Transcript Document 7168806

Breastfeeding and Human Milk
Properties
AAP Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2005;115;496-506.
WHO: Breast Feeding http://www.who.int/topics/breastfeeding/en/
1
‫( َو ْال َوا ِلدَ ُ‬
‫ض ْع َن أ َ ْوالدَ ُهن َح ْولَي ِْن َك ِ‬
‫املَ ْي ِن ِل َم ْن أ َ َرادَ‬
‫ات يُ ْر ِ‬
‫عة َ )‬
‫ضا َ‬
‫أ َ ْن يُتِم الر َ‬
Learning Objectives
Describe why breast feeding is the best source
of nourishment for infants and young children
 Describe the quantity and quality of components in
breast milk
 Describe the beneficial impact on infant’s health,
maternal condition, and socio-environment
 Describe the few contraindications and
common challenges of breast feeding, which could
be faced in clinical practice by parents and
clinicians

3
Content
Breast feeding - definition, goal & rates
 Human milk
◦ Composition
◦ Functional components
◦ Benefits
◦ Relative contradictions
 Support system

4
Definition & Goal
Exclusive breast feeding is defined as the consumption
of human milk with no supplementation of any type
except for vitamins and medications
 Breast feeding is the best nutrition and health protection
for the first 6 months of life
 Breast feeding with complementary foods for at least 12
months is the ideal feeding pattern for infants
 Exclusive breast feeding rate target in the US:
◦ 75% at initiation
◦ 50% at 6 months
◦ 25% at 12 months

Agostoni C, et al. J Pediatr Gastroenterol Nutr 2008;46:99-110.
http://www.healthypeople.gov/document/HTML/Volume2/16MICH.htm
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Breast Feeding Rates

From 1970 through 1990 breast
feeding dropped
◦ More mothers stepped into the workplace
◦ Easier access to commercial
infant formula
◦ Misunderstandings of breast feeding

Since 2000:
◦ Recognition of the benefits of breast feeding
by the public and by health professionals
made breast feeding initiation rates increase
gradually
6
Global Breast Feeding Rates

At 4 months:
◦ 66% in Norway
◦ 41% in Japan
◦ 28% in Vietnam


At 6 months: 33% in the US
Breast feeding rate in Taiwan is unsatisfactory
In 2004:
◦ Immediately postpartum, 50% of mothers
breast fed
◦ At 1 month, 29%-33% exclusively breast fed
◦ At 6 months,13% exclusively breast fed & 20%
supplemented breast feeding with formula feeding
WHO Global Data Bank on Breastfeeding and Complementary Feeding
http://apps.who.int/research/iycf/bfcf/
7
Structure of the Human Breast

The Human breast are modified sweat
glands responsible for lactation (milk
production).

The breast contains adipose tissue and
fibrous connective tissue.

Different hormones are responsible
for the development of the breast and
changes that occur during pregnancy.

The major hormones affecting breast
development and enlargement are
estrogen, progesterone and prolactin.
Structure of the Human Breast (Cont’d)

Each breast contains about 20 lobes, each lobes
contains several lobules which at the end have alveolar
in which milk is produced.

Milk production and secretion are responsive to two
major hormones – prolactin and oxytocin; and the
sucking reflex.

After production of milk in the alveolus, the milk
moves through the ducts and are stored in the
lactiferous sinus. When the infant latches on the breast,
milk is expressed from the sinuses.
Suckling Hormonal Reflex Arc (Cont’d)

The sucking reflex arc is a hormonal positive feedback
mechanism.

The sucking of the breast by the infant stimulates the nipple;
this sends messages to the spinal cord and subsequently to
the brain.

Prolactin is released from the anterior pituitary for milk
production and oxytocin from the posterior pituitary for the
milk let down.

Prolactin receptors are established within the first eight days
of delivery.

Suckling at breast increases prolactin levels, so at each
feeding, levels rise, hence more milk production.
Physiology of lactation

Lactation and milk production goes
into 3 stages:
1. Lactogenesis I
2. Lactogenesis II
3. Lactogenesis III

Lactogenesis ( I & II )  milk supply is
hormonally driven endocrine control
system.
 Lactogenesis III  switch to the autocrine (or
local) control system.
Physiology of lactation
Physiology of lactation


The mother will start making
colostrum about halfway through
pregnancy (Lactogenesis I), but high
levels of progesterone inhibit milk
secretion.
At birth, the delivery of the
progesterone/estrogen
placenta results
in a sudden drop in
Prolactine
progesterone/estrogen levels.
Lactogenesis
II
Physiology of lactation

After Lactogenesis II, there is a switch
to the autocrine (or local) control
system (Lactogenesis III )
Maintenance stage of milk production


Milk removal is the primary control
mechanism for supply.
Under normal circumstances, the
breasts will continue to make milk
indefinitely as long as milk removal
continues.
Neonatal feeding reflexes:-
1) Rooting reflex: touching the check or
circumaural area leads to turning the head to
the side of the stimulus leading to opening the
mouth seeking for the nipple.
2) Suckling reflex: tactile stimuli of the nipple or
aereolar tissue filling the mouth leading to
milking action by tongue against hard palate.
3) Swallowing reflex: follows suckling or allows
interruption to breathing to prevent choking
during swallowing.
Facts about babies and newborns.
1.
2.
3.
4.
They are considered as
immunocompromised due to there
immature immunity.
Thy need a high amount of energy for
growth and development.
There renal solute load is low.
There different organs and systems
are still not 100% mature.
Breast Milk is tailored to help coping with
these different immaturity aspects
Composition of breast milk:
Colostrum:
Small amount during days 3 up to 5.
Thin yellowish fluid, provide passive immunity to
the baby.
High in protein, immunoglobulins and minerals.
Low in lactose and fat.
Bright lemon yellow ; alkaline ; viscous fluid
secreted during first 5-7 days : compared to mature
milk it is :
1) More rich in protein (2.3gm/dl) but less CHO or fat.
2) Very rich in immunoglobulin especially IgA.
3) rich in cholesterol , Na , K , Cl , Zinc ,
Copper , leucocytes ( macrophages ,
lymphocytes )
Antibacterial ( lactofissin , lactofirrin )
more rich in Vit.A than mature milk.
4) Laxative effect by enhancing GIT motility
leading to prevention of meconium blood
formation which is the most common cause
intestinal destruction.
5) reducing enterohepatic circulation and
prevent hyperbilirubinaemia.
Milk composition:
 Transitional
milk:
 produced during days 4 to10
High in fat, lactose
Lower in protein and minerals
Milk composition:

Mature milk: available by 2 weeks postpartum.
Milk yield: 750 ml/d
Provides 67 kcal/100 ml
60-80% whey protein.
7% Lactose  provides 40% of caloric need.
4% fat  Provides 50% of the caloric need
Growth promoting factors
Low in vitamin D
Breast feeding

Nowadays there is a world wide efforts to
rise the awareness of the importance of
breast feeding for the benefit of the baby,
and better health for all humans.

WHO strongly recommends exclusive
breastfeeding for the first six months of
life.
Exclusive Breast Feeding
Breast milk ONLY, and no other foods or liquids. Not
even water !!
Signs of Effective Breastfeeding

Frequent feedings 8-12 times daily.

Intermittent episodes of rhythmic sucking with audible
swallows should be heard while the infant is nursing.

Infant should have about 6-8 wet diapers in a 24 hour
period once breast feeding is established.

Infant should have minimum of 3-4 bowel movements
every 24 hours.

Stools should be about one tablespoon or larger and
should be soft and yellow after day 3.

Average daily weight gain of 15 -30g.

Infant has regained birth weight by day 10 of life.
Good Breastfeeding Techniques

The baby should be properly positioned to achieve effective latching.

The mother should wear comfortable apparel, with the breast well
exposed for the infant to be able to latch.

The infant’s mouth, chin and umbilicus should be lined up with the
head in a neutral position.

The infant is brought to the breast, with the nose touching or close
to the breast.

The gum line should overlap the areola, and the nipple straight back
into the mouth.

The tongue moves forward beyond the lower gum, cupped and
forming a reservoir.

Milk is removed for the lactiferous sinuses, the jaw moves down
creating a negative pressure gradient that helped transfer milk to
the pharynx.
Good Breastfeeding Techniques
Breastfeeding Positions
Cradle Hold

This is the most common
position used by mothers.

Infant’s head is supported in
the elbow, the back and
buttock is supported by the
arm and lifted to the breast.
Adapted from AAFP Journal September 2001
Breastfeeding Positions
Football Hold Position

The infant’s is placed under the
arm, like holding a football

Baby’s body is supported with
the forearm and the head is
supported with the hand.

Many mothers are not
comfortable with this position

Good position after operative
procedures
Adapted from AAFP Journal September 2001
Breastfeeding Positions
Side Lying Position

The mother lies on her side
propping up her head and
shoulder with pillows.

The infant is also lying down
facing the mother.

Good position after Caesarean
section.

Allows the new mother some
rest.

Most mothers are scared of
crushing the baby.
Adapted from AAFP Journal September 2001
Breastfeeding Positions
Cross Cradle Hold Position

Ideal for early breastfeeding.

Mother holds the baby
crosswise in the crook of the
arm opposite the breast the
infant is to be fed.

The baby's trunk and head are
supported with the forearm
and palm.

The other hand is placed
beneath the breast in a Ushaped to guide the baby's
mouth to your breast.
Adapted from AAFP Journal September 2001
Breastfeeding Positions
Australian Hold Position

This is also called the saddle
hold

Usually used for older
infants

Not commonly used by
mothers.

Best used in older infants
with runny nose, ear
infection.
Adapted from AAFP Journal September 2001
Breast Milk vs. Cow Milk
Composition (approx.)
Breast Milk
Cow Milk
Water (%)
87
87
Calories (Kcal/100ml)
67
67
0.9 – 1.5
3.3
3 – 3.5
3.7
Lactose (g/100ml)
6.8
4.8
Casein (%)
40
82
Whey (%)
60
18
Calcium (mg/L)
240 - 280
1000 -1200
Phosphorus (mg/L)
100 - 140
960
Protein (g/100ml)
Fat (g/100ml)
33
Breast Milk Contains:



Macronutrients
◦ Protein
◦ Fat
◦ Carbohydrate
Micronutrients
◦ Minerals
◦ Vitamins
Enzymes, hormones, growth factors, immune
globulins, trace elements and cells
34
Protein



75% of the nitrogen-containing compounds in breast milk:
◦ Aqueous whey
◦ Micellar casein
◦ Ratio varies considerably during lactation
Non-protein nitrogen substances include urea, nucleotides,
peptides, free amino acids, and DNA
Colostrum:
◦ Protein: 2.5 gm/dl
◦ Rich in cells
◦ Provides numerous immune factors - secretory IgA
and lactoferrin
◦ Relatively low fat
35
Protein
Human Milk
Bovine Milk
Major protein
Alpha-lactalbumin
Beta-lactoglobulin
Whey
components
Secretory IgA,
lactoferrin, lysozyme
Trace quantities only
Lonnerdal B. Am J Clin Nutr. 2003 Jun;77(6):1537S.
Markus CR. Am J Clin Nutr. 2002 Jun;75(6):1051-6.
36
Fat


About 50% of kcal
More than 98% as triglycerides
◦ Oleic acid (18:1), palmitic acid (16:0) are
the most abundant fatty acids
Human milk: palmitic acid esterified to
center
or 2-position of the triglyceride
 Vegetable oil: palmitic acid esterified
mainly
at external or 1- & 3-positions
 Human milk has significant beneficial
effects
on intestinal absorption of fat and calcium
in healthy term infants

37
Long-Chain Polyunsaturated Fatty Acids (LCPUFA)

Fatty acids with chain length of 18 carbons
or more and at least 2 double bonds

They have a positive impact on cognitive function
and visual development

Arachidonic acid [20:4ω6] and docosahexaenoic
acid [22:6ω3] are higher in plasma and
erythrocytes in breast fed infants than in formulafed infants

Maternal supply of egg yolk lipid, fish oil or
vegetable oil can increase human milk content of
LC-PUFA
38
Enzymes

Human milk lipases
◦ Lipoprotein lipase
 Essential for formation of milk lipid in mammary
gland
◦ Bile salt-stimulated lipase





Stable at low pH
Not affected by intestinal proteolytic enzymes
Heat labile, inactivated by pasteurization
Effective for optional vitamin A absorption
Beneficial for newborn, premature infants
39
Carbohydrates
Lactose is the major carbohydrate
◦ Hydrolyzed to glucose and galactose
◦
 Oligosaccharides
◦ About 10% of total milk carbohydrates
 Lactose-N-tetraose and
monofucosylated derivatives

◦ Some have structures that mimic specific bacterial
antigen ligands - prevent bacteria and toxins’
attachment to the host mucosa
◦ Production of beneficial short-chain fatty acids
is increased by intestinal flora
40
Minerals and Vitamins

Human milk calcium
• Combined with phosphorus & bound to casein
• High bioavailability
• 0.2 g casein/100 g milk
• 280 mg/L (41mg/100Kcal)

3 forms of calcium:
• Free or ionized
• Combined with inorganic anions
(eg, phosphate, citrate)
• Bound to casein
41
Iron
 Infants born with abundant iron stores
• Meet the infant’s requirement until 4 to 6 months
• Low birth weight, preterm infants
need supplementation
 Iron absorption from a variety of foods is about 1%
 Iron absorption from human milk is greater than 50%
 At 6 months, breast fed infants need 1 mg iron
supplementation/kg/day
Dee DL, et al. Pediatrics 2008;122:S98-S104.
American Academy of Pediatrics. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.
42
Vitamins K and D
Vitamin K
◦ Transmitted poorly across the placenta and is in
low concentrations in human milk
◦ A single intramuscular dose of vitamin K at birth
to prevent hemorrhagic disease
 Vitamin D
◦ Vitamin D deficiency may harm bone growth
and tooth enamel formation
◦ Adequate sun exposure may help vitamin D formation
◦ In 2008, the American Academy of Pediatrics (AAP)
recommended that all infants have a minimum intake of
400 IU of vitamin D per day, beginning during the first few
days of life

www.pediatrics.org/cgi/doi/10.1542/peds.2008-1862.
43
Selected Bioactive Factors in
Human Milk
Secretory IgA
Specific antigen-targeted antiinfective action
Lactoferrin
Immunomodulation, iron chelation,
antimicrobial action, anti-adhesive,
trophic for intestinal growth
Nucleotides
Enhances immune response,
promotes growth of mucosa
Oligosaccharides
Reduce bacterial attachment,
nourish beneficial bacteria in
GI tract
Lysozyme, macrophages,
lymphocytes
Lysis of microorganisms,
immunomodulation
44
Selected Bioactive Factors in
Human Milk
Vitamin A, E, C
Carotenoids
Growth factors
• Epidermal growth factor
Antioxidants
Repair of intestinal epithelium
Promotes epithelial cell growth
•
Transforming growth factor
Suppresses lymphocyte function
Promotes epithelial cell growth
•
Nerve growth factor
Promotes nerve growth
Enzymes
•
Platelet activating factor (PAF)acetylhydrolase
•
Glutathione peroxidase
Free amino acids: Glutamine
Blocks action of PAF
Prevents lipid oxidation
Intestinal cell fuel, promotes immune
responses
45
Breast Feeding: Benefits for Infants



Preventing infectious diseases
◦ Bacterial meningitis, bacteremia,
diarrhea, respiratory tract infection, necrotizing
enterocolitis, otitis media,
urinary tract infection, and late-onset
sepsis in preterm infants
Reduced chronic diseases/conditions
◦ Sudden infant death syndrome, diabetes,
lymphoma, leukemia, Hodgkin’s disease, obesity,
hypercholesterolemia, atopy, asthma
Neurobehavioral aspects
◦ Cognitive development
Pediatrics 2005;115:496-506. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496).
46
Breast Feeding: Benefits for
Mothers

Short-Term

Long-Term
◦ Decreased postpartum bleeding
◦ Uterine involution
◦ Decreased menstrual blood loss
◦ Increased child spacing
◦ Postpartum weight loss
◦ Reduced risk of breast and ovarian cancer
◦ Decreased risks of hip fractures
in menopause
Pediatrics 2005;115:496-506. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496).
47
Breast Feeding: Benefits for
Communities





Decreased annual health care costs
Decreased public health program costs
Decreased absenteeism
◦ Decreased loss of family income
More time for siblings and family matters
Decreased environmental burdens
Pediatrics 2005;115:496-506. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496).
48
Breast Feeding:
Do NOT recommend when:
Infants
 The baby is diagnosed with galactosemia, or other
inborn errors of metabolism
Mothers
 Infected with the human immunodeficiency virus (HIV)
 Those with human T-cell lymphotropic virus
 Herpetic lesions localized to the breast
 Untreated active pulmonary tuberculosis
 Is taking prescribed cancer chemotherapy agents, such
as antimetabolites
 Is using or dependent upon an illicit drug
 Is taking antiretroviral medications
 Is undergoing radiation therapies
49
Breast Feeding: Conditions that are NOT
Contraindications
Mothers who are infected with hepatitis
B
or hepatitis C virus
 Mothers who are seropositive carriers
of cytomegalovirus (CMV)
 Mothers who are febrile unless cause is
a contraindication previously outlined
 Mothers who have been exposed to lowlevel environmental chemical agents
 Tobacco smoking
 Breastfeeding mothers who use
alcoholic beverages

50
Counseling and FAQ …

A mother has mastitis, Does she continue
breastfeeding or not ?!
◦ Breast feeding is NOT contraindicated in
mastitis.

What about breast abscess ?!
◦ The mother can nurse form the contralateral
breast.
Drugs …

Absolute:







Antineoplastic.
Radiopharmaceuticals.
Atropine.
Lithium.
Chloramphenicol.
Alcohol.
Relative:






Neuroleptics.
Sedatives.
Metronidazole.
Tetracycline
Sulfonamides.
Steroids.
Challenges to Breast Feeding

Jaundice / hyperbilirubinemia

Growth

Iron deficiency
◦ Interrupt breast feeding temporarily during
severe hyperbilirubinemia
◦ WHO growth charts establish the breast fed
infant as the normative model
◦ Introduce iron-rich complementary foods
at 6 months of age
◦ Supplement infants who have hematologic
disorders or inadequate stores at
birth to >6 months of age
Pediatrics 2005;115:496-506. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496).
American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Pediatrics 2004;114:297–316.
54
Obstacles to Breast Feeding

Insufficient prenatal education about breast feeding

Inappropriate hospital policies and practices

Lack postpartum home health visits and routine follow-up care

Maternal employment

Lack of family and broad societal support

Commercial promotion and media portrayal
of bottle feeding as normative

Lack of guidance and encouragement from health care professionals
55
Breast Milk Storage



Many mothers manage and store breast milk
Directions for safe handling and storage:
www.cdc.gov/breastfeeding/recommendation
s/handling_breastmilk.htm
Preparing expressed breast milk for feeding
◦ Expressed milk held at room temperature should
be fed within 6-8 hours of collection
◦ Avoid thawing or heating milk in a
microwave oven
◦ Do not re-freeze breast milk once it has
been thawed
56
Support Systems
A successful practice of breast feeding
requires education and support:
◦ Breastfeeding Helpline: The DHHS Office on
Women’s Health
http://www.4woman.gov/Breastfeeding/index.
cfm?page=ask
◦ Breastfeeding for Parents
La Leche League International
http://www.lalecheleague.org/nb.html
◦ One-on-One Consultation The International
Lactation Consultant Association
http://www.ilca.org/
◦ Local communities’ hotline
57
10 Steps to Successful Breast
Feeding
1. Have a written breast feeding policy that is
routinely communicated to all health care staff
2. Train all health care staff in skills necessary to
implement this policy
3. Inform all pregnant women about the benefits
and management of breast feeding
4. Help mothers initiate breast feeding within half
an hour of birth
5. Show mothers how to breast feed and how
to maintain lactation even if they should be
separated from their infants
http://www.unicef.org/programme/breastfeeding/baby.htm
58
10 Steps to Successful Breast Feeding
6. Give newborn infants no other foods or drinks
besides breast milk, unless medically indicated
7. Practice “rooming-in,” that is, allow mothers and
infants to remain together 24 hours a day
8. Encourage breast feeding on demand
9. Do not give artificial teats or pacifiers (also called
dummies or soothers) to breast feeding infants
10. Foster the establishment of breast feeding
support groups and refer mothers to them upon
discharge from the hospital or clinic
http://www.unicef.org/programme/breastfeeding/baby.htm
59
Representative Values
for Constituents of Human Milk
Constituent (per liter)
Early Milk
Energy (kcal)
Mature Milk
650-700
Carbohydrate
Lactose (g)
20-30
67
Glucose (g)
0.2-1.0
0.2-0.3
Oligosaccharides (g)
22-24
12-14
Total nitrogen (g)
3.0
1.9
Nonprotein nitrogen
(g)
0.5
0.45
2.5
1.45
Protein nitrogen (g)
60
Constituent (per liter)
Early Milk
Mature Milk
Total protein (g)
16
9
Casein (g)
3.8
5.7
β-casein (g)
2.6
4.4
κ-casein (g)
1.2
1.3
α-lactalbumin (g)
3.62
3.26
Lactoferrin (g)
3.53
1.94
Serum albumin (g)
0.39
0.41
sIgA (g)
2.0
1.0
IgM (g)
0.12
0.2
IgG (g)
0.34
0.05
2
3.5
Triglyceride (% total lipids)
97-98
97-98
Cholesterol+ (% total lipids)
0.7-1.3
0.4-0.5
1.1
0.6-0.8
Total lipids (%)
Phospholipids (% total lipids)
61
Constituent (per liter)
Fatty acids (weight %)
Total saturated
Early Milk
Mature Milk
88
88
43-44
44-45
C12:0
5
C14:0
6
C16:0
20
C18:0
8
Monounsaturated
40
C18:1ω-9
32
31
Polyunsaturated
13
14-15
Totalω-3
1.5
1.5
C18:3ω-3
0.7
0.9
C22:5ω-3
0.2
0.1
C22:6ω-3
0.5
0.2
11.6
13.06
C18:2ω-6
8.9
11.3
C20:4ω-6
0.7
0.5
C22:4ω-6
0.2
0.1
Totalω-6
62
Constituent (per liter)
Early Milk
Mature Milk
Water-soluble vitamins
Ascorbic acid (mg)
Thiamin (μg)
100
20
Riboflavin (μg)
Niacin (mg)
200
400-600
0.5
Vitamin B6 (mg)
1.8-6.0
0.09-0.31
Folate (μg)
80-140
Vitamin B12 (μg)
0.5-1.0
Pantothenic acid (mg)
2.0-2.5
Biotin (μg)
5-9
Fat-soluble vitamins
Retinol (mg)
2
0.3-0.6
Carotenoids (mg)
2
0.2-0.6
2-5
2-3
Vitamin K (μg)
Vitamin D (μg)
Vitamin E (mg)
0.33
8-12
3-8
63
Constituent (per liter)
Early Milk
Mature Milk
250
200-250
Magnesium (mg)
30-35
30-35
Phosphorus (mg)
120-160
120-140
Sodium (mg)
300-400
120-250
Potassium (mg)
600-700
400-550
Chloride (mg)
600-800
400-450
Iron (mg)
0.5-1.0
0.3-0.9
Zinc (mg)
8-12
1-3
0.5-0.8
0.2-0.4
Manganese (μg)
5-6
3
Selenium (μg)
40
7-33
Minerals
Major minerals
Calcium (mg)
Trace minerals
Copper (mg)
Iodine (μg)
150
Fluoride (μg)
4-15
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Conclusions
Strong evidence continues to demonstrate that
human milk is the optimal source of nutrition
for the human infant
 Breast feeding not only decreases the risk of infectious
diseases of infants, but also provides benefits for
maternal health and for the environment
 Support for breast feeding from clinicians
plays an important role
 It is predictable that substantial improvements in breast
feeding ratio could result in valuable health gains to
women and their infants

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