BREAST-FEEDINGMyrna D.C. San Pedro MD,

FPPS

BREAST-FEEDING

• Breast milk: the most ideal, safe & complete food

• Breast milk protein of good biological value

• Thus by WHO, lactation may continue to 18-24 months

BREAST STRUCTURE• Each breast has 15 to 20 lobes

of milk-producing glandular tissue • Each lobe is made up of many

smaller lobules• Special channels called ducts run

from these lobes• Spaces around the lobules and

ducts are filled with fatty & connective tissue stroma that determines the size

• The actual milk-producing structures nearly the same in all

• Nipple skin contains many nerves, oil & sweat secreting glands

WHAT HAS CHANGED?

University of Western Australia’s Human Lactation Research Group, with Medela, investigated the lactating breast using sophisticated ultrasound technology & research results overturned 160 years of received wisdom concerning the female breast.

SUCKLING HORMONE REFLEX ARC

• Nipple stimulation from baby’s breast suckling

• Message sent to spinal cord, then brain

• Increased prolactin levels released by anterior pituitary for milk production

• Increased oxytocin levels released by posterior pituitary for milk ejection reflex

TYPE TIMING QUANTITY CHARACTERISTICS

COLOSTRUM 1st 2-4 days

10-40 ml/day

Deep, yellow fluid w/ more protein (95% globulins & more IgA) but less fat & sugar, more vitamins especially vitamin A, more salt (Na+ & K+), sp. gr. 1.040-1.060 w/ alkaline pH of 7.7

TRANSITIONAL

From the 4th to the 10th day to the 1st month

Increases to less than 600 ml

Fall in protein due to decreasing cells/cu mm & concentration of immunoglobulins but total volume increases w/ gradual increase in fat & lactose, concentrations of Na+, K+ & Cl- decrease but Ca+ & PO4- constant

MATURE By end of 1st month of lactation

About 600 ml in the 1st month to 800 ml in the 6th month after which falls to 25-400 ml on the 2nd yr of life

About 5% fat, 1.1% protein & 7% lactose that is fairly consistent, fatty acids generally reflect maternal diet, total N2 content of 1.2% includes a significant portion of non-protein N2, sp. gr. 1.026-1.036 average being 1.031 w/ pH 6.8-7.4 average of 7**In poorly nourished women, composition constant but total yields lower

ADVANTAGES OF BREAST-FEEDING

1. Proper quality & quantity of nutrients

2. Rates of growth better in the 1st 3-4 months

3. Anti-infective properties universally accepted

4. Prevents allergy due to high IgA preventing antigen absorption

5. Contraceptive property, high levels of prolactin inhibit synthesis of ovarian steroids causing delay of ovulation & pregnancy

6. Psychological advantagesa. Fosters mother-child relationshipb. Tactile contact makes babies

more secure, emotionally stablec. A sense of fulfillment,

satisfaction & joy for the mother7. Protective against

a. Necrotizing enterocolitisb. Otitis mediac. Dental caries

8. Others:a. Safe, contains no pathogensb. Always at the right temperaturec. Convenient & always available

ANTI-INFECTIVE PROPERTIES

a. Breast milk esp colostrum contains plenty of antibodies

b. E. coli antibodies present

c. High % of lactose stimulates Lactobacillus bifidus

d. Lactoferrin binds iron & inhibits growth of E. coli, staphylococci & Candida albicans

e. Lysozyme bacteriostatic against enterobacteriaceae & staphylococcus species

f. Anti-staphylococcus factor

g. Lactoperoxidase kills streptococcic & enteric bacteria

h. Secretory IgA against intestinal bacteria

i. Macrophages 90% of leucocytes involved in phagocytosis & synthesis of bacteriostatic proteins: lactoferrin, lysozyme & complements C3, C4

j. Lymphocytes comprise 10%, approximately 34% B-lymphocytes responsible for synthesis of IgA

k. T-lymphocytes 50% against E. coli, rubella, CMV & mumps viruses & transfer delayed hypersensitivity

ANTENATAL PREPARATIONTECHNIQUES

1. Wear fitted maternity bra from 5th month2. Daily bath enough for cleaning nipples, avoid

soap, alcohol & drying agents3. Rub nipples & areolae with little anhydrous

lanolin to make more supple4. Express colostrum from 7th month by

squeezing areola between index finger & thumb about 3x each side

5. Practice Hoffman’s maneuver (tactile stimulation by thumb & opposing forefinger in the horizontal & vertical planes) for flat or pseudo-inverted nipple

POSTNATAL PROCEDURES

1. Breast-feeding maybe started about 30 min after NSD & 3-4 hrs after C/S

2. The baby should be in a comfortable, semi-sitting position with the baby’s lips engaging considerable areola & the breast not obstructing breathing

3. The mother should be seated comfortably & relaxed (she can feed in the recumbent position if she prefers) with the areola held between her index & middle fingers or between thumb & index finger to enable & control milk flow

4. Baby obtains 95% of milk in the 1st 5 min & frequent feeds as well as short feeds on alternate breasts ideal then burp after

5. It is important to teach mother how to break suction of baby when she feels it is time to stop by pressing on a portion of the breast near baby’s lips to let air into mouth which prevents painful tagging between mother & child minimizing sore nipples

FACTORS INFLUENCING COMPOSITION

1. Time of day2. Mother’s diet3. Mother’s emotional state4. Whether fore or hind milk5. Drugs6. Smoking

CONTENT BREAST MILK COW’S MILKpH Both have pH 6.8-7.4 w/ average of 7

Water content & Specific gravity

Both have water content of 87-87.5% w/ sp. gr. 1.026-1.036 average being 1.031

Proteins 1-1.5% 3.3%

a. Whey-to-casein ratio

60:40 20:80

b. Whey proteins a-lactalbumin (40%)lactoferrin (25%)lysozyme (0.08%), albumin (0.08%), IgA, IgG, IgM (0.15%)

Mostly b-lactoglobulin, some a-lactalbumin & traces of lactoferrin

c. Casein Low ratio of methionine to cystine, lower levels phenylalanine & tyrosine

High ratio of methionine to cystine, higher levels phenylalanine & tyrosine

d. Curds Softer, smaller Less digestible

CONTENT BREAST MILKCOW’S MILK

Fats 3.5% but varies w/ maternal diet

a. Neutral fat or triglycerides palmitin, stearin & olein

Twice as much of the more absorbable olein

b. Volatile fatty acids butyric, capric, caproic & caprylic

1.3% 9%

c. Linoleic acid 4-5% of fat calories, hence, better source of this

d. Digestion & absorption

Contains bile-salt stimulated lipase plus specific fatty acids, hence, more efficient

Steatorrhea may occur

Carbohydrates mainly lactose

7% 4.8%

CONTENT BREAST MILK COW’S MILKMineral content 0.15-0.25% 0.7-0.75%

a. Water Ensures free water Need for extra water

b. With diarrhea

Hypotonic dehydration

Hypertonicity & acidosis common

c. Ca+2/P- ratio 2:1 Neonatal hypocalcemia may occur

d. Iron Although low, sufficient because better absorbed

Lower & lesser absorbed

Vitamins

a. Fat-soluble Both contains large amounts of vitamin A, minimal vitamin D & should be given vitamin K to prevent hemorrhagic disease of the newborn

b. B complex More niacin More thiamine & riboflavin

c. Ascorbic acid

More vitamin C Lesser

DETERMINING ADEQUACY

• If infant is satisfied after breast feeding• Sleeps well, about 2-4 hours, and

contented till next feeding time• Regularly and adequately gaining weight• The “let-down” or milk rejection reflex in

the mother is an important sign

REASONS FOR NOT OR STOPPING BREAST-FEEDING

1. Lack of motivation or preparation of mothers2. Anxiety, fear & uncertainty in the mother3. Aesthetic reasons4. Status seeking & effective promotion of infant foods5. Mothers work to increase & augment family income6. Separate maternity & nursery wards7. Milk formula easily sucked from the bottle nipple8. Cultural milieu9. Mothers who can’t despite all desires & attempts10. Presence of contraindications

CONTRAINDICATIONS

1. Absolute: chronic diseases like open TB, cardiac diseases, thyrotoxicosis, advanced nephritis, mental & seizure disorders

2. Relative: when mother is taking anticoagulants, antibiotics, steroids or potentially toxic substances like benzene products

3. Mechanical contraindications on the part of the mother: retracted or oversized nipples

4. Mechanical contraindications on the part of the baby: congenital anomalies like harelip & cleft palate but breast milk may be pumped & given

5. Allergy should be proven

WET NURSING

• When breast milk fed to an infant is obtained from a lactating woman other than the mother

• For infants, like LBWs, who don’t seem to do well with any other type of milk

• A good lactating woman should be able to supply milk for 2-3 babies at same time

• A wet nurse should be in good health, have good personal hygiene & enough milk for another infant in addition to her own who is thriving well

The positive thinker sees the invisible, feels the intangible, and achieves the impossible.