baby get your milk easily.
• If extra feeds are needed, but only at some feeds or in small amounts, it may be easier to give them from a cup or syringe.

How do I get a breastfeeding supplementer?

A breastfeeding supplementer may be bought online from some breastfeeding retailers. Some hospitals and pharmacies also sell them. Based on the experiences of many mothers, it is best if you have your own support while you are using a breastfeeding supplementer. This can be from an Breastfeeding Association counselor or a health professional who knows a lot about its use. Breastfeeding Association counselors are not medically trained. They are mothers who have breastfed at least one baby and who have completed a training course that includes information about breastfeeding and counseling breastfeeding mothers. This training is conducted according to Registered Training Organization guidelines. Counselors offer friendship and counseling on a mother-to-mother basis to women who wish to breastfeed and who ask for their help. If there are medical problems, mothers are referred to their doctor or child health nurse.

What to do if your baby falls asleep while nursing

Most women can start breastfeeding within 1 hour after giving birth. Most babies have a strong need to suck when they are first born, so if you are both well you can start straight away. Nurses and lactation consultants can help you get started. However, if your baby falls asleep while breastfeeding, you may be worried about if he’s getting enough milk.

Your breasts make milk in response to your baby’s sucking. The more milk your baby takes, the more milk you make.

You are more likely to establish a good supply of milk if you:

• Breastfeed frequently, whenever your baby fusses or seems hungry.
• Let baby finish the first breast. You will know this because the baby will stop sucking and swallowing and will let go of the breast. Then offer the second breast.
• Breastfeed your baby at night. This also helps prevent your breasts becoming too full and uncomfortable.
• Many young babies feed between 8-12 times in 24 hours.
• Avoid giving complementary bottles (‘comps’) unless medically necessary, as these will reduce your baby’s needs to suck at the breast and so reduce your supply.

You know your baby is getting enough breast milk if she:

• Is breastfeeding well and frequently
• Has plenty of pale, wet nappies (at least 5 disposable or 6 cloth nappies in 24 hours)
• Has 3 or more soft bowel motions a day (babies older than around 6 weeks may have less than this)
• Is gaining weight and has some periods in which she seems reasonably alert, active and happy.

Figure 1. Female breast

How breastfeeding works

During pregnancy your breasts change and develop to be ready to make milk for your baby. Milk is there even when your baby is born prematurely. The amount usually increases greatly a few days after birth (the milk comes in). The first milk in the breasts after the birth and, often before, is called colostrum. This thick, yellowish milk is more concentrated than mature milk. It is rich in protein and antibodies that help to protect your baby from illness. Your baby only needs a small amount of food in the first few days after birth. The amount of colostrum in your breasts is enough to meet his needs. Mature breastmilk, which is thin and bluish-white in appearance, gradually replaces colostrum over this time.

When he sucks at the breast, your baby stimulates tiny nerves in the nipple. This causes the release of hormones into your bloodstream. One of the hormones (prolactin) activates the milk-making tissues. The other hormone (oxytocin) causes the breast to push out or let down the milk (let-down reflex).

How do I know if my baby is getting enough breastmilk?

If your baby shows the following signs then it is likely that you do have enough breast milk.

• At least 6 very wet cloth nappies or at least 5 very wet disposable nappies in 24 hours. The urine should be odorless and clear/very pale in color. Strong, dark urine suggest that the baby needs more breastmilk and you should seek medical advice.
• A very young baby will usually have 3 or more soft or runny bowel movements each day for several weeks. An older baby is likely to have fewer bowel movements than this. Formed bowel motions suggest that the baby needs more breastmilk and you should seek medical advice.
• Good skin color and muscle tone. Does she look like she fits her skin? If you gently ‘pinch’ her skin, it should spring back into place.
• Your baby is alert and reasonably contented and does not want to feed constantly. It is however normal for babies to have times when they feed more frequently. It is also normal for babies to wake for night feeds. Some babies sleep through the night at an early age while others wake during the night for some time.
• Some weight gain and growth in length and head circumference.

A newborn’s nappies

Wide variation exists in what is seen in a newborn’s nappies. The following gives a general guide as to what might be seen.

The first bowel motions a baby has are black and sticky. This is from the meconium present in the baby’s digestive tract before birth. By day 2, the bowel motions should be softer but still dark in color. Over the next few days, the bowel motions change to a greenish-brown and then to a mustard-yellow. As the color changes they become less sticky and larger in volume.

A baby should have at least 1 wet nappy on day one, at least 2 on day two, at least 3 on day three, at least 4 on day four and at least 5 on day five. From day 5 onwards, the information above is relevant.

Over the first few days, salts of uric acid in your baby’s urine may leave a rusty, orange-red stain on the nappy. This is normal during this time. If you see this after day 4, consult a doctor.

How to make more breast milk

Demand = Supply

More frequent feeding means more milk:

• Feed your baby more often than usual.
• Check that baby is well positioned at the breast.
• Allow the baby to decide the length of a feed.

To build your breast milk supply, the following ideas may help:

• Provided that your baby is correctly attached, you will find that the quickest and most successful way to boost your supply is to breastfeed more often. Offer a breastfeed every 2–3 hours during the day, for a few days, or increase the number of feeds by offering the breast in between your baby’s usual breastfeeds.
• Here is an easy way to do this. If your baby does not settle after a feed, try offering another quick little ‘top up’ breastfeed. Those few minutes of extra feeding and cuddling may be all that is needed to soothe and satisfy him.
• Let your baby finish the first breast before switching to the second breast.
• Or, you may find it helps to change sides several times during a feed, whenever your baby’s sucking seems to become less strong. Some people find that this encourages the baby to suck more strongly and stimulates a good let-down reflex.
• You can also try massaging your breast. Stroke it towards the nipple on all sides as your baby feeds. Take care not to disturb the nipple in your baby’s mouth.
• If your baby is awake you can offer little ‘snack’ feeds without waiting for baby to cry for them.
• You can try offering the breast to soothe your baby for a few days, instead of other comforting strategies (eg a dummy).
• You may find that your baby has fussy periods when he wants to breastfeed more frequently.
• Although they vary greatly, many new babies need 8–12 or more feeds in 24 hours. Babies generally feed less often as they get older. Babies also generally feed more efficiently as they get older.
• To increase your supply, you will need to fit in more feeds than is usual for YOUR BABY. Feeds do not need to be very long, just more often. In each 24 hours some feeds may be only 5–10 minutes long, others may be 30 minutes or longer, particularly when baby feeds to sleep slowly and contentedly.
• Help your milk to let-down quickly. Relax and enjoy feed times. Try to remove distractions (turn your phone off, put a ‘do not disturb’ sign on your door), then settle with baby into a comfortable chair. Breathe deeply, relaxing each part of your body separately as you may have learned to do at antenatal classes. Have a drink on hand, a book or a magazine, listen to the radio or watch TV. For more ideas, see the let-down reflex article on this website.
• Babies vary greatly in the amount of sucking they seem to need. There is no need to worry if your baby is contented with a fairly short feed. Some babies however love to continue sucking long after the flow of milk has dwindled to a trickle. This is fine too. Your baby will let you know how long his feeds need to be.
• A baby who is well attached and positioned is more able to drain the breast well.

Do I need to wake my baby for feeds?

Newborns have tiny tummies and so need to feed frequently. For example, the Academy of Breastfeeding Medicine supplementation protocol ¹⁾ reports that the average intakes of colostrum per feed by healthy, term breastfed is 2-10 mL on day 1, 5-15 mL on day 2, 15-30 mL on day 3 and 30-60 mL on day 4. Feeding frequently in the early days and weeks helps make sure you have a good milk supply.

Because breastmilk is easily digested, it is common for breastfed babies to feed 8–12 times in a 24-hour period. This usually means that your baby will breastfeed on average every 2–3 hours around the clock (day and night), with possibly one longer stretch (eg up to about 5 hours) between feeds somewhere in a 24-hour period. The length of time between feeds can vary greatly from baby to baby. The time between feeds is from the beginning of the last feed, not the end. Newborns also tend to have periods each day where they feed very frequently for a few hours (cluster feeds). Often these cluster feeding periods are followed by a longer stretch of sleep.

In most cases, healthy, thriving newborns will wake of their own accord for feeds and so get all the milk they need. Feeding your baby when he is showing early feeding cues can help him to feed better.

However, there are some reasons why a newborn may be extra sleepy. It may be necessary to wake the baby for feeds to ensure he gets the milk he needs. Some of the reasons are medical (eg jaundice, infection, heart problem), or perhaps medications for pain relief used during the birth are still affecting the baby. It is important to be guided by your medical adviser in these situations.

Feeding cues can be hard to pick in a sleepy baby so it is important to keep your baby close to you so you can learn.

There are many ways to tell if your baby is getting enough milk. See the article ‘Low supply’ for further information.

If you need to wake your baby for feeds, here are some tips:

• Change your baby’s nappy.
• Breastfeed in a different position eg some mothers find the underarm helps keep the baby awake.
• Undress your baby down to his nappy and place him on your chest with as much skin-to-skin contact between you and him as possible.
• Give your baby a warm bath.
• Talk to him and make eye contact.
• Place your baby on your lap with his legs near your tummy and head on your knees. Gently support your baby, raise him into a sitting position, like doing a ‘sit-up’. Repeat a few times.
• Gently massage his back in circular motions.
• Stroke his feet and hands.

Babies can breastfeed even when not fully awake. Once your baby is feeding, some of the ideas above can be used to keep him awake and feeding. In addition, it can help to switch breasts each time your baby slows in his sucking and starts to doze off. Take him off, burp him and wake him again to start on the other side. He can have each side more than once if he stays awake.

It can also be helpful to use breast compressions — ie squeeze your breast while he is sucking at the breast but is not swallowing milk. Breast compressions increase the flow of breastmilk which helps encourage the baby to suck and swallow, and thus get more milk.

Even if you have a sleepy newborn who needs waking for feeds in the early weeks, this will change. Soon enough you will be able to relax and let your baby set his own individual feeding pattern.

What about night feeds?

New babies wake at night from hunger and need to be breastfed. This also helps your milk supply. Some babies sleep through the night quite early while others take much longer to do so. Breastfeeding is a quick and easy way to soothe and settle your baby.

Baby hunger cues

Babies instinctively let you know when she/he needs to be fed. Your baby’s body language can tell you how he’s feeling and what he needs from you. All babies give cues to how they’re feeling and what they need from you. But each baby develops her own mix of signs to tell you what she wants. Eventually you’ll get to know your baby’s individual cues and what they tell you about your baby’s feelings.

And as you and your baby get to know each other, you’ll figure out the best way to respond to your baby’s individual cues too. For example, your grizzling baby might look relaxed when you smile at him, or he might seem to like it better when you sing and talk to him. This helps you know how to respond the next time he grizzles.

Your baby’s body language gives you important cues about whether she’s:

• tired
• hungry
• wide awake and ready to play
• needing a break.

Newborns need to feed every 2-3 hours. Here are signs your baby might be hungry:

1. Bringing his hands to his face.
2. Rooting (looking for the nipple with his mouth)
3. Making sucking motions and noises.
4. Turn towards your breast
5. Sucking on his fingers or putting his fist in his mouth.
6. Flexing his hands, arms and/or legs.
7. Breathing fast.

You can start to look for these cues every 1-2 hours in newborns or every 3-4 hours for an older baby.

When you notice your baby’s body language and respond to it, he feels safe and secure. This helps you to build a strong relationship with your baby. And a strong relationship with you and other main caregivers is vital to your baby’s development.

Watch the video to see what hunger cues look like in real babies.

Figure 1. Baby feeding cues

Preparing for labor

Labor is also called childbirth, labor is the process of your baby leaving the uterus (womb). You’re in labor when you have regular contractions that cause your cervix to change. Contractions are when the muscles of your uterus get tight and then relax. Contractions help push your baby out of your uterus. Your cervix is the opening to the uterus that sits at the top of the vagina. When labor starts, your cervix dilates (opens up).

Stages of labor include the whole process of labor, from your first contractions (stage 1) to pushing (stage 2) to delivery of the placenta (stage 3) after your baby is born. Learning about the stages of labor can help you know what to expect during labor and birth.

Labor is divided into three stages:

1. Labor (stage 1)
2. Pushing and birth (stage 2)
3. Delivery of the placenta (stage 3) 

In most pregnancies, labor starts naturally between 37 and 42 weeks. When labor starts, a number of changes occur in your body:

• your cervix (opening of your uterus / womb) will ‘ripen’ and become soft and open
• you will experience strong, regular contractions that dilate (open) your cervix leading to the birth of your baby
• the bag of membranes (‘waters’) around your baby may break

When labor starts on its own, it is called spontaneous labor.

A labor that is started with medical treatment is called ‘induced’ labor. Induction of labor is a common procedure used to start the process of labor and childbirth. An induction of labor may be recommended when you or your baby will benefit from birth being brought on sooner rather than waiting for labor to start naturally.

The most common reasons for induction are:

• you have a specific health concern, such as high blood pressure
• your baby is overdue (more than 41 weeks)
• there are concerns with your baby (less movements, low fluid, not growing well) your waters have already broken but your contractions have not started naturally.

Every woman’s labor is different. And your labor may be different each time you have a baby. But there are patterns to labor that are true for most women. Learning about the stages of labor and what happens during each one can help you know what to expect once labor begins.

Lots of pregnant women take childbirth classes to learn what happens during labor and birth. These classes can help you feel ready when labor starts so you’re not scared or surprised. You’ll learn how to breathe and relax to help with labor pain. And you’ll learn about different ways your health care provider can reduce your pain during labor.

You can probably take a childbirth class at your hospital. Some classes are free or low cost. Ask your provider if you need help finding a class. Think about taking a class in your sixth or seventh month of pregnancy. And take your partner or a friend with you who will be there to help during labor.

What happens in the first stage of labor?

The first stage of labor is the longest stage. For first-time moms, it can last from 12 to 19 hours . It may be shorter (about 14 hours) for moms who’ve already had children. It’s when contractions become strong and regular enough to cause your cervix to dilate (open) and thin out (efface). This lets your baby move lower into your pelvis and into your birth canal (vagina). This stage of labor ends when you are 10 centimeters dilated. The first stage is divided into three parts: early labor, active labor and transition to stage 2 of labor.

Early labor

For most first-time moms, early labor lasts about 6 to 12 hours. You can spend this time at home or wherever you’re most comfortable. During early labor:

You may feel mild contractions that come every 5 to 15 minutes and last 60 to 90 seconds.
You may have a bloody show. This is a pink, red or bloody vaginal discharge. If you have heavy bleeding or bleeding like your period, call your provider right away.

What you can do in early labor:

This is a great time for you to rely on your doula or labor support person. A doula is a trained professional who provides information and physical and emotional care and support to women before, during and after childbirth, including continuous support through labor and birth. Try the methods you learned about in childbirth education classes about how to relax and cope with pain.

During early labor:

• Rest and relax as much as you can.
• Take a shower or bath.
• Go for a walk.
• Change positions often.
• Make sure you’re ready to go to the hospital.
• Take slow, relaxing breaths during contractions.

Active labor

This is when you head to the hospital! Active labor usually lasts about 4 to 8 hours. It starts when your contractions are regular and your cervix has dilated to 6 centimeters. In active labor:

• Your contractions get stronger, longer and more painful. Each lasts about 45 seconds and they can be as close as 3 minutes apart.
• You may feel pressure in your lower back, and your legs may cramp.
• You may feel the urge to push.
• Your cervix will dilate up to 10 centimeters.
• If your water hasn’t broken, it may break now.
• You may feel sick to your stomach.

What you can do in active labor:

• Make sure the hospital staff has a copy of your birth plan.
• Try to stay relaxed and not think too hard about the next contraction.
• Move around or change positions. Walk the hallways in the hospital.
• Drink water or other liquids. But don’t eat solid foods.
• If you’re going to take medicine to help relieve labor pain, you can start taking it now. Your choice about pain relief is part of your birth plan.
• Go to the bathroom often to empty your bladder. An empty bladder gives more room for your baby’s head to move down.
• If you feel like you want to push, tell your provider. You don’t want to start pushing until your provider checks your cervix to see how dilated it is.

Transition to the second stage of labor

This can be the toughest and most painful part of labor. It can last 15 minutes to an hour. During the transition:

• Contractions come closer together and can last 60 to 90 seconds. You may feel like you want to bear down.
• You may feel a lot of pressure in your lower back and rectum. If you feel like you want to push, tell your provider.

What happens in the second stage of labor?

In the second stage of labor, your cervix is fully dilated and ready for childbirth. This stage is the most work for you because your provider wants you to start pushing your baby out. This stage can be as short as 20 minutes or as long as a few hours. It may be longer for first-time moms or if you’ve had an epidural. And epidural is pain medicine you get through a tube in your lower back that helps numb your lower body during labor. It’s the most common kind of pain relief used during labor. The second stage ends when your baby is born.

During the second stage of labor:

• Your contractions may slow down to come every 2 to 5 minutes apart. They last about 60 to 90 seconds.
• You may get an episiotomy. This is a small cut made at the opening of the vagina to help let the baby out. Most women don’t need an episiotomy.
• Your baby’s head begins to show. This is called crowning.
• Your healthcare provider guides your baby out of the birth canal. She may use special tools, like forceps or suction, to help your baby out.
• Your baby is born, and the umbilical cord is cut. Instructions about who’s cutting the umbilical cord are in your birth plan. What you can do:
• Find a position that is comfortable for you. You can squat, sit, kneel or lie back.
• Push during contractions and rest between them. Push when you feel the urge or when your provider tells you.
• If you’re uncomfortable or pushing has stopped, try a new position.

What happens in the third stage of labor?

In the third stage of labor, the placenta is delivered. The placenta grows in your uterus and supplies your baby with food and oxygen through the umbilical cord. This stage is the shortest and usually doesn’t take more than 20 minutes.

During the third stage of labor:

• You have contractions that are closer together and not as painful as earlier. These contractions help the placenta separate from the uterus and move into the birth canal. They begin 5 to 30 minutes after birth.
• You continue to have contractions even after the placenta is delivered. You may get medicine to help with contractions and to prevent heavy bleeding.
• Your healthcare provider squeezes and presses on your belly to make sure the uterus feels right.
• If you had an episiotomy, your provider repairs it now.
• If you’re storing your umbilical cord blood, your provider collects it now. Umbilical cord blood is blood left in the umbilical cord and placenta after your baby is born and the cord is cut. Some moms and families want to store or donate umbilical cord blood so it can be used later to treat certain diseases, like cancer. Your instructions about umbilical cord blood can be part of your birth plan.
• You may have chills or feel shaky. Tell your provider if these are making you uncomfortable.

What you can do:

• Enjoy the first few moments with your baby.
• Start breastfeeding. Most women can start breastfeeding within 1 hour of their baby’s birth.
• Give yourself a big pat on the back for all your hard work. You’ve made it through childbirth.

How do I know when I’m in labor?

• You have strong and regular contractions. A contraction is when the muscles of your uterus tighten up like a fist and then relax. Contractions help push your baby out.
• Your contractions come about 5 to 10 minutes apart.
• Your contractions are so strong you can’t walk or talk during them.
• Your water breaks. Your baby has been growing in amniotic fluid (bag of waters) in your uterus. When the bag of waters breaks, you may feel a big rush of water. Or you may feel just a trickle.
• You have a bloody (brownish or reddish) mucus discharge. This is called bloody show.
• You feel pain in your belly and lower back. This pain doesn’t go away when you move or change positions.

What is preterm labor?

Preterm labor is labor that begins too early, before 37 weeks of pregnancy. Premature babies (born before 37 weeks of pregnancy) can have health problems at birth and later in life. If you’re not to 37 weeks of pregnancy and you have signs or symptoms of preterm labor, call your provider. Getting help quickly is the best thing you can do. Learn about risk factors for preterm labor and what you can do to help reduce your risk.

What are the different ways you can have your baby?

• Vaginal birth. This is the way most babies are born. During vaginal birth, your uterus contracts to help push the baby out through your vagina.
• Cesarean birth. Also called a C-section. A cesarean section is surgery in which your baby is born through a cut that your doctor makes in your belly and uterus. If there are problems with your pregnancy or your baby’s health, a c-section may be safer than vaginal birth. You and your provider may plan for a c-section. Or you may need to have an emergency (unplanned) c-section if something goes wrong during pregnancy, labor or birth. If your pregnancy is healthy and you don’t have any medical reasons to have a c-section, it’s best to have your baby through vaginal birth.
• Vaginal birth after cesarean also called VBAC. If you’ve already had a cesarean birth, you may be able to have a vaginal birth in your next pregnancy. Talk to your provider to see if VBAC is safe for you.

Scheduling your baby’s birth means you and your health care provider decide when to have your baby instead of waiting for labor to begin on its own. Scheduling birth a little early for non-medical reasons can cause problems for you and your baby. If your pregnancy is healthy, it’s best to stay pregnant for at least 39 weeks. This gives important organs — like your baby’s brain, lungs, liver, eyes and ears — time to develop before birth.

If your pregnancy is healthy, wait for labor to begin on its own. If you choose to induce labor, talk to your provider about waiting until you’re full term at 39 weeks. Inducing labor or having a c-section before 39 weeks should only be for medical reasons. Inducing labor means your provider gives you medicine or breaks your water to make your labor begin.

What happens after my baby is born?

Right after birth your provider places your baby skin-to-skin on your chest and covers him with a blanket. Holding your baby skin-to-skin helps your baby stay warm as he gets used to being outside the womb. It’s also a great way to get started breastfeeding. You can start breastfeeding even within an hour of your baby’s birth. Even if you don’t plan to breastfeed, hold your baby skin-to-skin so you get to know each other right away. Your baby will welcome your gentle touch, and this closeness can help you and your baby bond.

After birth, your body starts to change to help you heal. Your healthcare provider takes your temperature and checks your heart and blood pressure to make sure you’re doing well. If you had anesthesia during labor, your healthcare provider makes sure you’re recovering without any complications.

What is a birth plan?

A birth plan is a set of instructions you make about your baby’s birth. A birth plan includes things like:

• Where you want to have your baby
• Who you want to be with you during labor and birth
• What position you’d like to give birth in
• If you want medicine to help with labor pain
• If there are cultural traditions you’d like to follow during labor and birth
• If you plan to breastfeed

A birth plan tells your doctor how you feel about things like who you want with you during labor, what you want to do during labor, if you want drugs to help with labor pain, and if there are special religious or cultural practices you want to have happen once your baby is born.

It’s a good way to let your midwife or doctor know what kind of care you’d like in labor, birth and afterwards (if possible), and if you’re planning to breastfeed.

A birth plan will also help you be more involved in decisions about your care and help you prepare for the big event. But before you make a plan, you need to know more about what birth is like and what choices you have.

You can find out more by:

• going to your antenatal classes
• asking your midwife or doctor about any issues or concerns you have about the approaching labor and birth
• ask about who will be involved in your care, how many people will be involved and who has access to your medical records
• reading about birth
• talking to other mothers who have given birth at the hospital or birth center you are going to, or to women who have had a homebirth, if that is what you are planning
• talking to your partner or other relatives or friends who’ll be there to support you at the birth. What sort of labor and birth would they like you to have? How do they see their role?

Remember that things may not go according to plan. There may be complications or you may change your mind about something. Some women say they want to give birth without pain-relieving drugs, for instance, then find they need them after all — and that’s OK.

So think of the birth plan as a guide, and stay flexible.

Things to think about:

• Where do I want to have my baby?
• Who do I want with me in labor (birth companion), for example my partner, my children, another family member or a friend? Support in labor is important.
• Do I want my birth companion to stay with me all the time, or are there certain procedures or stages in labor when I would prefer them to leave the room?
• How would I like the birth environment to be: do I want music, and low lighting?
• What birthing aids am I likely to need in labor — for example a beanbag, squatting bar or birth stool?
• Do I want pain relief — if so, what kind? Are there any types of pain relief I want to avoid?
• How will the type of pain relief I choose affect the labor or the baby?
• What position do I want to try during labor and to give birth in?
• What is the usual practice for an episiotomy?
• If my labor slows down or is taking too long, do I want my caregiver to do anything to speed it up? Or would I prefer to wait?
• What if I need a caesarean? Would I prefer to have a caesarean with an epidural anaesthetic so I can stay awake? Do I want my partner to be with me — and will my partner be able to cope?
• What is the usual practice for an induction?
• What procedures may be recommended and why?
• What equipment may be used in my pregnancy care, and for the birth of my baby, and why?
• Who will cut the cord?
• Do I want to have an injection to speed up the delivery of the placenta or not?
• Do I have any cultural or religious needs around giving birth?

When you decide about any kind of treatment it’s important to make decisions based on good information. Talk to your midwife or doctor about the pros and cons of different treatments before you’re likely to need them. Think of your own safety and wellbeing and that of your baby when you make these decisions. It is a good idea to have gone through your birth plan with your caregivers before you are 36 weeks pregnant.

Figure 1. Birth plan

How to use your birth plan

Fill out a birth plan with your partner. Then share it with your provider and with the nurses at the hospital or birthing center where you plan to have your baby. Share it with your family and other support people, too. It’s best for everyone to know ahead of time how you want labor and birth to be.

Signs your body is preparing for labor

Signs that you may be close to starting labor

You may be close to starting labor if:

• Your baby drops or moves lower into your pelvis. This is called lightening. It means that your baby is getting ready to move into position for birth. It can happen a few weeks or even just a few hours before your labor begins.
• You have an increase in vaginal discharge that’s clear, pink or slightly bloody. This is called show or bloody show. It can happen a few days before labor starts or at the beginning of labor.
• At a prenatal checkup, your health care provider tells you that your cervix has begun to efface (thin) and dilate (open). Before labor, your cervix is about 3.5 to 4 centimeters long. When it’s fully dilated (open) for labor, it’s 10 centimeters. Once labor starts, contractions help open your cervix.
• You have the nesting instinct. This is when you want to get things organized in your home to get ready for your baby. You may want to do things like cook meals or get the baby’s clothes and room ready. Doing these things is fine as long as you’re careful not to overdo it. You need your energy for labor and birth.

If you have any of these signs, you may start labor soon. Learn the signs of labor so you know when to call your provider.

You’ll know you’re in true labor when:

• You have strong and regular contractions. A contraction is when the muscles of your uterus tighten up like a fist and then relax. Contractions help push your baby out. When you’re in true labor, your contractions last about 30 to 70 seconds and come about 5 to 10 minutes apart. They’re so strong that you can’t walk or talk during them. They get stronger and closer together over time.
• You feel pain in your belly and lower back. This pain doesn’t go away when you move or change positions.
• You have a bloody (brownish or reddish) mucus discharge. This is called bloody show.
• Your water breaks. Your baby has been growing in amniotic fluid (the bag of waters) in your uterus. When the bag of waters breaks, you may feel a big rush of water. Or you may feel just a trickle.

​If you think you’re in labor, call your health care provider, no matter what time of day or night. Your provider can tell you if it’s time to head for the hospital. To see for sure that you’re in labor, your health care provider measures your cervix.

What are false labor and Braxton-Hicks contractions?

Not all contractions mean you’re in labor. You may have contractions on and off before true labor starts. These contractions are called false labor or Braxton-Hicks contractions. They soften and thin the cervix to help your body get ready for labor and birth. You may feel them in the weeks right before your due date. Learning the differences between true labor contractions and false labor contractions can help you know when you’re really in labor.

It can be hard to tell the difference between true labor and false labor. When you first feel contractions, time them. Write down how much time it takes from the start of one contraction to the start of the next. Make a note of how strong the contractions feel. Keep a record of your contractions for 1 hour. Walk or move around to see if the contractions stop when you change positions.

Preparing for induction at 39 weeks

In most pregnancies, labor starts naturally between 37 and 42 weeks. If your pregnancy is healthy, wait for labor to begin on its own. Babies aren’t fully developed until at least 39 weeks.

When labor starts, a number of changes occur in your body:

• your cervix (opening of your uterus / womb) will ‘ripen’ and become soft and open
• you will experience strong, regular contractions that dilate (open) your cervix leading to the birth of your baby
• the bag of membranes (‘waters’) around your baby may break

When labor starts on its own, it is called spontaneous labor.

A labor that is started with medical treatment is called ‘induced’ labor. You may have heard it referred to simply as induction or getting induced. Induction of labor is a common procedure used to start the process of labor and childbirth. Induction of labor is a way of artificially starting the process of childbirth, for babies who are physically ready to enter the world, but aren’t interested in leaving the cozy cocoon of mum’s womb. An induction of labor may be recommended when you or your baby will benefit from birth being brought on sooner rather than waiting for labor to start naturally.

The most common reasons for induction are:

• you have a specific health concern, such as high blood pressure
• your baby is overdue (more than 41 weeks)
• there are concerns with your baby (less movements, low fluid, not growing well) your waters have already broken but your contractions have not started naturally.

But induction of labor does involve some risks for mother and baby, so will only be performed when the benefit of the procedure outweighs the risks.

More than one in four pregnant women end up getting induced because:

• Their baby is overdue but needs a little bit of coaxing out into the world;
• They have a medical condition (most commonly diabetes) or pregnancy complication (most commonly premature rupture of the membranes) which creates health risks if they continue the pregnancy; or
• There is something wrong with the baby for example it is not growing properly, and may be in danger if the pregnancy continues.

However even in these situations, your doctor may not induce labor. If, after having the risks and benefits of induction of labor explained, the pregnant woman does not agree to be induced the procedure will not be performed.

When is induction of labor dangerous?

There are also some situations when labor will not be induced because it is too dangerous (no matter how much mum is ready and willing to do just about anything to get baby out of there). These are usually situations in which a vaginal birth is not possible, and a cesarean section (C-section) is the recommended method of bringing baby into the world.

Labor will not be induced unless the baby is doing everything just right. For example, if baby is not in the right position for vaginal birth (malpresentation) or the position of the umbilical cord poses a danger during vaginal birth, induction of labor is contraindicated meaning it’s a big no-no in doctor speak.

Similarly if the placenta or umbilical vessels are covering mum’s cervix, (conditions referred to as placenta previa and vasa previa respectively) getting induced is out of the question. If baby experiences sudden changes that indicate it may be distressed, for example if its heart rate slows down or it is not getting enough oxygen, induction is too dangerous.

Mums also needs to be just right to undergo induction of labor and vaginal delivery of their baby. Doctors won’t induce women with cephalopelvic disproportion (which means there’s not enough room for baby’s head to pass through their pelvic bone). For those with viruses (like HIV and genital herpes) that may infect their baby during normal medical procedures carried out for induction of a vaginal delivery such as breaking the waters, induction of labor also poses too great a risk.

What type of induction am I likely to have?

There are different ways to induce labor. To determine the best method of induction for you, your doctor or midwife will do a vaginal examination to check how ready your cervix is.

Based on this examination, they will recommend one of the following methods of induction:

• a hormone called prostaglandin
• balloon catheter
• artificial rupture of membranes (ARM)
• a hormone called syntocinon

The process of induction will vary for everyone. It may require one or a combination of these methods.

Ripening the cervix for induction of labor

Mum’s cervix also needs to be just right, or to use the correct medical term, the cervix must be ripe. The cervix is the entrance to the womb and it’s usually closed off to prevent all but the tiniest of particles (think sperm) entering the womb. However before the baby can move from the uterus through to the vagina to be born, the cervix needs to open up, or dilate to make room for baby’s head to pass through. The ripeness of the cervix is assessed by calculating the Bishop’s score.

As the cervical canal becomes wider it shortens and softens in preparation for baby’s passage. If all’s going well and baby’s in the correct position, this means the cervix is ready for childbirth, and labor can be induced.

If the cervix is not ripe, induction of labor is not out of the question. But the cervix must be ripened, by applying a gel or pessary containing chemicals called prostaglandins which help the cervix dilate, or by transcervical foley catheter, a procedure in which a catheter is inserted into the cervix to encourage it to soften and dilate. That usually takes at least six hours with prostaglandin gel and 12-18 hours with a transcervical foley catheter.

Methods of induction​

Once the cervix is just right (ripe) and the woman’s bladder empty, induction of labor can begin. There are two techniques; artificial rupture of the membranes and administration of the hormone oxytocin, which may also be used in combination.

Artificial rupture of the membranes is a procedure in which a small cut is made to the pregnancy membranes, the amnion and chorion, causing them to rupture. When labor occurs spontaneously, these membranes rupture without intervention, in a pregnancy event often referred to as the ‘waters breaking’. Once the membranes are ruptured doctors may wait for labor to start spontaneously, induce labor with oxytocin or use augmentation of labor techniques.

Oxytocin is a hormone produced naturally by the human body which stimulates contractions of the uterus (those same contractions which help move baby out into the world during childbirth). So administering a bit of extra oxytocin is an effective way of stimulating labor contractions. If this hormone is administered, the woman will be attached to a monitor which track her uterine contractions and her baby’s heart rate.

Prostaglandins

Prostaglandin is a naturally occurring hormone that prepares your body for labor. A synthetic version has been developed to mimic your body’s natural hormone. This hormone is placed in your vagina either as a gel or pessary (like a tampon) that works to ripen your cervix. Once the prostaglandin has been inserted, your baby will be monitored and you will need to stay in hospital.

Occasionally you may need more than one dose of prostaglandin. When the prostaglandin takes effect, your cervix will be soft and open and the next steps of your induction can start.
Some women may have their membranes ruptured (‘waters broken’) but this may happen naturally. Some women may require syntocinon to stimulate contractions.

Balloon catheter

Prostaglandins are not suitable for all women, for example, if you have had a previous caesarean section or a reaction to prostaglandins in the past. Your doctor may therefore recommend a balloon catheter to ripen your cervix.

This catheter is a thin tube which is placed inside your cervix and a small balloon inflated to place pressure on your cervix. This pressure should soften and open your cervix. This catheter will stay in place for several hours until either it falls out (indicating your cervix has opened) or until you are re-examined.

Artificial rupture of membranes (‘breaking your waters’)

If your waters have not broken, artificial rupture of membranes may be recommended. This is when your doctor or midwife puts a small hole in the bag of membranes or waters around your baby. This is done with a small instrument during a vaginal examination and can only occur once your cervix is open. Once your membranes have ruptured, contractions may start naturally, if not, a syntocinon infusion will be started.

Syntocinon

Syntocinon is a synthetic hormone that mimics your body’s natural hormone called Oxytocin. It is given through an intravenous infusion (drip) in your arm and stimulates contractions of the uterus. The infusion is slowly increased until you are having strong regular contractions. The infusion will continue until after your baby is born.

Once syntocinon has started, your baby’s heart rate will be monitored throughout labor using a cardiotocography (CTG) or electronic fetal monitoring (EFM) machine. Cardiotocography (CTG) is a technical means of recording the fetal heartbeat and the uterine contractions during pregnancy.

Childbirth after induction

Sometimes there are complications, for example uterine contractions fail to start or gain sufficient momentum for labor, uterine contractions occur too quickly or the baby’s heart rate changes. In these cases the hormones used to induce labor may be withdrawn, and sometimes an emergency cesarean section needed.

However, most women go on to deliver their baby vaginally after induction of labor. It is a common procedure performed in more than one in four pregnancies. As the procedure will only be performed when the benefits for both mum and bub outweigh the risks, you can rest assured that there’s a good reason, if your doctor asks you to consider induction of labor.

What risks are involved with an induction of labor?

• The induction may not work. Occasionally, the process to ripen the cervix does not work, which means your cervix has not opened enough for the membranes to be ruptured. If this happens, your doctor will talk to you about your options. These may include, returning home until a later date, using a different method of induction, or you may require a caesarean section. Sometimes, after your membranes have ruptured, contractions may not start and labor does not establish. In this situation, your doctor will recommend a caesarean section.
• Over-stimulation of the uterus. One of the side effects of the synthetic hormones is they may cause the uterus to contract too much. This can sometimes cause stress to you and your baby. If this occurs, you may be given medicine to relax the uterus. If you have a hormone pessary, it will be removed.
• Induction can be more painful than natural labor.
• Increased intervention. There may be an increased risk of further intervention in labor such as instrumental delivery (with forceps or ventouse) or caesarean section in some cases. However, it is always important to balance the risks and benefits of induction of labor carefully and discuss with your doctor or midwife.

Skin darkening during pregnancy

Skin darkening during pregnancy also called hyperpigmentation, occurs in up to 90% of pregnant women. This darkening of the skin may occur in specific areas of the body such as the midline of the tummy as in ‘linea nigra’ or on the face as in ‘the mask of pregnancy’ also known as melasma ¹⁾. Alternatively, the darkening of the skin may affect skin spots such as scars and freckles, may affect the nipples and area around the nipple (the areola), the external genitalia, or areas of increased friction including the armpits (axillae) or the inside of the thighs (groin). Women who are dark haired and have dark complexions are more likely to develop some degree of skin darkening, and it is also more likely to be more pronounced in these women also.

You may also develop stretch marks on your body, particularly around your stomach where your skin is stretching to accommodate your growing baby.

Figure 1. Mask of pregnancy

Figure 2. Linea nigra

When does skin darkening during pregnancy occur?

Skin darkening during pregnancy (hyperpigmentation) tends to develop in the first trimester of pregnancy and it is considered as one of the earliest signs of pregnancy.

However, in first pregnancies its appearance may be delayed until several months into the pregnancy.

How long does skin darkening during pregnancy last?

The increased pigmentation can continue to progress during the pregnancy until delivery.

The darkened areas almost always lighten following delivery of the baby, however, this may take months and in some women it will not completely fade.

In subsequent pregnancies it may appear earlier and darker than previously.

What causes skin darkening during pregnancy?

The exact cause is not known but it is thought to occur due to increased levels of hormones produced in pregnancy. These include:

• Melanocyte stimulating hormone (MSH) – a hormone that stimulates melanocytes – the cells in the body that produce pigment and give rise to darker skin, freckles, birthmarks (naevi) etc.;
• Estrogen; and
• Progesterone.

Skin darkening during pregnancy remedies

The darkened areas that developed in your pregnancy will generally fade following the delivery of your baby. Preventative measures and treatment options are limited.

It is recommended that pregnant women wishing to minimize skin darkening use a broad spectrum combined UVB+UVA sunscreen with SPF 50+ on sun exposed areas, wear appropriate protective clothing, avoid sunbathing and excessive sun exposure.

Current skin cancer prevention campaigns recommend that individuals use sun protection such as hats, clothing, sunscreen, sunglasses and/or shade during periods when ultraviolet (UV) index is high, typically between 10 am and 3 pm. Given that the sun is a major source of vitamin D, essential for bone health, there needs to be a balance between exposure and protection. The amount of sun exposure you need to prevent vitamin D deficiency varies depending on your skin type, location, season and time of day. Generally 30 minutes of sun exposure to the neck, hands and arms when the UV index is low gives sufficient exposure to maintain vitamin D levels.

The skin changes brought about by the increased levels of hormones in pregnancy are not associated with the development of skin cancer. However, if you have developed these skin changes from increased sun exposure you may be at risk of developing a skin cancer not related to these skin changes given that sun exposure is a risk factor for the development of skin cancer. There is no strong evidence that pregnancy is associated with changes in nevi (moles). Therefore if you have a mole that has changed in its appearance it should be looked at by your doctor. If suspicious for a cancer, your doctor can arrange for a biopsy of the mole.

There are multiple creams/lotions that can be used to help reduce the skin changes. These are typically prescribed by doctors who specialize in the treatment of skin conditions called dermatologists. Treatment is usually only used in those women in which the skin changes do not resolve spontaneously following delivery of the baby and are troublesome for the mother. Treatment is not recommended during pregnancy for several reasons:

• The hormones that are the cause of the skin condition persist during pregnancy, and hence it is harder to treat;
• Most cases resolve on their own once the baby is born, although this may take some months; and
• The treatments used can be harmful to the developing baby.

During your pregnancy or after the birth of your baby, you can consider camouflaging the skin changes with cosmetics. Foundations and powders with a white or yellow undertone can minimize the appearance.

If the areas fail to fade following the delivery of your baby, you may want to discuss this with your doctor who may be able to advise you further on treatment options or may refer you to a doctor who specializes in the treatment of skin conditions (a dermatologist). Depending on the area involved, treatment options may include:

• Creams such as hydroquinone, tretinoin and/or fluocinolone acetonide
• Chemical peels
• Dermabrasion
• Laser therapy

Treatments your dermatologist may prescribe

• Use bleaching agents (hydroquinone 4%) carefully. Do not apply these agents to the normally pigmented surrounding skin, as normal skin may also be bleached. Use hydroquinone under the supervision of a dermatologist, as side effects, such as darkening of the skin, may occur.
• Hydroquinone is often irritating and may require the use of 1% hydrocortisone cream, which may also help with the hyperpigmentation. Combination therapy with tretinoin cream may also be helpful.
• Superficial chemical peels (application of an acid to remove the top layers of the skin) and microdermabrasion (a facial sanding technique) may offer additional help.
• A topical agent, azelaic acid, may be helpful.
• Laser therapy has not yet been shown to be satisfactory treatment. Melasma may return and hyperpigmentation may develop in the treated area.

When you embark on a prescription skin lightening program with your dermatologist, it is often best to balance your entire skin care regimen with gentle, non-irritating cleansers and moisturizers. Keep your skin well hydrated as dry skin causes hyperpigmentation.

NOTE: it is important to understand that you must commit to a careful regimen of sun protection when using any of these medications – it is not optional. You must use an SPF 30 or greater every day on areas that are being treated. If you don’t protect those areas from sun exposure, they will continue to darken, making the situation even worse.

Hydroquinone: Handle with care

Hydroquinone is considered the “gold standard” when it comes to effectiveness. However, some dermatologists consider it a somewhat controversial medication because it can cause skin damage at high concentrations. In fact, hydroquinone has been banned in some countries because of fears of a cancer risk. It works by blocking a critical step in the synthesis of melanin.

When hydroquinone was first introduced (at 2% strength), there was good science and data behind its safety as well as its effectiveness in inhibiting melanin production. What concerns me most is that newer and stronger forms have flooded the market with much less scientific analysis. Hydroquinone is now available in concentrations up to 12%; note that all products containing 3% and greater are to be prescribed by a dermatologist.

It must stressed that there is a real danger in self-medicating with hydroquinone at higher concentrations without professional guidance on proper use, risks, and side effects. There are a lot of new choices when it comes to hydroquinone products. Various brands now offer hydroquinone combined with other ingredients that are thought to increase its potency such as tretinoin, glycolic acid, vitamin C, and steroids. But what is the best formulation? Is there any increased risk of cancer in patients who use hydroquinone? How long is it safe to use hydroquinone? There are many unanswered questions.

What do dermatologist know for sure? To start, hydroquinone will bleach skin without discrimination, so it should NOT be used on the full face. It should only be used as a “spot treatment,” under a dermatologist’s supervision. Care and discipline must be practiced to get the desired result. If it is used beyond the borders of affected areas, it may cause lightening of a larger area than intended (“halo effect”). Halos are not easily reversed even when the hydroquinone is discontinued. Lastly, over-the-counter as well as prescription strength hydroquinone should be AVOIDED during pregnancy and while breast-feeding.

Azelaic acid: Treat both acne and pigmentation disorders

Azelaic acid works wonders for acne, destroying acne-causing bacteria before they have the chance to cause outbreaks. An additional benefit is that it is a very effective treatment for post-inflammatory hyperpigmentation, much of which is caused by acne outbreaks. So it works on two levels – improves acne and some of the pigmentation disorders that appear with it.

Azelaic acid reduces melanin production by depressing certain enzymes necessary for the synthesis of melanin. While not as potent as hydroquinone, Azelaic acid offers many benefits for evening skin tone. You can use it all over the face as well as a spot treatment. It is well tolerated by most people with little risk of irritation even when combined with other acne medications and skin lighteners. Another advantage of azelaic acid is that in general, it is considered safe to use during pregnancy.

Corticosteroids: Can have serious side effects

Corticosteroids work on two levels – they decrease inflammation, which causes hyperpigmentation, and they decrease the function of melanocytes without destroying them. By adding corticosteroids to other lightening agents, it enhances their ability to work and decreases the likelihood of irritation as well as the inflammation that can cause hyperpigmentation.

Corticosteroids come in a wide range of strengths. Potent forms can have serious side effects in as little as two weeks if they are misused. In addition, patients who use steroids for an extended period of time will develop a dependency on them and may find it very difficult to stop using them. Therefore, corticosteroids should only be used with your dermatologist’s close supervision. Unfortunately, due to lax and less-than-uniform regulatory processes around the world, it is possible to get corticosteroids without a prescription; however this can be risky, and dermatologist would strongly advise against it.

Retinoids: Good for skin rejuvenation, too

It is easy to find retinol listed in skin care products, but it is not nearly as potent or effective as the prescription strength retinoids such as tretinoin (Retin-A®), adapalene (Differin®), and tazarotene (Tazorac®). These medications can actually repair damaged DNA in the skin and were initially manufactured to treat acne. Dermatologists learned that retinoids can also be a good treatment for the post-inflammatory hyperpigmentation often caused by acne.

Retinoids influence pigmentation by speeding up turnover in the skin, gradually eliminating anything sitting on the top layers. That sloughing process automatically begins to slow down in your mid twenties. Retinoids reverse that effect by producing a faster rate of cell turnover as well as eliminating abnormal melanin in the top layer of skin. They do not work by bleaching the skin, but rather returning the skin to its natural color. Retinoids are useful in treating melasma and acne scars by reducing the amount of excess melanin and distributing it more evenly.

While tretinoin, adapalene and tazarotene are only supposed to be prescribed by a dermatologist, they can be obtained without a prescription over the Internet. These medications should be used under the supervision of a dermatologist. So be very cautious about the source. Also, all retinoids are not created equally; some should be avoided altogether while others must be avoided during pregnancy or breastfeeding.

Mequinol: Excellent for sunspots

Mequinol is available in the U.S. in a 2% concentration, usually combined with tretinoin, and is harder to get without a prescription. Mequinol does not damage the melanocyte like hydroquinone, and it can be an excellent treatment for sunspots and other causes of hyperpigmentation.

However, dermatologist urge caution to those with darker skin tones because mequinol can actually cause post-inflammatory hyperpigmentation for unknown reasons. It can also cause irritation in all who use it and must NOT be used during pregnancy or breast-feeding.