There is the injection method: IM depo provera. Others: Implanon, progestogen (pills only). Normal OCP generally will reduce supply and therefore not recommended. – A lady ob-gyn in KL

I find it uncomfortable to have sex while I’m still breastfeeding. What I can do about it?

There are medications available to help ease off the feelings of anxiety, inadequacy. The most important thing is to allow someone else to look after the baby for a night or two, so that mom can sleep or for mum to take some light sedatives, all of which can be obtained from the doctor. Things like EPO will only help marginally. If a mum is getting up to breast-feed many times a night, then maybe expressing the milk and having someone else give it to the baby will help.

I am also not surprised by the questions of vaginal dryness during breastfeeding as the oestrogen levels fall during breastfeeding. Therefore the vagina and vulva becomes thin, inelastic and dry. Application of oestrogen cream to the area will help. Generally, application of this cream every night for one week, then two to three times a week will solve the problem throughout the breastfeeding period without affecting milk supply. Generally things become better once the periods become regular again. By the way, milk supply should not be reduced by the return of the periods. - A lady ob-gyn in KL

Can you tell me more about post-natal blues?

Post-natal blues is common and unrecognised most times. I think it helps to learn to let go a little, ie. take mothering one step at a time, let someone else looks after the baby on and off, and go out of the house often!

You will find that with the second baby onwards, mums generally are get better very quickly. I think it comes with confidence. So, I think assurances helps and it is transient. Medically, as doctors, we step in when there is clear post-natal depression. – A lady ob-gyn in KL

Dust mites feed mainly on skin scales (derived from humans or mammalian pets), fungi, hair/fur and body fragments of dead insects. The life span of the adult mite is about 2 to 3 months and during this period it will lay about 50 eggs per month. These eggs hatch and mature in about twenty-five days in the tropics. The major allergen of the house dust mite is derived from the fecal pellets (each dust mite defecates about 50 pellets daily) and dead dust mite parts. The fecal pellets are about 20 microns in size and can reach the upper airways of people breathing them. Fecal allergens contain enzymes that allow the allergen to penetrate mucosal surfaces rapidly and cause immune allergic sensitization.

Exposure to high levels of house dust mite allergens during infancy increases the risk of allergic sensitization and the development of asthma in later life. In Malaysia about 90% of children with asthma or allergic rhinitis are positive for house dust mites. In adults with asthma the prevalence rate of mite sensitization is close to 70%. Many adults with non-specific chronic cough are often positive to house dust mite allergens. Many patients with eczema also react to house dust mites. All patients with asthma or allergic rhinitis should undergo allergy tests for house dust mites to identify the causal factors for long term management of their clinical symptoms. Many studies have emphatically demonstrated that reduction of exposure to the mites in the home environment significantly lead to the improvement of allergic symptoms. One company in Malaysia has experience in home management of house dust mites. They also supply allergy products (mattress/pillow allergicovers, anti-dust mite sprays and air-filters.)

Previously, several allergy symptoms including regurgitation, vomiting, colic, diarrhoea, and eczema have been reported in breast feed infants. Elimination of the offending food allergens from the mother’s diet corrected the symptoms in the babies. In Malaysia we have found allergic skin reaction in exclusively breast fed infants. We tested the infant’s blood for specific IgE antibodies to common foods in the mother’s diet. We have found IgE-mediated response to cows milk, eggs, and wheat in different infants. In one infant with severe allergic disorder of skin the IgE antibody response in the baby was directed to many allergens in the mother’s diet. Thus parents need to be aware of the possibility of allergy symptoms developing in their infant via the breast milk particularly in families with a history of allergy. We recommend that special dietary precautions be taken during lactation for mothers of high-risk families.

In North Europe many parents with history of allergy plan their babies so that the later part of the pregnancy and early lactation falls outside spring and early summer when the air pollen counts are high to reduce exposure to pollen allergens.

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Recently, a new infant formula containing partially hydrolyzed cows milk whey formula (Nan HA) has been introduced. The highly allergenic proteins in the cows milk have been treated enzymatically to make them less allergenic. Over 20 research studies throughout the world including Singapore, demonstrates that this hypoallergenic formula significantly reduces the development of allergy. The use of partially hydrolyzed whey formula in infants for the first four to six months of life significant reduced the manifestations of allergic diseases for 5 to 10 years. In a study performed in Singapore a significant reduction in atopic disorders at 12, 24, 36 and 60 months was found in infants who were on partially-hydrolyzed hypoallergenic milk formula for 4 months. These observations suggest long term benefits detectable way past the period of direct intervention with the partially hydrolyzed milk formula. Some studies have suggested that partially hydrolyzed cows milk formula should be preferentially introduced for at least 4 months to all babies if the infant’s mother opts not to breast feed.

In predisposed infants in the first few months the initial symptom of allergy manifest in the skin as eczema and the severity of the symptoms slowly decrease with age giving the impression that the allergy is getting cured. Often the eczema is followed by allergic disorder of the gastrointestinal tract and when it appears that the symptoms are disappearing respiratory allergic disorder begins. The respiratory allergy initially manifest as rhinitis but soon followed by wheezing often ending up as asthma. This is called the Allergy March. Do not ever be complacent when the child develops an allergic symptom in early life. Immediately find the cause and manage it through avoidance. Early in life management of the allergy will prevent the child developing asthma later in childhood.

However, even when these nutrients are lower in breast milk than in formulas, their higher bioactivity and bioavailability nearly meet the complete needs of neonates than provided by even the best infant formulas. Also, in many instances human milk components compensate for immature function, such as a neonate’s inability to produce certain digestive enzymes, immunoglobulin A (IgA), taurine, nucleotides, and long-chain polyunsaturated fatty acids. In addition, the breast milk contains various cells (such as macrophages, neutrophils and lymphocytes) that play a critical role in the immune protection of the baby.

Babies on breast milk have lower risk for the development of allergy. Human milk lacks inflammatory mediators, and contains anti-inflammatory agents such as antiproteases, antioxidants, and enzymes that degrade inflammatory mediators and modulators of leukocyte activation. Furthermore, IgE (the principal immunoglobulin responsible for immediate hypersensitivity reactions), basophils, mast cells, eosinophils (the principal effector cells in these reactions) are absent in breast milk. The mediators from these cells are also absent in human milk. Immune and nonimmune protecting agents are present in milk throughout lactation and some, such as lysozyme, are present at higher concentrations during prolonged lactation than during the early stages. Therefore, although it is advocated that breast-fed infants receive food supplements after 4 to 6 months of exclusive breast-feeding, it is advisable to breast-feed for longer periods.

Moreover, the breast milk promotes the development of healthy gut flora that acts to suppress the development of the allergic reaction.

In recent years research studies have revealed that the foetus develops in an immunological environment biased for the humoral response during pregnancy. This means that genetically predisposed foetus has a very high risk for being sensitized to allergens during pregnancy. This means that the serum IgE levels will be elevated in the baby’s blood. Thus, the risk for allergy can be easily determined by estimating the total serum IgE level in the cord blood at birth. A high IgE concentration in the cord blood suggests that the baby has a high risk for the development of allergy. This information pre-warns the paediatrician of the possibility of allergy symptoms in the baby appearing anytime after birth depending on the exposure to allergens. Therefore, avoidance measures can be taken early even before the symptoms appear and reduce the chances for allergy symptoms in the predisposed baby.

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At birth an infant’s immune system is immature and the neonate is dependent on many factors present in breast milk for immune protection. Depriving the baby of breast milk may speed up the development of allergy in pre-disposed infants.

The Cap RAST method uses a state-of-the-art technique that is accepted world wide as the in-vitro Gold Standard. Moreover, the IgE level estimated by the equipment is standardized against the World Health Organization immunology standards for IgE maintained by them. The cap RAST reports the results in both quantitative and qualitative terms for professional assessment. Therefore, the allergy blood test using the cap RAST is the method of choice because it is sensitive, accurate, safer, convenient and unaffected by medication taken by the patient. The allergy blood test can be performed in babies and elderly and in persons with severe eczema in whom it is difficult to do the skin test.

The choice of the allergens selected for test depends on the clinical history. Usually the doctor may select about 12 to 15 allergens based on his experience but in some cases he may select less allergen for testing. Skill and experience is required to interpret the result and in most cases the test results often fit the clinical observation and confirm the diagnosis. Appropriate avoidance measures should be immediately implemented. The benefits of the avoidance measures usually become apparent within the first few days.