History taking for infant feeding

Chest reduction surgery

The type of surgery may impact milk production capacity and ability to remove milk. If client is planning to bodyfeed, review surgical history, refer to skilled infant feeding supports proactively (e.g., prenatal referral to trans-affirming IBCLC where available), make milk production and supplementation plan, and anticipate engorgement management needs.

For more information about engorgement management, see Anticipatory Guidance in Pregnancy and What to Expect During and After Pregnancy.

For more information about bodyfeeding after chest surgery, see Bodyfeeding: History of Chest Surgery.  

If client is not planning to bodyfeed, anticipate potential engorgement challenges in early postpartum and provide anticipatory guidance.  

For more information, see Lactation Suppression.  

Breast augmentation surgery

The reason for augmentation, as well as the type and timing of surgery, may impact the ability to create and remove milk. Review surgery type with client, discuss feeding goals, provide anticipatory guidance and referral for feeding supports as indicated.

For more information about bodyfeeding after augmentation, see Physician Guide to Breastfeeding Plastic Surgery and Breastfeeding.

Atrial or ventricular arrhythmias

Some medications (e.g., domperidone) used for lactation induction and for low milk supply may increase the risk of sudden cardiac death and ventricular arrhythmias. Review medical history for cardiac risk factors and consider ordering or referring to provider for ECG prior to beginning treatment if indicated.

Trans Care BC lactation induction content in development. For an overview of lactation induction, see the Academy of Breastfeeding Medicine’s Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients.  

Thromboembolic disorders

Using combined oral contraceptives (COC) for lactation induction may increase the risk of thromboembolic disorders. Screen for risk factors, and, if indicated, consider progestin-only pill instead of COC and/or refer to specialist (e.g., endocrinologist A doctor specially trained in the study of hormones and their actions and disorders in the body. , breastfeeding medicine physician) to inform best treatment plan.  

Testosterone therapy

Not currently taking testosterone, but has taken in the past

• Pregnant: no association with pregnancy or birth complications if stopped prior to pregnancy.  
• Bodyfeeding: No impact on infant feeding  

Currently taking testosterone

• Pregnant: contraindicated, may have teratogenic effects. If planning to continue the pregnancy, recommend client stop taking testosterone and consult a specialist for care recommendations.  
• Bodyfeeding: may decrease milk supply, no association with harm to infant in the limited research available.

For more information, see Testosterone and Pregnancy and Testosterone and Infant Feeding.  

Estrogen therapy

Length of estrogen therapy and mammary development plays a role in success of lactation induction in trans women.

Insulin resistance

Insulin resistance can impact development of glandular tissue and milk production in the postpartum period. Risk factors for insulin resistance include history of abnormal HA1C or blood glucose levels, gestational diabetes, pre-diabetes or diabetes, PCOS or features clinically associated with PCOS (control for normal side effects of testosterone therapy if relevant).  

If risk factors for or known history of insulin resistance are present, closely monitor infant growth and hydration in the early postpartum period, especially if bodyfeeding is the primary method of infant feeding. Consider early intervention for delayed onset of lactogenesis or low milk supply.  

Other endocrine disorders

Thyroid disorders can impact milk production and the milk ejection reflex, especially when they are not controlled. Other disorders impacting prolactin levels can also impact milk production (causing excessive or low milk supply). Refer to a specialist, such as breastfeeding physician or endocrinologist, for evaluation, guidance, and treatment.

HIV

In high-income countries, including Canada, exclusive formula feeding is the recommended feeding method for HIV positive parents. Despite this, “a more nuanced approach that may include the option of breastfeeding under certain circumstances is emerging in many resource-rich countries” [3].

PrEP in HIV negative people

Truvada (emtricitabine–tenofovir disoproxil fumarate) is safe to take when feeding human milk (bodyfeeding or expressing milk to feed), as it passes into human milk in doses much smaller than those recommended for infants taking the same medication [4].

For more information about having infant feeding conversations in the context of HIV, see:

• Canadian Pediatric & Perinatal HIV/AIDS Research Group Consensus Recommendations for Infant Feeding in the HIV Context.
• Infant Feeding for Persons living with and at Risk for HIV in the United States: Clinical Report.
• Client resource on making an informed infant feeding decision for people with HIV (uses gendered language). Feeding your Baby: A Guide to Infant Feeding for People Living with HIV.  

In most cases, people who use substances can continue to bodyfeed with appropriate supports and a comprehensive safety plan [7]. Bodyfeeding may decrease neonatal withdrawal, improve parent / infant bonding, and support the parent’s mental health [7].

For more information:  

• BC Reproductive Mental Health Program’s Best Practice Guidelines for Mental Health Disorders in the Perinatal Period: Substance Use Disorders
• Client resource (inclusive but uses some gendered language): Taking Care: A Short Guide to Breastfeeding and Substance Use.

Interpersonal Violence

Rates of interpersonal violence (IPV) may increase during the perinatal and postpartum periods [8,9]. Additionally, while the data is limited, TTNB people report higher rates of lifetime IPV than cisgender Refers to people who are non-trans, i.e. whose gender matches their assigned sex at birth. people [9]. 

Recommendations around routine screening Process of checking for signs of a health issue or medical condition before symptoms appear. are mixed [8,9]. The Canadian Psychiatric Association recommends a “case finding” approach that inquires into past and current experiences of IPV when taking a history during perinatal care [9].  

For more information:  

• The Violence Evidence Guidance Action (VEGA) Project offers resources for discussing and supporting clients who are experiencing IPV.  
• Canadian Psychiatric Association: Recognizing and Responding to Intimate Partner Violence: An Update

Past infant feeding experiences

Many factors impact infant feeding decisions (e.g., personal experiences, self-efficacy, supports available). Previous infant feeding experiences may inform current recommendations, feeding plans, and expectations. For some people, past traumatic or dysphoric infant feeding experiences may cause anxiety around infant feeding. Those who have had difficult bodyfeeding experiences may choose not to bodyfeed after subsequent pregnancies. Conversations about past infant feeding experiences may provide an opportunity to explore alternative feeding options (e.g., pumping to bottle feed).