Lactation Suppression : Nonpharmaceutical Versus Pharmaceutical Method

research and studies

Lactation Suppression Nonpharmaceutical Versus Pharmaceutical Method SHIRLEY WONG, RN, MSN, AND ELIZABETH STEPP-GILBERT, RN, MS

Mothers bottlefeeding their infants need an adequate method of lactation suppression to prevent/lessen discomfort related to breast engorgement. This study compared the effectiveness of a nonpharmaceutical method (ice and tight bra) of suppressing lactation to a pharmaceutical therapy (bromocriptine mesylate). The sample consisted of 36 subjects who used the pharmaceutical therapy (drug group) and 17 subjects who used the nonpharmaceutical method (protocol group). The data showed that the drug group had significantly less engorgement, milk production, and discomfort on the fourth postpartum day, but the lactation process was prolonged until postpartum day nine or 16. The protocol group had more engorgement, milk leakage, and discomfort on postpartum day four, but the lactation process was completed before postpartum day 16.

Some mothers choose to bottlefeed their infants because of personal preference, fear of los- ing their figure, embarrassment, or compliance with their partner's wishes. A few mothers are forced to bottlefeed because of a neonatal abnormality, breast anomaly, or breast disease. Others fail in their attempt to breastfeed or must suppress lactation due to neonatal death. These mothers need adequate treatment in suppressing lactation to prevent or lessen the discomfort related to breast engorgement.

Lactation can be suppressed with pharmaceutical or nonpharmaceutical therapy. Several non-

Submitted: July 1983. Revised: No- vember 1983. Accepted: January 1984.

pharmaceutical methods have been used to suppress lactation, e.g., a tight bra/binder, ice packs applied to the breasts, and restriction of maternal fluid intake. Restriction of fluids has not proven to be beneficial, but a tight bra/binder and ice appear to help physiologically.' Ice constricts the blood vessels and decreases lymph and blood flow to the breast, decreasing initial engorgement; a tight bra/binder causes pressure atrophy of the alveoli by decreasing cell oxygenation lead- ing to decreased milk production, decreasing secondary engorgement.

Currently, two types of pharmaceutical methods are being used to suppress lactation: 1) hor- mones, particularly estrogenic

compounds, and 2) prolactin in- hibitors. Estrogens are thought to block the peripheral action of prolactin on the alveolar breast cells, which are responsible for milk secretion.* Chlorotrianisene (TaceB) is the synthetic estrogenic compound prescribed most often. The recommended dose is 1) one 12-mg capsule four times daily for seven days; 2) two 25- mg capsules every six hours for six doses; or 3) one 72-mg capsule every 12 hours for two days. The first dose is usually given within eight hours after delivery. A single, intramuscular injection of Delad- umonem (4 cc) administered at the time of delivery may also be prescribed. Deladumone contains both estrogen and testosterone.

The prolactin inhibitor currently

302 July/August 1985 JOG"

used is bromocriptine mesylate (Parlodela), a dopamine antago- nist . The recommended dose is one 2.5-mg tablet twice daily with meals for 14 days. This drug sup- presses lactation by stimulating the pituitary dopamine receptors, which block the release of prolactin from the anterior pituitary gland.' Thus, the stimulus for lactation is removed and painful engorgement, related to overdisten- tion of the ductal system with milk, may be lessened. However, initial engorgement related to ve- nous and lymphatic filling is not lessened.

These drugs are not without side-effects, such as thromboembolism with an estrogenic compound, and hypotension, nausea, headache, dizziness, o r stimulation of early ovulation with a prolactin-inhibiting agent. Research also indicates that both estrogen and prolactin inhibitor may only delay engorgement.:'."

Vast research has been done comparing the effectiveness of different lactation suppressant drugs and their side-effects. However, minimal research has been done to determine the most effective nonpharmaceutical lactation suppressant method. Also, very little research has been done in comparing the effectiveness of nonpharmaceutical methods to a pharmaceutical therapy.

LITERATURE REVIEW

Niebyl et (11. compared 90 patients who were divided into two groups: those who received Tace and those who received placebos. The investigators found the overall incidence of breast engorgement the same in both groups, with a delayed breast engorgement in the treated group.3 Similarly, in a study of 500 patients, MacDonald and O'Driscoll concluded that a placebo was almost as effective as pharmaceutical the rap^.^ How-

ever, other researchers, such a s Morris, Creasy, and Hohe (N = 484), Grant et al. (N = 134), and Dewhurst, Harrison, and Biswas (N = 52), concluded that pharmaceutical therapy was significantly more effective than placebo therapy."'

Schwartz et al. studied 353 subjects and compared four methods of suppressing lactation: Tace, StilbestrolB, Deladumone, and an oral p l a ~ e b o . ~ All subjects were fitted with a tight bra. Clinical evaluation was made on postpartum day one through three o r four, and a follow-up evaluation was done five weeks later. The estrogen compounds were found to be more effective than a placebo. However, the patients' symptomatologies during the engorgement periods were not reported. According to Grant et al., the peak day for breast discomfort related to engorgement is the fourth postpartum day.7

I f the woman is on an estrogen suppressant, Rolland and Schelle- keus found a rebound phenomenon or a breakthrough engorgement occurred between postpartum days seven to 1O.Io Similarly, other researchers found that rebound lactation occurred from eight to 10 days after estrogen therapy, and late mammary congestion occurred 10 to 14 days after therapy."," The rebound effect of estrogenic compounds appears to be related to the fact that plasma prolactin val- ues increase significantly when patients are treated with an estrogenic c ~ m p o u n d . ' ~ Nilsen et al. compared the effects of ParlodeP to diethylstilbestrol in 38 women who were suppressing l a ~ t a t i o n . ~ Rebound lactation occurred between day 10 and 14 in eight of the 18 women treated with diethylstilbestrol (an estrogenic compound), and rebound lactation occurred after two weeks in four of the 18 women being treated with Parlodel.

Turnbull compared natural methods of suppression to suppression with Stilbestrol, but did not define the natural method that was used." In this epidemio- logic study of 6227 patients, 75% of the patients being treated with Stilbestrol and 60% of the natural suppression subjects experienced no pain. After the initial week, none of the patients in the natural suppression group experienced pain, but one in four patients being treated with Stilbestrol experienced severe mammary discomfort.

Other research studies have fo- cused on the possible side-effects of a particular drug. Several retrospective studies have shown that women who received an estrogenic compound to suppress lactation have had an increased incidence of thromboembolism. For example, Daniel et al. exam- ined 9324 women treated for suppression of lactation and found 44 cases of puerperal thromboembolism." All cases had received diethylstilbestrol. The low parity women had a fourfold increased risk of thromboembolism, and the risk was increased tenfold in mothers 25 years and older when taking an estrogenic medication for suppressing lactation. Tindall found similar results in his study of puerperal thromboembolism.'5 Niebyl et af. studied 50 postpartum patients who received Tace or a placebo for suppressing lactatiom3 The investigators found a statistically significant decrease in antithrombin I l l levels in the platelet count of patients who received Tace. Antithrombin 111 and platelet count are factors that increased the risk of developing throm- boemboli.

Jeffcoate et al. analyzed 111 cases of puerperal thromboembolism and found a threefold increase of thromboembolism in women treated for suppression of lactation with estrogenic com-

July/August 1985 JOG" 303

pounds.'" In women over 35 years of age, the incidence of thromboembolism increased threefold. Estrogen therapy is also contraindicated in patients with diseases of the breast, all known or sus- pected neoplasia, thromboembolic disorders, and impaired liver f ~ n c t i o n . ~

Bromocriptine, a prolactin in- hibitory, is a nonhormonal agent and, therefore, does not increase the risk for thrombosis. However, in 23% of treated patients, a risk exists for at least one side-effect, such as hypotension, nausea, headache, dizziness, o r the stimulation of early ovulation.' Dis- continuation of therapy is required in about three percent of treated patients.I7

METHODS AND PROCEDURES

The purpose of this study was to compare the results of a nonpharmaceutical lactation suppressant method-a tight bra and ice (protocol group)-to a lactation suppressant drug therapy (drug group). The drug used in this study was Parlodel.

Definitions

The following operational definitions were used.

Engorgement is a filling of the breast with blood, lymph, and/ or milk, which causes the breast tissue to distend and/or become firm or very hard. When pal- pated, the breasts feel 1. Soft-Breasts feel like they

did before the pregnancy. 2. Full-Breasts feel nodular o r

bumpy. 3. Firm-Breasts feel solid but

finger can make an indenta- tion.

4. Hard-Breasts feel solid but finger cannot make an inden- tation.

Lactation is the secretion of milk from the breast. Manual expression of breasts produces

304

1. N o milk 2. Some drops 3. Slight flow 4. Stream of milk

0 Breast discomfort is a subjective feeling of breast pain. Breast discomfort is 1. Absent-There is no feeling

of discomfort in the breasts. 2. Mild-Discomfort is felt in

breasts, but can be relieved or lessened with distraction.

3. Moderate-Discomfort can be relieved with a pain medication and/or nonmedication treatment, such a s ice and/ or tight bra.

4. Severe-With pain medication and/or nonmedication treatment, the discomfort is still severe. The discomfort may lessen but it is not relieved.

Tight bra is a tight, well-fitting bra worn continuously for five days postpartum. Ice therapy is ice packs placed over the axillary area of the breasts for 15 to 20 minutes a t least four times a day for five days postpartum.

Sample

The study population consisted of nonbreastfeeding mothers who met the following criteria: no cur- rent breast disease (i.e., cancer or fibrocystic disease a s documented in the hospital chart); normal full- term delivery; able to speak and write English; and a telephone at home.

The convenience sample consisted of 36 subjects in the drug group and 17 subjects in the protocol group. Subjects were as- signed to either the drug or protocol group, depending on the subject's choice of lactation suppressant method.

A questionnaire was used to gather demographic information and data related to methods of lactation suppression. Subjects filled out this questionnaire during postpartum day one or two.

1. Apply tight bra/binder within six hours after delivery and wear for five days. Can be removed to shower.

2. Apply ice pack over the axillary area of the breasts for 15 to 20 minutes at least four times a day for five days. First application should be within six hours after delivery.

3. When showering, do not allow the warm water to hit the breasts.

4. Do not stimulate the nipple (massage or oral stimulation by partner) for one week.

Figure 1. Nonpharmaceutical lactation suppressant protocol.

Subjects who chose to suppress lactation by using a nonpharmaceutical method were instructed to follow the lactation suppressant protocol (Figure 1). The postpartum staff initiated this protocol within six hours after delivery and four times daily during the subjects' hospital stay. Subjects then continued this protocol after dis- charge through the fifth postpartum day.

A lactation suppressant chart (Figure 2) was used to gather data on effectiveness and comfort of both methods a s perceived by the subjects. The lactation suppression chart was adapted and mod- ified from Nilsen et al., Rolland Schellekens, and Morris et al.4.6.10 Items evaluating effectiveness include self-assessment of degree of engorgement/congestion, self-assessment of milk production/lactation, and self-assessment of degree of discomfort. Non-pharmaceutical lactation suppressant items include type of therapy, postpartum day therapy started, and duration and frequency of therapy. Analgesic is included in the nonpharmaceutical lactation suppressant items due to its effectiveness in decreasing discomfort, but it does not have any lactation suppressant property. Information from the lactation suppression

JulyJAugust 1985 JOCNN

Code # ___

Results of Suppressants IL Therap! ~

Engorgement/ Congestion

Upon palpation: 0 Breast soft 0 Breast full 0 Breast firm 0 Breast hard

Milk Production/ Lactation

Upon manual expression:

0 No milk 0 Some drops 0 Slight flow 0 Stream of milk

Other (specify)

Tight Bra/ Day pp 1 1 Binder Analgesics

Yes No Drug ____ Amount - Time taken - Did it relieve

the pain? -

Discomfort Ice

Yes No PP day started

Yes No PP day started

0 Absent 0 Mild 0 Moderate 0 Severe

1-2 Avg. hrs./day Frequency

Duration -

Continued Yes No

Frequency - Duration - PP day stopped

Yes No Drug ___ Amount - Time taken - Did it relieve

the pain? -




Continued Yes No

Avg. hrs./day 0 Absent 0 Mild 0 Moderate 0 Severe

4

PP day stopped

Continued Yes No

Avg. hrs./day

Continued Yes No


Yes No Drug ~

Amount - Time taken - Did it relieve

the pain? -

Yes No Drug ___ Amount - Time taken - Did it relieve

the pain? -







9

-

16

PP day stopped

Continued Yes No

Avg. hrs./day

PP day stopped

Continued Yes No




on chart. Figure 2. Lactation supprer

chart on postpartum day one or and ratings of engorgement, milk two was obtained through per- production/lactation, and discom- sonal interviews with the subjects fort. Ratings according to the sub- at the hospital. Subjects were ject’s perception were marked on given the operational definitions the lactation suppression chart by

researchers. The same information on postpartum days four, nine, and 16 was obtained through telephone calls to subjects.

RESULTS

The demographic data (Table 1) show that both groups were very similar in the mother’s age, number of children, and number of mothers who reported work and convenience as reasons for bottlefeeding. However, a greater percentage of mothers in the protocol group (24%) reported no prior success as a reason for bottlefeeding, as compared to the drug group (eight percent). Both groups had the same percentage of mothers who had previous experience suppressing lactation, but 73% in the protocol group reported no prior success in sup-

Table 1. Demographic Data on Drug and Protocol Groups

Drug Protocol (N = 17) (N = 36)

~~~

Mean age Mean number of children Reason for lactation suppression

Work Convenience No prior success Dislike breastfeeding Others

Yes No

Yes No

Previous experience suppressing lactation

Prior success in suppressing lactation

~

26 years 2

10 (28%) 3 (8%) 3 (8%) 4 (1 1%) 16 (45%)

23 (64%) 13 (36%)

15 (65%) 8 (35%)

24 years 2

5 (29%) 1 (6%) 4 (24%) 0 7 (41%)

1 1 (65%) 6 (35%)

3 (27%) 8 (73%)

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pressing lactation, as compared to 35% in the drug group.

Significant effects (50.05) were found in analysis of engorgement between the two groups, with time and group by time interaction (Table 2). Due to significant interactional effects, an analysis of variance testing differences between groups at each time period was done (Figure 3) . A significant effect between the drug group and the protocol group occurred on day four (Table 3). No other significance was found. Although the protocol group was not significantly different from the drug group on days nine and 16, they were less engorged than the drug group (Table 3).

Significant effects were also found in the analysis of milk production/lactation between the two groups, with time and group by time interaction (Table 4). Analy- sis of variance testing differences between the two groups at each time period was again used because of significant interactional effects (Figure 4). A significant effect was found between the drug group and the protocol group on day four (Table 5 ) . N o other significant differences were found.

Significant effects were also found in analysis of discomfort between groups, with time and group by time interaction (Table 6). As with engorgement and milk production/lactation, analysis of variance testing differences between groups at each time period was used (Figure 5 ) . Significance was found for the drug group on days one to two and day four (Table 7). N o significance was found on day nine and day 16. Although the differences at day 16 did not reach the traditional 0.05 level of significance, the protocol group experienced less discomfort than the drug group.

Data concerning the analgesics used were gathered from the protocol group. Six subjects took

Table 2. Analysis of Variance: Engorgement

Sum of Degrees of Mean Source Squares Freedom Squares F P

Group 3.15 1 3.15 5.08 0.0 Error 31.57 51 0.62 Time 30.75 3 10.25 21.61 <o.o Group X time 26.58 3 8.86 18.68 <o.o Error 72.59 153 0.47

some type of analgesic: aspirin/ Tylenol@ (four) or Empirin@/Ty- lenol #3@ (two). Aspirin/Tylenol provided relief for three of the subjects. Subjects who took Em- pirin/Tylenol #3 obtained 100% relief. Analgesics were used by five of the subjects on the third o r fourth postpartum days.

Subjects in the protocol group were asked if they would recom-

mend the nonpharmaceutica method to others. Fifteen of the subjects said they would recom mend this method and two said they would not. Those who would recommend the method felt tha ice decreased the engorgemen and diminished pain. The reasone given by the subjects who would not recommend this method were that ice was inconvenient, and one

2.5

2.0

1.5

1 .o 1-2 4 9 16

Postpartum Days

Figure 3. Degree of engorgement between the drug and protocol groups.

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Table 3. Mean Engorgement and Level of Significance for the Drug and Protocol Groups by Time Period

Drug Protocol Days (N = 36) (N = 17) P

One to two 1.17 1.18 0.94 Four 1.33 2.88 10.01 Nine 1.64 1.24 0.15 16 1.11 1 .oo 0.25

subject stated she had no choice as to which method she could use to suppress lactation.

DISCUSSION

This study was designed to compare the effectiveness of a nonpharmaceutical method of suppressing lactation to the cur- rent drug therapy used because many women are concerned about the use of medication. In both the drug group and the protocol group, some subjects experienced no engorgement, milk production, or discomfort at any time. How- ever, most subjects in both groups experienced the lactation process. The drug group, in general, started experiencing some degree of engorgement on day four, which peaked on day nine. Three subjects still experienced engorgement on day 16. In contrast, engorgement in the protocol group peaked on day four, gradually decreased, and by day 16, none of the 17 subjects experienced engorgement.

The amount of discomfort experienced closely paralleled en-

1.0 ’ I I I I 1-2 4 9 16

Postpartum Days

Figure 4. Degree of milk production/lactation between the drug and protocol groups.

gorgement. The peak discomfort in the drug group was on day nine, and six subjects still experienced milk pain on day 16; however, the peak discomfort in the protocol group was day four, and no one experienced discomfort by day 16. The drug group experienced more milk leakage on day nine, and 11 out of 36 still experienced leakage on day 16. The protocol group started experienc-

Table 4. Analvsis of Variance: Milk ProductionlLactation


Group 2.59 1 2.59 4.25 0.04 Error 31.12 51 0.61 Time 5.13 3 1.71 6.87 <0.01 Group X time 3.99 3 1.33 5.35 <0.01 Error 38.10 153 0.25

ing milk leakage on days one to two, which peaked on day four, and six still experienced some drops on day 16.

In summary, the drug group had significantly less engorgement, milk leakage, and discomfort on the fourth postpartum day, but the lactation process was pro-

Table 5. Mean Milk Production/ Lactation and Level of Significance for the Drug and Protocol Groups by Time Period


One to two 1.14 1.18 0.72 Four 1.14 1.88 <0.01 Nine 1.53 1.65 0.59 16 1.31 1.35 0.75

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Table 6. Analysis of Variance: Discomfort


Group 1.59 1 1.59 5.55 0.02 Error 14.61 51 0.29 Time 5.52 3 1.84 8.98 <0.01 Group X time 8.42 3 2.81 13.72 <0.01 Error 31.31 153 0.20

longed until the ninth or 16th postpartum day. The protocol group had more engorgement, milk leakage, and discomfort on postpartum day four, but the lactation process was completed before postpartum day 16.

In comparing these results to the review of literature, some sim- ilarities were noted. The results of engorgement, milk production, and discomfort in the protocol group corresponded to the normal physiology of lactation which oc- curs on the third or fourth postpartum day and lasts 24 to 48 hours.7 The results of engorgement, milk production, and discomfort in the drug group were similar to the study done by Nilsen et al., which showed a two-week delay in lactation in women treated with P a r l ~ d e l . ~

Several other interesting findings were noted during data col- lection. Many patients and several maternal-child nurses had the misconception that, if engorgement, discomfort, or milk leakage did not occur on the first postpartum day, suppressing lactation would not be a problem. On several occasions, the physician failed to order any suppressant drug therapy until the second o r fourth postpartum day. It was noted, but not statistically analyzed due to the small sample size, that these subjects had more engorgement, discomfort, and milk leakage than those subjects who started the drug therapy on the first postpartum day. The same was true of the subjects who stopped the

medication before the prescribed 14 days.

LIMITATIONS

Several limitations in this study were recognized. The first limitation was the small sample size in the protocol group. The health- care professionals were not famil- iar with other alternatives in sup-

Table 7. Significance for the Drug and Protocol Groups by Time Period

Mean Discomfort and Level of


One to two 1.00 1.18 0.04 Four 1.06 1.94 <0.01 Nine 1.39 1.24 0.35 16 1.17 1 .oo 0.07

pressing lactation, so most clients were counseled to suppress lactation with drug therapy. Also, some subjects in the protocol group were eliminated when they switched to drug therapy at mid- study or did not use ice and only wore a tight bra.

A second limitation was that

1-2 4 9 16

Postpartum Days

Figure 5. Degree of discomfort between the drug and protocol groups.

JulyfAugust 1985 JOG”

the researchers had no control over whether or not the protocol subjects actually followed the nonpharmaceutical lactation suppression protocol. The researchers assumed that the subjects in the drug group continued taking their medication for 14 days unless the researchers were told of discontinuance.

The third limitation was the subjects’ self-selection of treatment group, and self-reporting of effectiveness and comfort in both groups. Subjects may have been biased and, therefore, may have influenced the results of the study.

The fourth limitation was that the reliability and validity of the instrument used was not assessed. However, the lactation suppression chart was able to detect significant differences between the two groups in this study, so there may be some reliability. Possible threat to the validity also was looked at after the research study was done. The only threat to validity was local history, a s there was a crossover interaction with two of the three variables (Figures 1 and 3).18

Replication of the research with a larger sample in the protocol group is needed. The research study would also be strengthened if data regarding engorgement, milk production/lactation, and discomfort could be objectively measured, and the two groups could be controlled by random sampling.

NURSING IMPLICATIONS

Since most women have little or no discomfort related to engorgement during the first two postpartum days, they usually see very little need to d o anything to facilitate lactation suppression unless they have experienced prior engorgement pain. There- fore, maternal-child nurses need to explain to these patients the

normal physiology of lactation and the need to follow some type of suppressant therapy because the peak day for breast discomfort related to engorgement is on the fourth postpartum day. Once the need is aroused, alternatives should be discussed with the interested client.

Many childbearing women are interested in alternatives to lactation suppressant drug therapy because of the potential side-effects and rising medical costs. Thus, it is important that maternal-child nurses be aware of alternatives to offer their clients. When a client requests a nonpharmaceutical therapy, the nurse should provide instructions to facilitate suppressing lactation. On the other hand, when drug therapy is used to suppress lactation, it should be started on the first postpartum day. The nurse may need to remind the attending physician to order medication. The maternal-child nurse needs to emphasize to the patient that, if Parlodel is not taken for the prescribed 14 days, the effectiveness of the drug is lessened.

CONCLUSION

Nonpharmaceutical therapy, using ice and a tight bra, can be offered as an alternative method to clients who do not wish to suppress lactation with drug therapy. Application of ice and a tight bra should start soon after delivery and continue for five days to decrease milk production and engorgement. Analgesics can be used for the mild discomfort of engorgement on the third o r fourth postpartum day.

Clients using drug therapy to suppress lactation should be instructed to start taking the medication on the first postpartum day, and for the prescribed 14 days, to enhance the effectiveness of the drug. Whatever lactation suppres-

sant method is used should be discussed with the client prena- tally so she can make an informed health-care decision.

ACKNOWLEDGMENTS

This study was partially funded by Arizona State University Col- lege of Nursing Research Incentive Fund. The authors express appre- ciation to Dolores Sands, RN, PhD, and Joseph Hepworth for their assistance in the study and statis- tical analysis.

REFERENCES

1. Harrison R. Suppression of lactation. Semin Perinatol 1979;3:287- 97.

2. Brundel R, del Pozo E, de Grandi P. Prolactin inhibition and suppression of puerperal lactation by a bromocriptine: a comparison with estrogen. J Obstet Gynecol

3. Niebyl JR, Bell WR, Schaaf MF, et 1973;41:884-90.

4.

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6.

7.

8.

9.

10.

al. The effect of chlorotrianisene as postpartum lactation suppression on blood coagulation factors. Am J Obstet Gynecol 1979;134: 518. Nilsen PA, Meling A, Abildgaard U. Study of the suppression of lactation and the influence on blood clotting with bromocriptine (Parlodel): a double blind comparison with diethystilboestrol. Acta Obstet Gynecol Scand

MacDonald D, O’Driscoll K. Sup- pression of lactation. Lancet 1965; 2623. Morris J, Creasy R, Hohe P. Inhi- bition of puerperal lactation. J Obstet Gynecol 1970;36:107. Grant K, Rabello Y, Freeman A, et al. Comparison of quinestrol and Tace@ for relief of postpartum breast discomfort. J Obstet Gy- necol 1978;1:636-9. Dewhurst CJ, Harrison R, Biswas S. Inhibition of puerperal lactation. Acta Obstet Gynecol Scand

Schwartz D, Evans P, Garcia C, et al. A clinical study of lactation suppression. J Obstet Gynecol 1973;42(4):599. Rolland R, Schellekens L. A new approach to the inhibition of

1976;55:39-44.

1977;56:327-31.

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11.

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14.

puerperal lactation. J Obstet Gy- necol Br Commonw 1973;80:945. Hodge C. Suppression of lactation by stilboestrol. Lancet 1967;

Daniel DG, Campbell H, Turnbull A. Puerperal thromboembolism and suppression of lactation. Lan- cet 1967;2:287-9. David A, Romen I, Lunenfeld B, et al. Stilbestrol administration in the puerperium and its effect on the prolactin excretion of nonlactating patients. Acta Obstet Gynecol Scand 1977;56:211-5. Turnbull A. Puerperal thromboembolism and the suppression of lactation. J Obstet Gynecol Br Commonw 1968;75:1321.

21286-7.

15. Tindall V. Factors influencing puerperal thromboembolism. J Obstet Gynecol Br Commonw 1968;75: 1324.

16. Jeffcoate TNA, Miller J , Roos R, Tindall V. Puerperal thromboembolism in relation to the inhibition of lactation by oestrogen therapy. Br Med J 1968;4:19-25.

17. Duchesne C, Leke R. Bromocrip- tine mesylate for prevention of postpartum lactation. Obstet Gy- necol 1981;57(4):464-467.

18. Cook TD, Campbell DT. Quasiex- perimentation design and analysis issues for field setting. Chicago: Rand McNally, College Publishing Co., 1979.

Address for correspondence: Shirley Wong, R N , College of Nursing, Grand Canyon College, 3300 West Camelback Road, P.O. Box 11097, Phoenix, AZ 8506 1.

Shirley Wong is an assistant professor in the Samaritan College of Nursing at Grand Canyon College in Phoenix, Arizona. Ms. Wong is a member of Sigma Theta Tau, NAPNAP, and ANA.

Elizabeth Stepp-Gilbert is an assistant professor in the Samaritan College of Nursing at Grand Canyon College in Phoenix, Arizona. Ms. Stepp-Gilbert is a member of NAACOG, Sigma Theta Tau, and the Childbirth Edu- cation Association.

letters

(Continued from page 307) well-written. However, it was from those who jogged less inten- at 10 Columbus Circle, New York, somewhat unclear whether joggers sively. This retrospective look at N Y 100 19- 1346. had started jogging prior to men- age of menarche merely suggested

arche, and if they did not, why that, for this group of women, YVONNE PARNES, R N C one would expect a difference in later participation in intensive ex- the age of beginning menses ac- ercise was not related to reported Great Neck, New York

cording to the intensity of jogging. menarche age. Effects of Jogging

I want to commend you for your article, “Intensity of Jogging: Re- lationship with Menstrual/Repro- ductive Variables,” by Estok and Rudy (November/December 1984 JOCNN). A s the article mentioned, we must dispel myths regarding the effect of exercise on menstrual and reproductive function. It is an important and timely issue. In this day and age where physical fitness and health promotion are empha- sized, we want to know about the positive and adverse effects on our bodies. 1 recommend the continuation of research on the subject.

Having jogged throughout my pregnancies, 1 was very interested in the findings about this subject; unfortunately, there were not enough subjects from which to draw any conclusions.

The article was interesting and

LENORE B. WEINSTEIN, RN, MA Milwaukee, Wisconsin

Authors’ reply: A s indicated by Ms. Weinstein, the section in which age at menarche was discussed (on page 393 of our article on jogging) can be confusing. Data were not collected on age at onset of jogging. Controversy exists in the literature regarding the rela- tionship between delayed menarche and intensive exercise. It is often difficult to discern if exercise delayed menarche in the female athlete being studied, or if these young women, who are late ma- turing and usually taller and thin- ner, become athletes through natural selection. We found that, out of the 319 women studied, those who jogged most intensively were not significantly differeht in their self-reported age of menarche

Patient Options

Regarding the article in the January/February 1985 issue of JOCNN entitled “Pregnancy and Cardiac Valvular Prostheses,” I am very disturbed by two statements. The first one is “Breastfeeding will be contraindicated due to sodium warfarin excretion in breast milk,” and the second is “Advise against breastfeeding, depending upon anticoagulant regimen.”

Deborah Chyun, RN, is not an obstetric o r pediatric nurse and may not recognize the great im- portance of breastfeeding to both mother and baby, but I feel she is recommending inappropriate procedures for pregnant women.

Her first statement should have read, “Breastfeeding is contraindicated with the use of sodium

(Continued on page 337)

310 July/August 1985 JOCNN

Lactation Suppression : Nonpharmaceutical Versus Pharmaceutical Method

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