BREASTFEEDING
Before the 20th century, breastfeeding was the main way of feeding babies. If for any reason the natural mother was unable to breastfeed, a wet nurse was used. Attempts were made in 15th century
Breastfeeding is one of the most effective ways to ensure child health and survival. Optimal breastfeeding together with complementary feeding help prevent malnutrition and can save about a million child lives. Globally less than 40% of infants under six months of age are exclusively breastfed. Adequate breastfeeding support for mothers and families could save many young lives. Human breast milk is the healthiest form of milk for babies.
International Breastfeeding Symbol
WHO actively promotes breastfeeding as the best source of nourishment for infants and young children. Infants should be exclusively breastfed – i.e. receive only breast milk – for the first six months of life to achieve optimal growth, development and health. “Exclusive breastfeeding” is defined as giving no other food or drink – not even water – except breast milk. It does, however, allow the infant to receive oral rehydration salts (ORS), drops and syrups (vitamins, minerals and medicines). Breast milk is the ideal food for the healthy growth and development of infants; breastfeeding is also an integral part of the reproductive process with important implications for the health of mothers.
WHO strongly recommends
– exclusive breastfeeding for the first six months of life;
– breastfeeding should begin within an hour of birth;
– breastfeeding should be “on demand”, as often as the child wants day and night;
– bottles or pacifiers should be avoided.
– at six months, other foods should complement breastfeeding for up to two years or more.
Breastfeeding provides benefits for the infant.
1. Early breast milk is liquid gold – known as liquid gold, colostrum is the thick yellow first breast milk that is made during pregnancy and just after birth. This milk is very rich iutrients and antibodies to protect baby. Although baby only gets a small amount of colostrum at each feeding, it matches the amount his or her tiny stomach can hold.
2. Breast milk changes as baby grows – colostrum changes into what is called mature milk. By the third to fifth day after birth, this mature breast milk has just the right amount of fat, sugar, water, and protein to help your baby continue to grow. It is a thinner type of milk than colostrum, but it provides all of the nutrients and antibodies baby needs.
3. Breast milk is easier to digest – for most babies, especially premature babies, breast milk is easier to digest than formula. The proteins in formula are made from cow’s milk and it takes time for babies’ stomachs to adjust to digesting them.
4. Physical contact is important to newborns. It can help them feel more secure, warm, and comforted.
5. Breast milk fights disease – the cells, hormones, and antibodies in breast milk protect babies from illness. This protection is unique. Breast milk:
– greater immune health – during breastfeeding, approximately 0.25-
– reduces sudden infant death syndrome;
– decreases risk of fewer infections (diarrhea, lower respiratory infection, otitis media, bacteremia, bacterial meningitis, botulism, urinary tract infection);
– prevents diabetes – infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than babies with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods.Breastfeeding also appears to protect against diabetes mellitus type 2, at least in part due to its effects on the child’s weight.
– prevents childhood obesity – breastfeeding reduces the risk of extreme obesity in children. The protective effect of breastfeeding against obesity increases with the duration of breastfeeding. Infants who are bottle-fed in early infancy are more likely to empty the bottle or cup in late infancy than those who are breastfed. “Bottle-feeding, regardless of the type of milk, is distinct from feeding at the breast in its effect on infants’ self-regulation of milk intake.” This may be due to factor, that when bottle feeding, parents may encourage an infant to finish the contents of the bottle whereas when breastfeeding, an infant naturally develops self-regulation of milk intake;
– prevents necrotizing enterocolitis (NEC) – necrotizing enterocolitis is an acute inflammatory disease in the intestines of infants. It is mainly found in premature births/ NEC was found to be six to ten times more common in infants fed formula exclusively, and three times more common in infants fed a mixture of breast milk and formula, compared with exclusive breastfeeding. In infants born at more than 30 weeks, NEC was twenty times more common in infants fed exclusively on formula.
– prevents Crohn’s disease, ulcerative colitis, lymphoma, allergic diseases and other chronic diseases;
– enhancement of cognitive development – there is evidence that people who were breastfed perform better in intelligence tests.
Breastfeeding during an emergency
When an emergency occurs, breastfeeding can save lives:
– Breastfeeding protects babies from the risks of a contaminated water supply.
– Breastfeeding can help protect against respiratory illnesses and diarrhea. These diseases can be fatal in populations displaced by disaster.
– Breast milk is the right temperature for babies and helps to prevent hypothermia when the body temperature drops too low.
– Breast milk is readily available without needing other supplies.
Breastfeeding provides benefits for mother.
1. Bonding.
Hormones released during breastfeeding help to strengthen the maternal bond. Teaching partners how to manage common difficulties is associated with higher breastfeeding rates. Support for a mother while breastfeeding can assist in familial bonds and help build a paternal bond between father and child.
The skin-to-skin contact between mother and baby can calm the mother and child.
2. Hormone release.
Breastfeeding contact releases oxytocin and prolactin, hormones that relax the mother and make her feel more nurturing toward her baby.Breastfeeding soon after giving birth increases the mother’s oxytocin levels, making her uterus contract more quickly and reducing bleeding.
3. Weight loss.
As the fat accumulated during pregnancy is used to produce milk, extended breastfeeding—at least 6 months—can help mothers lose weight. It has been observed that prolonged exclusivity of breastfeeding is associated with increased weight loss when controlling for gestational weight gain and postpartum caloric intake
4. Long-term health effects
– less risk of breast cancer, ovarian cancer, and endometrial cancer;
– less risk of coronary heart disease, rheumatoid arthritis;
– mothers who breastfeed longer than eight months benefit from bone re-mineralisation;
– breastfeeding diabetic mothers require less insulin;
– reduced risk of metabolic syndrome;
– reduced risk of post-partum bleeding.Prevent postpartum depression.
5. Life can be easier for mother, who breastfeed –there are no bottles and nipples to sterilize. Mother does not have to buy, measure, and mix formula. And there are no bottles to warm in the middle of the night! Woman can satisfy baby’s hunger right away when breastfeeding.
6. Breastfeeding can save money – formula and feeding supplies can cost well over $1,500 each year, depending on how much your baby eats. Breastfed babies are also sick less often, which can lower health care costs.
7. Mothers miss less work – Breastfeeding mothers miss fewer days from work because their infants are sick less often.
Breastfeeding provides benefits for society.
1. The nation benefits overall when mothers breastfeed. Recent research shows that if 90 percent of families breastfed exclusively for 6 months, nearly 1,000 deaths among infants could be prevented. The
2. Breastfeeding also contributes to a more productive workforce since mothers miss less work to care for sick infants. Employer medical costs are also lower.
3. Breastfeeding is also better for the environment. There is less trash and plastic waste compared to that produced by formula cans and bottle supplies.
Breast milk has just the right amount of fat, sugar, water, and protein that is needed for a baby’s growth and development. The composition of breast milk changes depending on how long the baby nurses at each session, as well as on the age of the child.
Why not infant formula?
Infant formula does not contain the antibodies found in breast milk. When infant formula is not properly prepared, there are some risks arising from the use of unsafe water and unsterilized equipment or the potential presence of bacteria in powdered formula. Malnutrition can result from over-diluting formula to “stretch” supplies. Further, frequent feedings maintain the breast milk supply. If formula is used but becomes unavailable, a return to breastfeeding may not be an option due to diminished breast milk production.
How breast milk is made
Knowing how the breast works to produce milk can help you understand the breastfeeding process. The breast itself is a gland that is made up of several parts, including:
Glandular tissue – body tissue that makes and releases one or more substances for use in the body. Some glands make fluids that affect tissues or organs. Others make hormones or assist with blood production. In the breast, this tissue is involved in milk production.
Connective tissue – a type of body tissue that supports other tissues and binds them together. This tissue provides support in the breast.
Blood – fluid in the body made up of plasma, red and white blood cells, and platelets. Blood carries oxygen and nutrients to and waste materials away from all body tissues. In the breast, blood nourishes the breast tissue and provides nutrients needed for milk production.
Lymph – the almost colorless fluid that travels through the lymphatic system and carries cells that help fight infection and disease. Lymph tissue in the breast helps remove waste.
Nerves – cells that are the building blocks of the nervous system (the system that records and transmits information chemically and electrically within a person). Nerve tissue in the breast makes breasts sensitive to touch, allowing the baby’s sucking to stimulate the let-down or milk-ejection reflex and milk production. Learn more about let-down reflex.
Fatty tissue – connective tissue that contains stored fat. It is also known as adipose tissue. Fatty tissue in the breast protects the breast from injury. Fatty tissue is what mostly affects the size of a woman’s breast. Breast size does not have an effect on the amount of milk or the quality of milk a woman makes.
Special cells inside breasts make milk. These cells are called alveoli. When breasts become fuller and tender during pregnancy, this is a sign that the alveoli are getting ready to work. Some women do not feel these changes in their breasts. Others may sense these changes after their baby is born.
The alveoli make milk in response to the hormone prolactin. Prolactin rises when the baby suckles. Another hormone, oxytocin, causes small muscles around the cells to contract and move the milk through a series of small tubes called milk ducts. This moving of the milk is called let-down reflex.
A let-down reflex or milk ejection reflex is a conditioned reflex ejecting milk from the alveoli through the ducts to the sinuses of the breast and the nipple. This reflex makes it easier to breastfeed your baby. Let-down happens a few seconds to several minutes after mother starts breastfeeding baby. It can happen a few times during a feeding, too. Woman may feel a tingle in your breast or you may feel a little uncomfortable. Some women don’t feel anything. Let-down can happen at other times, too, such as when mother hear baby cry or when may just be thinking about baby.
Oxytocin also causes the muscles of the uterus to contract during and after birth. This helps the uterus to get back to its original size. It also lessens any bleeding a woman may have after giving birth. The release of both prolactin and oxytocin may be responsible in part for a mother’s intense feeling of needing to be with her baby.
Time and place for breastfeeding
Feeding a baby “on demand” (sometimes referred to as “on cue”), means feeding when the baby shows signs of hunger. Newborn babies usually express demand for feeding every 1 to 3 hours per 24 hours (resulting in 8-12 times in 24 hours) for the first two to four weeks.
Experienced breastfeeding mothers learn that the sucking patterns and needs of babies vary. While some infants’ sucking needs are met primarily during feedings, other babies may need additional sucking at the breast soon after a feeding even though they are not really hungry. Babies may also nurse when they are lonely, frightened or in pain.
Most US states now have laws that allow a mother to breastfeed her baby anywhere she is allowed to be. In hospitals, rooming-in care permits the baby to stay with the mother and improves the ease of breastfeeding. Some commercial establishments provide breastfeeding rooms, although laws generally specify that mothers may breastfeed anywhere, without requiring them to go to a special area.
Duration of each session
During the newborn period, most breastfeeding sessions will take from 20 to 45 minutes. After the finishing of a breast, the mother may offer the other breast.
Exclusively breastfed infants feed anywhere from 6 to 14 times a day. Newborns consume from 30 to 90 ml (1 to 3 US fluid ounces) per feed. After the age of four weeks, babies consume about 120ml (4 US fluid ounces) per feed. Each baby is different, but as it grows the amount will increase.
It is important to recognize the baby’s hunger signs. It is assumed that the baby knows how much milk it needs and it is therefore advised that the baby should dictate the number, frequency, and length of each feed. The supply of milk from the breast is determined by the number and length of these feeds or the amount of milk expressed. The birth weight of the baby may affect its feeding habits, and mothers may be influenced by what they perceive its requirements to be. For example, a baby born small for gestational age may lead a mother to believe that her child needs to feed more than if it is larger; they should, however, go by the demands of the baby rather than what they feel is necessary.
Number of daily feedings:
First 2 months of life: 7 feedings per day every 3 hours with night break in 6 hrs.
3-5 months of life: 6 feedings per day every 3,5 hours with night break in 6,5 hrs.
After 6 months: 5 feedings per day every 4 hours with night break in 8 hrs.
Correct position and technique for latching
Every mother must know the correct positioning and technique for latching to prevent nipple soreness and allow the baby to obtain enough milk. The “rooting reflex” is the baby’s natural tendency to turn towards the breast with the mouth open wide; mothers sometimes make use of this by gently stroking the baby’s cheek or lips with their nipple to induce the baby to move into position for a breastfeeding session, then quickly moving the baby onto the breast while its mouth is wide open. To prevent nipple soreness and allow the baby to get enough milk, a large part of the breast and areola need to enter the baby’s mouth. Failure to latch on is one of the main reasons for ineffective feeding and can lead to infant health concerns. A study found that inadequate parental education, incorrect breastfeeding techniques, or both were associated with higher rates of preventable hospital re-admissions of newborns.
Technique for latching:
1. Hold baby, wearing only a diaper, against bare chest. Hold the baby upright with his or her head under mother’s chin. Baby will be comfortable in that cozy valley between breasts. Mother’s skin temperature will rise to warm baby.
2. Support his or her neck and shoulders with one hand and hips with the other. He or she may move in an effort to find mother’s breast.
3. Baby’s head should be tilted back slightly to make it easy to suck and swallow. With his or her head back and mouth open, the tongue is naturally down and ready for the breast to go on top of it.
4. Allow breast to hang naturally. When baby feels it with his or her cheek, he or she may open his or her mouth wide and reach it up and over the nipple. Mother can also guide the baby to latch on as in the illustrations below.
5. At first, baby’s nose will be lined up opposite nipple. As his or her chin presses into breast, his or her wide, open mouth will get a large mouthful of breast for a deep latch. Keep in mind that baby can breathe at the breast. The nostrils flare to allow air in.
1. Tickle the baby’s lips to encourage him or her to open wide.
2. Pull your baby close so that the chin and lower jaw moves into your breast first.
3. Watch the lower lip and aim it as far from base of nipple as possible, so the baby takes a large mouthful of breast.
Proper latching onto nipple. Wrong latching onto nipple.
Some moms find that the following positions are helpful ways to get comfortable and support their babies in finding a good latch. Mother also can use pillows under your arms, elbows, neck, or back to give you added comfort and support. Keep in mind that what works well for one feeding may not work well for the next.
Breast feeding technique (video).
Breastfeeding positions:
- Cradle — Hold your baby in one arm, with its head resting in the bend of your elbow. The baby’s lower arm is tucked out of the way. Its mouth is close to your breast and the two of you are tummy to tummy. This is the most frequently used position. This position can be used when you are sitting up in bed with pillows supporting your back or sitting in a chair.
2. Cross cradle or transitional hold – Useful for premature babies or babies with a weak suck because it gives extra head support and may help babies stay latched. Hold baby along the opposite arm from the breast you are using. Support baby’s head with the palm of your hand at the base of his or her neck.
3. Clutch or “football” hold – Useful for mothers who had a c-section and mothers with large breasts, flat or inverted nipples, or a strong letdown reflex. It is also helpful for babies who prefer to be more upright. This hold allows you to better see and control your baby’s head, and keep the baby away from a c-section incision. Hold your baby at your side, lying on his or her back, with his or her head at the level of your nipple. Support baby’s head with the palm of your hand at the base of the head. (The baby is placed almost under the arm.)
4. Side-lying position – Useful for mothers who had a c-section or to help any mother get extra rest while the baby breastfeeds. Lie on your side with your baby facing you. Pull your baby close so your baby faces your body.
How to know that baby is getting enough milk
Many babies, but not all, lose a small amount of weight in the first days after birth. Baby is getting plenty of milk if he or she is mostly content and gaining weight steadily after the first week of age. From birth to three months, typical weight gain is two-thirds to one ounce each day.
Other signs that your baby is getting plenty of milk:
– He or she is passing enough clear or pale yellow urine, and it’s not deep yellow or orange (see the chart below).
– He or she has enough bowel movements (see the chart below).
– He or she switches between short sleeping periods and wakeful, alert periods.
– He or she is satisfied and content after feedings.
– Mother’s breasts feel softer after feeding baby.
If necessary, it is possible to estimate feeding from wet and soiled nappies (diapers): 8 wet cloth or 5–6 wet disposable, and 2–5 soiled per 24 hours suggests an acceptable amount of input for newborns older than 5–6 days old. After 2–3 months, stool frequency is a less accurate measure of adequate input as some normal infants may go up to 10 days between stools.
Babies can also be weighed before and after feeds.
Common Problems During Breast Feeding.
Although breastfeeding is the recommended method of feeding infants, it is not without complications or occasional discomforts for the mother. By being aware of these common problems, the health care professional can offer advice to mothers to help alleviate potential difficulties. As a general rule, breastfeeding should be continued through most illnesses, including periods of diarrhea. Some of the most common problems are listed below.
Sore nipples
Most women experience sore nipples at some period during their breastfeeding course, especially during the first 2 weeks postpartum. Breastfeeding should be comfortable once mother has found some positions that work and a good latch is established. Woman may also have pain if your baby is sucking on only the nipple.
Prescription for Sore nipples:
– Check for proper positioning. Baby should be latching onto at least 3/4″ of the areola, not just the nipple
– If baby is sucking only on the nipple, gently break your baby’s suction to your breast by placing a clean finger in the corner of baby’s mouth and try again.
– Offer least sore side first
– Break suction at end of feeding by inserting a finger or pulling gently down on baby’s chin.
– After breastfeeding, express a few drops of milk and gently rub it on your nipples with clean hands. Human milk has natural healing properties and emollients that soothe. Also try letting your nipples air-dry after feeding, or wear a soft cotton shirt.
– Avoid wearing bras or clothes that are too tight and put pressure on your nipples.
– Change nursing pads often to avoid trapping in moisture.
– Avoid using soap or ointments that contain astringents or other chemicals on your nipples. Make sure to avoid products that must be removed before breastfeeding. Washing with clean water is all that is needed to keep your nipples and breasts clean.
Engorgement
It is normal for breasts to become larger, heavier, and a little tender when they begin making more milk. Sometimes this fullness may turn into engorgement, when mother’s breasts feel very hard and painful. Woman also may have breast swelling, tenderness, warmth, redness, throbbing, and flattening of the nipple. Engorgement sometimes also causes a low-grade fever and can be confused with a breast infection. Engorgement is the result of the milk building up. It usually happens during the third to fifth day after birth, but it can happen at any time.
Engorgement can lead to plugged ducts or a breast infection, so it is important to try to prevent it before this happens. If treated properly, engorgement should resolve.
Prescription for engorgement:
– Breastfeed often after birth, allowing the baby to feed as long as he or she likes, as long as he or she is latched on well and sucking effectively. In the early weeks after birth, mother should wake baby to feed if four hours have passed since the beginning of the last feeding.
– Work with a lactation consultant to improve the baby’s latch.
– Breastfeed often on the affected side to remove the milk, keep it moving freely, and prevent the breast from becoming overly full.
– Avoid overusing pacifiers and using bottles to supplement feedings.
– Hand express or pump a little milk to first soften the breast, areola, and nipple before breastfeeding.
– Massage the breast.
– Use cold compresses in between feedings to help ease pain.
– If mother is returning to work, she must try to pump milk on the same schedule that the baby breastfed at home. Or, can pump at least every four hours.
– Get enough rest, proper nutrition, and fluids.
– Wear a well-fitting, supportive bra that is not too tight.
Plugged ducts.
It is common for many women to have a plugged duct at some point breastfeeding. A plugged milk duct feels like a tender and sore lump in the breast. It is not accompanied by a fever or other symptoms. It happens when a milk duct does not properly drain and becomes inflamed. Then, pressure builds up behind the plug, and surrounding tissue becomes inflamed. A plugged duct usually only occurs in one breast at a time.
Prescription for plugged duct:
– Breastfeed often on the affected side, as often as every two hours. This helps loosen the plug, and keeps the milk moving freely.
– Massage the area, starting behind the sore spot. Use your fingers in a circular motion and massage toward the nipple.
– Use a warm compress on the sore area.
– Get extra sleep or relax with your feet up to help speed healing. Often a plugged duct is the first sign that a mother is doing too much.
– Wear a well-fitting supportive bra that is not too tight, since this can constrict milk ducts. Consider trying a bra without underwire.
Breast infection (mastitis)
Mastitis is soreness or a lump in the breast that can be accompanied by a fever and/or flu-like symptoms, such as feeling run down or very achy. Some women with a breast infection also have nausea and vomiting. Woman also may have yellowish discharge from the nipple that looks like colostrum. Or, the breasts may feel warm or hot to the touch and appear pink or red. A breast infection can occur when other family members have a cold or the flu. It usually only occurs in one breast. It is not always easy to tell the difference between a breast infection and a plugged duct because both have similar symptoms and can improve within 24 to 48 hours. Most breast infections that do not improve on their own within this time period need to be treated with medicine given by a doctor.
Prescription for mastitis:
– Breastfeed often on the affected side, as often as every two hours. This keeps the milk moving freely, and keeps the breast from becoming overly full.
– Massage the area, starting behind the sore spot. Use your fingers in a circular motion and massage toward the nipple.
– Apply heat to the sore area with a warm compress (not cold).
– Drink plenty of fluids
– Get extra sleep or relax with your feet up to help speed healing. Often a breast infection is the first sign that a mother is doing too much and becoming overly tired.
– Wear a well-fitting supportive bra that is not too tight, since this can constrict milk ducts.
Breastfeeding a baby with health problems
There are some health problems in babies that can make it harder to breastfeed. Yet breast milk and early breastfeeding are still best for the health of both you and your baby — even more so if your baby is premature or sick. Even if your baby cannot breastfeed directly from mother, it’s best to express or pump your milk and give it to baby with a cup or dropper.
Some common health problems in babies are listed below.
Jaundice
Jaundice is caused by an excess of bilirubin, a substance that is in the blood usually in very small amounts. In the newborn period, bilirubin can build up faster than it can be removed from the intestinal track. Jaundice can appear as a yellowing of the skin and eyes. It affects most newborns to some degree, appearing between the second and third day of life. The jaundice usually clears up by two weeks of age and is not harmful.
Two types of jaundice can affect breastfed infants — breastfeeding jaundice and breast milk jaundice.
Breastfeeding jaundice can occur when a breastfeeding baby is not getting enough breast milk. This can happen either because of breastfeeding challenges or because the mother’s milk hasn’t yet come in. This is not caused by a problem with the breast milk itself.
Breast milk jaundice may be caused by substances in the mother’s milk that prevents bilirubin from being excreted from the body. Such jaundice appears in some healthy, breastfed babies after about one week of age. It may last for a month or more and it is usually not harmful.
Jaundice is best treated by breastfeeding more frequently or for longer periods of time. It is crucial to have a health care provider help you make sure the baby is latching on and removing milk well. This is usually all that is needed for the infant’s body to rid itself of excess bilirubin.
Premature and/or low birth weight
Most babies who are low birth weight but born after 37 weeks (full term) can begin breastfeeding right away. They will need more skin-to-skin contact with mom and dad to help keep them warm. These smaller babies may also need more frequent feedings, and they may get sleepier during those feedings.
Many babies born prematurely are ofteot able to breastfeed at first, but they do benefit from expressed milk. Mother can express colostrum by hand or pump as soon as can in the hospital. Once baby is ready to breastfeed directly, skin-to-skin contact can be very calming and a great start to first feeding.
Expressing breast milk and storage
When direct breastfeeding is not possible, a mother can express (artificially remove and store) her milk. With manual massage or using a breast pump, a woman can express her milk and keep it in freezer storage bags, a supplemental nursing system, or a bottle ready for use. Breast milk may be kept at room temperature for up to six hours, refrigerated for up to eight days or frozen for up to four to six months. Antioxidant activity in expressed breast milk decreases over time but it still remains at higher levels than in infant formula. Expressing breast milk can maintain a mother’s milk supply when she and her child are apart. If a sick baby is unable to feed, expressed milk can be fed through a nasogastric tube.
Before express breast milk, mother must wash her hands with soap and water, or a waterless hand cleanser if hands don’t appear dirty. The breast and nipples do not need to be washed before pumping. Also, the area where woman is expressing must be clean.
Ways to express milk
|
Type |
How it works |
What’s involved |
|
Hand expression |
You use your hand to massage and compress your breast to remove milk. |
· Requires practice, skill, and coordination. · Gets easier with practice; can be as fast as pumping. · Good if you are seldom away from baby or need an option that is always with you. But all moms should learn how to hand express. |
|
Manual pump |
You use your hand and wrist to operate a hand-held device to pump the milk. |
· Requires practice, skill, and coordination. · Useful for occasional pumping if you are away from baby once in a while. · May put you at higher risk of breast infection. |
|
Automatic, electric breast pump |
Runs on battery or plugs into an electrical outlet. |
· Can be easier for some moms. · Can pump one breast at a time or both breasts at the same time. · Double pumping may collect more milk in less time, so they are helpful if you are going back to work or school full-time. · Need places to clean and store the equipment between uses. |
Manual pump Electric pumps Milk storage bags and bottles
Storage of breast milk
Breast milk can be stored in clean glass or hard BPA-free plastic bottles with tight fitting lids. You can also use milk storage bags, which are made for freezing human milk. Do not use disposable bottle liners or other plastic bags to store breast milk.
After each pumping
· Label the date on the storage container. Include your child’s name if you are giving the milk to a childcare provider.
· Gently swirl the container to mix the cream part of the breast milk that may rise to the top back into the rest of the milk. Shaking the milk is not recommended — this can cause a breakdown of some of the milk’s valuable components.
· Refrigerate or chill milk right after it is expressed. You can put it in the refrigerator, place it in a cooler or insulated cooler pack, or freeze it in small (2 to
Tips for freezing milk
· Wait to tighten bottle caps or lids until the milk is completely frozen.
· Try to leave an inch or so from the milk to the top of the container because it will expand when freezing.
· Store milk in the back of the freezer — not in the freezer door.
Tips for thawing and warming up milk
· Clearly label milk containers with the date it was expressed. Use the oldest stored milk first.
· Breast milk does not necessarily need to be warmed. Some moms prefer to take the chill off and serve at room temperature. Some moms serve it cold.
· Thaw frozen milk in the refrigerator overnight, by holding the bottle or frozen bag of milk under warm running water, or setting it in a container of warm water.
· Never put a bottle or bag of breast milk in the microwave. Microwaving creates hot spots that could burn your baby and damage the components of the milk.
· Swirl the milk and test the temperature by dropping some on your wrist. It should be comfortably warm.
· Use thawed breast milk within 24 hours. Do not refreeze thawed breast milk.
Recommendations for mother’s diet.
Women who are breastfeeding need to be careful about what they eat and drink, since things can be passed to the baby through the breast milk
· To drink approximately
· The nursing mother requires an additional 500 calories and 20-
· She has to take her prenatal vitamins with iron.
· Breastfeeding women should avoid fish that are high in mercury, and limit lower mercury fish intake
· The mother need not to avoid certain foods unless she observes consistent increased fussiness in the baby in association with the mother ingestion such foods.
Foods commonly incriminated:
• Garlic
• Onions
• Cabbage
• Chocolate
• Great quantities of caffeine.
HIV and breastfeeding
An HIV-infected mother can pass the infection to her infant during pregnancy, delivery and through breastfeeding. Antiretroviral (ARV) drug interventions to either the mother or HIV-exposed infant reduces the risk of transmission of HIV through breastfeeding. Together, breastfeeding and ARV interventions have the potential to significantly improve infants’ chances of surviving while remaining HIV uninfected. WHO recommends that when HIV-infected mothers breastfeed, they should receive ARVs and follow WHO guidance for breastfeeding and complementary feeding.
Regulating breast-milk substitutes
An international code to regulate the marketing of breast-milk substitutes was adopted in 1981. It calls for:
– all formula labels and information to state the benefits of breastfeeding and the health risks of substitutes;
– no promotion of breast-milk substitutes;
– no free samples of substitutes to be given to pregnant women, mothers or their families;
– no distribution of free or subsidized substitutes to health workers or facilities.
Support for mothers is essential
Breastfeeding has to be learned and many women encounter difficulties at the beginning. Nipple pain, and fear that there is not enough milk to sustain the baby are common. Health facilities that support breastfeeding – by making trained breastfeeding counsellors available to new mothers – encourage higher rates of the practice. To provide this support and improve care for mothers and newborns, there are now more than 20 000 “baby-friendly” facilities in 152 countries thanks to a WHO-UNICEF initiative. video
Plan of weaning in breast feeding
To meet the growing needs of babies at six months of age, complementary foods should be introduced as they continue to breastfeed. Foods for the baby can be specially prepared or modified from family meals. WHO notes that:
· breastfeeding should not be decreased when starting complementary feeding (weaning) complementary foods should be given with a spoon or cup, not in a bottle;
· foods should be clean, safe and locally available; and
· ample time is needed for young children to learn to eat solid foods.
In the first 6 months, water, juice, and other foods are generally unnecessary for breastfed infants.
Vitamin D and iron may need to be given before 6 months of age in selected groups of infants (vitamin D for infants whose mothers are vitamin D-deficient or those infants not exposed to adequate sunlight; iron for those who have low iron stores or anemia).
Fluoride should not be administered to infants during the first 6 months after birth, whether they are breast- or formula-fed. During the period from 6 months to 3 years of age, breastfed infants (and formula-fed infants) require fluoride supplementation only if the water supply is severely deficient in fluoride (<0.3 ppm).
WHO recommended plan of weaning in breast feeding
|
Food stuffs |
Time of giving |
Age (in months) depending volume of food |
||||
|
6 |
7 |
8 |
9 |
10 |
||
|
Juice (fruit, vegetable), ml |
6 |
30-50 |
50-70 |
50-70 |
80 |
100 |
|
Fruit puree, ml
|
6 |
40-50 |
50-70 |
50-70 |
80 |
90-100 |
|
Vegetable puree, g
|
6 |
50-150 |
150 |
170 |
180 |
200 |
|
Groats (porridge, rice, buckwheat), g |
6-7 |
5-50 |
50-100 |
150 |
180 |
200 |
|
Cereals (semolina, barley, corn), g |
7-8 |
5-50 |
50-100 |
150 |
180 |
200 |
|
Yoghurt, kefir, ml
|
8-9 |
– |
– |
10-50 |
50-150 |
150-200 |
|
Soft cheese, g
|
6,5-7,5 |
5-25 |
10-30 |
30 |
30 |
50 |
|
Yolk
|
7,0-7,5 |
– |
1/8-1/4 |
¼-½ |
¼-½ |
½-3/4 |
|
Meat puree, g
|
6,5-7,0 |
5-30 |
30 |
50 |
50 |
50-60 |
|
Fish puree, g
|
9-10 |
– |
– |
10-20 |
30-50 |
50-60 |
|
Vegetable oil
|
6 |
½ tsp |
½ tsp. |
1 tsp |
1 tsp |
1 tsp |
|
Butter
|
6-7 |
½ tsp |
½ tsp |
1 tsp |
1 tsp |
1 tsp |
|
Bread, g
|
8-9 |
– |
– |
5 |
5 |
10 |
§ Female’s milk – is a unique combination of nutrients, complex biological system, which conducts plastic, energetic and immuno-modulating functions
Human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions.
§ The ultimate decision on feeding of the infant is the mother’s.
§ Pediatricians should provide parents with complete, current information on the benefits and methods of breastfeeding to ensure that the feeding decision is a fully informed one.
§ When direct breastfeeding is not possible, expressed human milk, fortified wheecessary for the premature infant, should be provided.
Before advising against breastfeeding or recommending premature weaning, the practitioner should weigh thoughtfully the benefits of breastfeeding against the risks of not receiving human milk
Epidemiologic research
§ shows that human milk and breastfeeding of infants provide advantages with regard to general health, growth, and development, while significantly decreasing risk for a large number of acute and chronic diseases. Research in the United States, Canada, Europe, and other developed countries, among predominantly middle-class populations, provides strong evidence that human milk feeding decreases the incidence and/or severity of diarrhea, lower respiratory infection, otitis media, bacteremia, bacterial meningitis, botulism, urinary tract infection, and necrotizing enterocolitis
• Breast milk contains lactoferrin (an iron-binding whey protein), which inhibits bacterial growth by depriving them of iron, which is necessary for growth.
• Breast milk contains cystine and tyrosine, which are not synthesized by infants but they are essential for proper growth and development.
• Breast milk contains taurine that is synthesized in inadequate amounts in infants. It is important for normal differentiation of CNS.
• Breast milk contains nonspecific factors of immune difence: lisozyme, macrofagocytes, neutrofiles, lymphocytes, complement
• There are 5 times more essential fatty acids (polyunsaturated: arachidonic, docosahexacnoic, linoleic, and α-linolenic) in breasts milk than in cow’s milk.
• Breast milk contains ferments (lipase, lactase) and mothers hormones.
• Breast milk is ‘species specific’ and therefore allergy to breast milk is rare.
•
•
•
Table 1. Medicines that should be avoided with nursing mothers
|
Drug |
Reported sign or symptom in infant or effect on lactation |
|
Aspirin (salicylates) |
Metabolic acidosis (dose related); may affect platelet function; hemorrhagic rash |
|
Clemastine |
Drowsiness, irritability, refusal to feed, high-pitched cry, neck stiffness |
|
Phenobarbital |
Sedation; infantile spasms after weaning from milk containing phenolbarbitol, methemoglobinemia |
|
Primidone |
Sedation; feeding problems |
|
Sulfasalazine |
Bloody diarrhea |
Table 2. Drugs of abuse that are contraindicated during breast-feeding
|
Drug |
Reported sign or symptom in infant or effect on lactation |
|
Amphetamine |
Irritability, poor sleep pattern |
|
Cocaine |
Cocaine intoxication |
|
Heroin |
Irritability, Heroin intoxication |
|
Nicotine (smoking) |
Shock, vomiting, diarrhea, rapid heart rate, restlessness; decreased milk production |
|
Phencyclidine |
Potent hallucinogen |
Other reasons why a mother may not breastfeed her baby:
• Working outside the home makes it more difficult to breastfeed exclusively, especially if there is no support at her workplace for her to either bring her baby or to express and store her milk.
• Choosing not to breastfeed for personal reasons, either from the birth of the baby or after breastfeeding for a short while, is a mother’s prerogative.
Recommendations for Working Women:
• The mother who goes back to work can usually continue breast-feeding without problems. The milk supply adjusts itself to the demand. If the mother is working at least 8 hours a day, it is sometimes prudent to pump the breasts once during her work day in order to stay comfortable and maintain a good milk supply. Each woman is different in what is required to maintain a supply. Some women can work for a long time without pumping and without compromising the supply. Others have a supply that is more responsive to decreased feeds. A woman will rarely “dry up” because she has returned to work.
• Working mothers, however, can easily breast-feed part-time and formula-feed part-time.
• Breast pumps and storage of milk
• Hand expression is superior if the mother can learn the technique.
• Several pumps are available if the mother is unable to express by hand.
• It is good if the woman can borrow a pump from a friend before she decides which pump to purchase. Another alternative is to rent an electric pump.
• Milk should be stored in clean containers and immediately refrigerated or frozen.
• If refrigerated, it will stay good for 48 hours.
• If frozen at
• Recommendations for mother’s diet:
• To drink approximately
• The nursing mother requires an additional 500 calories and 20-
• She has to take her prenatal vitamins with iron.
• The mother need not to avoid certain foods unless she observes consistent increased fussiness in the baby in association with the mother ingestion such foods.
• Foods commonly incriminated:
•
• Garlic
• Onions
• Cabbage
• Chocolate
• Great quantities of caffeine.
• Nursing mother may drink small amounts of alcohol: a glass of sherry or wine may be beneficial in late afternoon if she is having let-down reflex problems.
• Common problems encountered with breast-feeding
• Poor Let-Down (Milk ejection reflex)
• Poor Weight Gain
• Mastitis
• Cracked Nipples
• Jaundice From Breast- Feeding
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• 1979 – Joint WHO/UNICEF meeting on Infant and Young Child Feeding (
• 1981 – Adoption of International Code of Marketing of Breast-Milk Substitutes
• 1985 –
• 1989 – Joint WHO/UNICEF statement on the Special Role of Maternity Services to Protect, Promote, and Support Breastfeeding (Ten Steps to Successful Breastfeeding)
• 1990 –World Summit for Children declaration (“Empowerment of all women to breastfeed their children exclusively for 6 months and continue breastfeeding with complementary food well into the second year”) 1991 – Launch of Baby-Friendly Hospital Initiative with 12 lead countries (Bolivia, Brazil, Côte d’Ivoire, Egypt, Gabon, Kenya, Mexico, Nigeria, Pakistan, Philippines, Thailand, and Turkey)
• 1992 – FAO/WHO International Conference on Nutrition (ICN) Declaration adopting breastmilk as food security for infant from birth to 6 months
•
• Rooming in
• Early initiation
• Demand feeding
• No separation of mother and infant
• Exclusive Breastfeeding
• Four “Pillars” of Safe Motherhood
• Family planning
• Antenatal care
• Clean/safe delivery
• Essential obstetric care
RECOMMENDED BREASTFEEDING PRACTICES
• Human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions. The ultimate decision on feeding of the infant is the mother’s. Pediatricians should provide parents with complete, current information on the benefits and methods of
• breastfeeding to ensure that the feeding decision is a fully informed one. When direct breastfeeding is not possible, expressed human milk, fortified wheecessary for the premature infant, should be provided. Before advising against breastfeeding or recommending premature weaning, the practitioner should weigh thoughtfully the benefits of breastfeeding against the risks of not receiving human milk.
• Basic rules for successful
breastfeeding
• Apply baby to mother’s breast within the first hour of life if there are no contraindications.
• Round the clock rooming mother and child.
• Proper application of the child to the mother’s breast.
• Breastfeeding at the request of the child, including at night.
• Do not give the child other foods and liquids up to 6 months, except for cases of medical indications.
• Do not use pacifiers.
• Exclusively breastfeeding up to 6 months.
• Mandatory introduction of adequate complementary foods from 6 months.
• Continued breastfeeding up to 1 year and longer, if possible.
• When discharged <48 hours after delivery, all breastfeeding mothers and their newborns should be seen by a pediatrician or other knowledgeable health care practitioner when the newborn is 2 to 4 days of age. In addition to determination of infant weight and general health assessment, breastfeeding should be observed and evaluated for evidence of successful breastfeeding behavior. The infant should be assessed for jaundice, adequate hydration, and age-appropriate elimination patterns (at least six urinations per day and three to four stools per day) by 5 to 7 days of age.
• Colostrum
• All newborns should be seen by 1 month of ageImmunological protection (high level Ig A);
• More uniquely loss of meconii;
• The level of hyperbilirubinemia is more less;
• Hyper energy features;
• Compensation of needing on energy first 2 day of life.
Caloric of colostrum:
|
1 day |
150 ccаl |
В 100 мl |
|
2 day |
120 ccаl |
В 100 мl |
|
3 day |
80 ccаl |
В 100 мl |
|
4 day |
75 ccаl |
В 100 мl |
• Components of mother milks (WHО, 1991 years.)
•
|
Components |
Clostrum |
Transitory milk |
Developed milk |
|
Water, г |
87 |
88 |
88 |
|
Protein, г |
2,7 |
1,59 |
1,1 |
|
Lacto-Albumini |
1,2 |
0,51 |
0,4 |
|
Lactoglobulinu |
1,5 |
0,8 |
0,6 |
|
Fats, g |
2,9 |
3,5 |
4,5 |
|
Fats Acidi |
7 |
– |
8 |
|
Cholesteroli |
0,028 |
0,024 |
0,014 |
|
Carbohydrates (lactosae) |
5,7 |
6,4 |
7,1 |
• Assessment of breastfeeding performed at each mandatory medical examination of the child care
•
Signs of the correct application of the child to the mother’s breast:
1. head and body of the child are in the same plane;
2. body of the child is close to the mother, face to chest, nose is opposite to the nipple;
3. mother supports the whole body of the child at the bottom and not just his head and shoulders;
4. mother supports breast with fingers underneath the index finger on the bottom and thumb -top (fingers should be close to the nipple);
5. first, mother needs to move the nipple to child’s lips and wait for the baby to widely open it’s mouth, and then quickly bring the child to the chest, sending it’s lower lip below the nipples of that the baby sucking lower part of the areola;
6. posture should be comfortable for mother.
Credible signs of a poor child breast milk:
§ Ages when a child may need more breast milk:
1. 3 weeks;
2. 6 weeks;
3. 3 months.
§ This is due to the intense growth of children in these age periods, which requires more frequent application of the breast. It should not be considered as a reason for the introduction in the diet of baby milk.
§ If there are abnormalities in physical development and feeding, reevaluation of breastfeeding should be made not later than 2 days after the preliminary assessment and further if necessary
• Signs of effective suckling:
• a child’s slow, deep sucking with few interruptions.
• One of the most common reasons for introduction of infant formula into the baby’s diet and stopping exclusive breastfeeding is sufficient mother’s concern regarding the quantity of breast milk.
• Credible signs of a poor breast milk
•
• Weight gain of less than
• Urination less than 6 times a day, concentrated yellow urine with pungent odor
• Advising mothers with feeding children under 6 months
• If during the assessment of breastfeeding it is found that baby gets enough breast milk, it is important to praise the mother for her efforts.
• If during the evaluation of breastfeeding it is found that the child receives insufficient milk supply, it is important to identify the possible causes and give mother recommendations:
• Mother should:
• Pay attention to the number of feedings during the day. If breastfeeding at least 8-10 times a day, mothers should be advised to increase the frequency of feedings.
• Adhere to the principles of feeding at the request of the child, to feed at night.
• If the child is properly attached to the chest or ineffective sucks, it is important to teach the mother to properly put baby to breast.
• If the child receives other foods or drinks, you should advise mothers to breastfeed more often, reduce portions of other foods or drinks and later abandon them.
• Should advise the mother to fully eat and involve other family members to care for the child for her good rest
• Refuse nipple, soothers.
• Keep in mind:
• During breast-feeding, mother may face the lactational crises. This is a temporary reduction in the amount of milk for no apparent reason, which lasts an average of 3-4 days and is reversible.
• You should inform the mother about the possibility of such crises, which can cause a temporary decrease in milk.
• During this period, the mother needs psychological support and relaxation.
In case of illness of mother with acute respiratory illness breastfeeding should be continued.
• Breastfeeding should be discontinued if the mother is taking drugs, which according to the instructions on the application have contraindications for mothers who breast fed children.
• The position of the mother and a child
•
• 6-12 months of life: feeding and nutrition.
•
• At the age of 6 months, breast milk is the primary product for the child, but there is a need to expand the diet of the child and enrich it with additional products (foods)
• Breast milk is the age of 6 months may no longer meet the needs of the child in calories, micronutrients, especially iron, for its normal development.
• Baby food- is food that is introduced in addition to breastmilk (milk mixture in the case of artificial feeding) baby first year).
• Before the introduction of complementary foods to ensure the readiness of the child to do so.
• Recommendations. Part 1
• To prevent iron deficiency anemia of 6 months must introduce food products that contain iron (meat, then liver, egg yolk, fish).
• It is not recommended the use of any type of tea and coffee to children under 2 years, as these drinks hinder the process of absorption of iron.
• We should not give milk diluted cow’s milk for children up to 9 months (a factor of iron deficiency anemia).
• Whole milk and dairy products can be given to children in the age= of 9-12 months.
• During the introduction of complementary foods should not add to foods food salt and spices.
• If you see signs of poor tolerance towards certain food products (dysfunction of the digestive system, allergic reactions, or others), you should stop giving this product and offer another one.
• Recommendations. Part 2
•
• Food products. The first food products, offered to the child in the age of 6 months may be porridge (preference is given to cereals, which do not contain gluten (buckwheat, rice, corn), vegetable or fruit puree.
• Frequency of administration of these products should be 1-2 times a day with a gradual increase in volume of portions.
It is important that a child aged 6 months start receiving foods with high iron content.
• Foods with high content of iron:
• cereals, industrial production, iron-fortified;
• meat;
• fish;
• egg yolk;
• well cook legumes (beans, peas).
•
• Cereal
•
• We should start with cereal that contains one grits advisable with high iron content (such as rice or buckwheat porridge). Then introduce cereal with other cereals (corn, oat).
• Mixed cereal with several cereals should be introduced only after the child has already received cereal grains of each type separately.
• Cereal can be diluted in breast milk.
• To prepare the porridge milk mixture or diluted cow’s milk can be used.
• Type of milk
• colostrum before 3-4 day lactation;
• Early milk(from4–5-day lactation);
• Cross milk (from 5–6–го day till14-20 day lactation);
• Developed milk (from 2-3 weak of lactation)
• Main Rules Of Additional Feeding:
• Starting from little dosage (5-10 ml) we increase the dose later on to fulfill 1 breast feeding.
• Another type of additional feeding should be given when the child become adapted with the previous feeding.
• Additional feeding should be given before breast feeding because after breast feeding the child dislikes to intake any other unknown food.
• Food must be very soft and easy to swallow and should not be irritable to digestive tract.
•
• Preparing of cereals
•
• To 200 ml of diluted milk to boil 70 ml of water,
• add 130 ml of boiled cow or goat milk,
• add 1 teaspoon of sugar topless
• Do not give your baby cereal for adults.
• Cereal can be mixed with vegetables or fruits, but only after the child tried each of these products separately
• Feed the baby only with a spoon.
• Meat and alternative products
• It is important that for a child to receive foods with a high content of iron contained in meat at the age of 6 months .
• Meet, recommended for children in the age of 6-9 months: beef, chicken, turkey, rabbit meat, lean pork.
• We should start with small distorted or mashed meat, gradually moving to the pieces of.
• Meat must be dry and store natural moisture that the child could swallow it easily.
• Do not give the child smoked meats, sausage, hot dogs, as they contain large amounts of fat and salt.
• We must give children fish (from 8-10 months) and egg yolk (from 7 months), which is also a source of iron.
• Egg protein is an allergenic food and until the child reaches 1 year, it should not be given.
• Fruits and Vegetables
• Vegetables should be introduced before fruits because some kids may not like the taste of vegetables, if they are used to the sweet taste of fruit. However, it does not necessarily apply to all children.
• We should start with one type of vegetable or fruit, and only after the child received each of them separately, you can mix them.
• We should start with mild-tasting vegetables (zucchini, squash, potatoes, cabbage, squash) and fruits (apples, peaches, apricots, plums).
• Vegetable / fruit puree as low protein dish foods, give no more than 2 weeks, you’ll need to enrich these dishes by adding these high-protein foods (soft cheese, meat).
• You can give your baby pureed fresh fruit and vegetables, which should be well before you wash and clean. Over time, you can give the baby vegetables and fruit pieces.
• Juices and other drinks
•
• The child is enough fluids it receives from breast milk. From 6 months, some babies may sometimes require water. You caot give the child distilled, carbonated mineral water.
• Juice should be given to the baby when it is already receiving other foods. Juice can be given in small quantities (80-100 ml at the age of 1 year), making sure that the child drinks enough breast milk (milk mixture in the case of artificial feeding). Juices do not dilute with water and add sugar.
• From 6 months to help your child learn to drink from a cup.
• Do not use any type of tea (black, green, herbal) and coffee up to two years. These drinks prevent the absorption of iron. After two years of age should avoid drinking tea during meals. Dairy products:
• It is recommended to give the baby soft cheese (from 6 months).
• Do not give your baby undiluted cow’s or goat’s milk up to 9 months of age, and preferably up to 1 year.
• Dilutions of cow’s milk can be used for cooking foods.
• We do not recommend feeding baby goat’s milk exclusively, particularly through risk folice deficiency anemia.
•
• Frequency of complementary feeding
•
•
• A child under the age of 8 months needs to get foods 3 times a day,
• Aged 9-11 months – 4 times a day.
• At the age of 1 year the child should receive various foods from each food groups, to be able to drink from a cup.
• Breast milk is the most important staple
food for a child
• Even after the full introduction of complementary foods should feed your baby with a breast milk after meals.
• If a child is hungry, you need to give her breast milk (milk mixture in the case of artificial feeding) at the request of the child, not the graphics.
• Feeding of the child has to take place at the table with other family members.
• Number of proposed intakes should be based on the principles of active encouragement of the child to eat. You should gradually change the texture and increase the variety of foods products, adhering to the recommended frequency of introduction of complementary foods.
• Approximately in the age of 9 months baby can borrow items thumb and forefinger. We must offer herself to keep small pieces of foods during meals, feed himself with a spoon.
• Food (soft cooked vegetables and fruits, ripe soft fruit, well boiled tender meat and fish) should be given in the form of small pieces of which are easy to swallow.
• You must enter in the diet of the child other cereal products, which can be given by pieces (crackers, bread, cookies).
• If the child is already offered all types of products, you can offer it whole cow’s milk 3.25% fat, but not before 9-12 months. Do not give children under 2 years of milk and dairy products with 1-2% fat. or without fat .
• Before each meal you should wash child’s hands
•
•
•
•
• Evaluation of nutrition. Children in the age 6-12 months
• Evaluation of baby’s nutrition is made at each of the required medical examination of the child. To assess the nutrition, it is necessary to ask it’s mother for:
• the presence of difficulties or problems with feeding the child
• clarify whether it continues breastfeeding;
• if breastfeeding continues, it is necessary to clarify how many times a day a child is put to the breast;
• determine whether mother started to introduce solid foods;
• what foods in the child’s diet are rich in iron;
• what is the frequency of complementary feeding;
• What is the quantity of consumed food;
• what is the consistency food products:
• liquid, creamy, thick;
• whether the mother is feeding baby with
• a spoon or only with a bottle;
• Does mother actively engages a
• child into the process of food consumption.
• Advising mothers with breastfeeding
and child nutrition from 6 to 12 months
• After evaluating feeding and child nutrition, counseling is necessary to be held for the mother.
• During the consultation is very important to provide the mother
with psychological support.
• Tell the mother to continue breastfeeding on demand of the baby. Food products should not completely displace breastfeeding.
• Tell the mother to gradually, according to the appetite of the child, increase the number of foods of different type. Explain the importance of foods enriched with iron. Clearly explain the frequency of feeding under age. Tell the mother to avoid consistency of child nutrition.
• Explain the importance of the mother to the child during feeding. You must feed the child with other family members, allow the child to feed themselves, to be prepared for confusion, which is an integral part of the learning process.
• Advising mothers with breastfeeding
and child nutrition from 6 to 12 months
• After evaluating feeding and child nutrition, counseling is necessary to be held for the mother.
• During the consultation is very important to provide the mother
with psychological support.
• Tell the mother to continue breastfeeding on demand of the baby. Food products should not completely displace breastfeeding.
• Mother’s safety tips during feeding.
• Tell the mother to gradually, according to the appetite of the child, increase the number of foods of different type. Explain the importance of foods enriched with iron. Clearly explain the frequency of feeding under age. Tell the mother to avoid consistency of child nutrition.
• Explain the importance of the mother to the child during feeding. You must feed the child with other family members, allow the child to feed themselves, to be prepared for confusion, which is an integral part of the learning process
• We must teach the mother to communicate with the child during feeding: speak softly, gently. Do not compare your child with others, as well as healthy children do not like each other, they can eat different amounts of foods, abandon products like other children and vice versa. Mother should know that reliable sign of normal development of the child is stable gain in weight.
• Explain the mother to feed the baby harm forcibly.
• You must advise mothers about safety during feeding Be sure to wash both mother’s and child’s hands before meals.
• Use clean water, clean utensils for cooking and serving food for the child.
• We must always be with the child when she eats, never leave it alone.
• Do not give your baby solid food in the form of small round objects (grapes, nuts, candies, candy, etc.).
• Avoid sharp objects.
• Do not force a child to eat.
• Food should be like body temperature (36-37 ° C).
BREAST-FEEDING
One of the 1st decisions a new or expectant mother must make—ideally, some time before the infant is born—is whether the infant will be breast-fed or formula-fed. Human milk is uniquely adapted to the infant’s needs and is the most appropriate milk for the human infant. Breast-feeding has practical and psychologic advantages. Thus, all mothers should be encouraged to breast-feed their babies, but they should not be coerced to do so.
ADVANTAGES OF BREAST-FEEDING.
Breast milk is the natural food for full-term infants and is the appropriate milk for the 1st year of life. It is always available at the proper temperature and requires no preparation time. It is fresh and free of contaminating bacteria, thereby reducing the chances of gastrointestinal disturbances. Although there is little, if any, difference in mortality rates between breast-fed and formula-fed infants receiving good care, the protective effects of breast milk against enteric and other pathogens result in less morbidity. These effects are particularly important in developing countries or any locality without a safe supply of potable water and effective methods for disposal of human waste.
Breast-feeding is associated with fewer feeding difficulties incident to allergy and/or intolerance to bovine milk. These include diarrhea, intestinal bleeding, occult melena, “spitting up,” colic, and atopic eczema. Breast-fed infants also appear to have a lower frequency of certain allergic and chronic diseases in later life than formula-fed infants.
Human milk contains bacterial and viral antibodies, including relatively high concentrations of secretory immunoglobulin A, that prevent microorganisms from adhering to the intestinal mucosa. It also contains substances that inhibit the growth of many common viruses as well as specific antibodies that are thought to provide local gastrointestinal immunity against organisms entering the body via this route. These factors probably account, at least partially, for the lower prevalence of diarrhea, otitis media, pneumonia, bacteremia, and meningitis during the 1st year of life in infants who are breast-fed exclusively compared with those who are formula-fed for the 1st 4 mo of life.
Macrophages in human milk may synthesize complement, lysozyme, and lactoferrin. In addition, breast milk contains lactoferrin, an iron-binding whey protein that is normally approximately ⅓ saturated with iron and has an inhibitory effect on the growth of Escherichia coli in the intestine. Further, the lower pH of the stool of breast-fed infants is thought to contribute to the favorable intestinal flora of infants fed human milk compared with formula (more bifidobacteria and lactobacilli; fewer Escherichia coli), and this helps protect against infections caused by some species of E. coli. Human milk also contains bile salt-stimulated lipase, which kills Giardia lamblia and Entamoeba histolytica. Transfer of tuberculin responsiveness by breast milk suggests passive transfer of T-cell immunity.
Milk from the mother whose diet is sufficient and properly balanced will supply all the necessary nutrients except fluoride and vitamin D. If the water supply is not adequately fluoridated (≤0.3 ppm), the breast-fed infant should receive at least 10 mg of fluoride daily for the 1st 6 mo of life; thereafter, the fluoride intake should approximate the adequate intake (see Table 41-3 ). The vitamin D intake should be 200 IU/day, starting at 2 mo of age for all breast-fed infants. The iron content of human milk is low, but most normal term infants have sufficient iron stores for the 1st 4–6 mo of life. Human milk iron is well absorbed. Nonetheless, by 4–6 mo of age, the breast-fed infant’s diet should be supplemented with iron-fortified complementary foods and/or a ferrous iron preparation.
The vitamin K content of human milk also is low and may contribute to hemorrhagic disease of the newborn. Parenteral administration of 1 mg of vitamin K1 at birth is recommended for all infants, and this is especially important for those who will be breast-fed.
The psychologic advantages of breast-feeding for both mother and infant are well recognized. The mother is personally involved iurturing of her infant, and this results in both a feeling of being essential and a sense of accomplishment. At the same time, the infant develops a close and comfortable physical relationship with the mother.
The resumption of menstruation should not deter continued breast-feeding. Pregnancy does not necessitate immediate cessation of nursing, but the combined demands of supplying milk to the infant and supplying nutrients to the developing fetus are formidable, necessitating special attention to maternal nutrition.
Transmission of HIV by breast-feeding is well documented (see Chapter 273 ). Thus, if safe alternatives are available, breast-feeding by HIV-infected mothers is not recommended. However, in many developing countries, breast-feeding may be crucial for infant survival; the risk of HIV transmission by breast-feeding may be less than the risk of other feeding methods. The World Health Organization (WHO) recommends that breast-feeding be continued, even in areas of high endemic rates of HIV infection, unless safe infant formula is readily available. This reflects the belief that the risk of formula-feeding in many developing countries is significantly greater than the risk of HIV infection with breast-feeding.
Cytomegalovirus (CMV), human T-cell lymphotropic virus type 1, rubella virus, hepatitis B virus, and herpes simplex virus have also been demonstrated in breast milk. Approximately ⅔ of CMV-seronegative breast-fed infants may become infected with CMV. In term infants, this appears to occur without symptoms or sequelae, but the risk of more serious infection in preterm infants may be greater. Thus, the use of fresh donor milk for feeding preterm infants is contraindicated unless the milk is known to be CMV-negative.
Evidence of breast milk transmission of other viruses is rare. However, vesicles have beeoted in the mouths of infants whose mothers’ milk contained herpes simplex virus. Thus, nursing women with active herpes simplex lesions should observe scrupulous handwashing technique and should avoid nursing if there are active lesions on or near the nipple.
Although hepatitis B virus has been isolated from human milk, the predominant means of mother-infant transmission of this virus appears to be through delivery. Active immunization of the infant within the 1st 24 hr of life, coupled with administration of specific high-titer hepatitis B immune globulin and a follow-up active vaccination, should permit the mother who is infected with hepatitis B to nurse with minimal risk to the infant. If a nursing mother acquires hepatitis B, the infant should receive the accelerated protocol of immunization (see Chapter 170 ).
PREPARATION OF THE MOTHER FOR BREAST-FEEDING.
Most women, if encouraged, educated, and protected from discouraging experiences and comments while milk secretion is becoming established, can successfully breast-feed their infants. The physician who is interested in helping the prospective mother breast-feed successfully should discuss the advantages of breast-feeding with her as early as the mid-trimester of pregnancy or whenever the mother begins planning for her infant (see Chapter 94 ). Many mothers who are ambivalent toward breast-feeding are able to nurse successfully if reassured and supported. Training of maternity staff and adoption of the Baby-Friendly Hospital Initiative, as recommended by WHO, are successful interventions to encourage breast-feeding (see Chapter 94 ) [ Table 42-1 ].
TABLE 42-1 — Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-Friendly
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MOTHERS TO LEARN |
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ADDITIONAL INSTRUCTIONS |
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Factors that are conducive to successful breast-feeding include good nutritional health, a proper balance of rest and exercise, freedom from worry, early and sufficient treatment of any intercurrent disease, and adequate nutrition. Retracted and/or inverted nipples are detractions but not contraindications to breast-feeding. Retracted nipples usually benefit from daily manual breast-pump suction during the latter weeks of pregnancy, and truly inverted nipples may be helped by the use of milk cups, starting as early as the 3rd month of pregnancy.
If the mother’s diet is adequate, she need not gain or lose weight while breast-feeding. Nursing will help the uterus return to its normal size sooner and also may help the mother return to her pre-pregnancy weight sooner. Many women must be reassured that breast tone will be preserved by the use of a properly fitted brassiere to support the breasts, especially before delivery and during the nursing period. Breast-feeding has no long-term adverse cosmetic effects on the breast appearance.
ESTABLISHING AND MAINTAINING THE MILK SUPPLY.
The most satisfactory stimulus to the secretion of human milk is regular and complete emptying of the breasts. Efforts should be directed toward the early establishment of normal, vigorous nursing, even during the 1st few days after birth, when there appears to be little, if any, milk. Breast-feeding should begin as soon after delivery as the conditions of the mother and the infant permit. Infants should room in with the mother and should not be offered other milks or water supplements. Infants who can’t be fed on demand should be brought to the mother for feeding approximately every 3 hr during the day and night. Once lactation is well established, most mothers are capable of producing more milk than their infant needs.
Appropriate care for tender or sore nipples should be instituted before severe pain from abrasions and cracking develops. Exposing the nipples to air, applying pure lanolin, avoiding soap and other drying agents, changing disposable nursing pads frequently, nursing more often, manually expressing milk, nursing in different positions, and keeping the breast dry between feedings are recommended. If nipple tenderness is sufficient to make the mother apprehensive, the milk-ejection reflex may be delayed. This leads to frustration of the infant and increasingly vigorous nursing, which further injures the nipple and areolar area. Nipple shields may be helpful in some such situations.
The 1st 2 wk after birth are crucial for establishing breast-feeding. Daily weight gains of the infant, although important for ascertaining the volume of milk produced, should not be overly emphasized during this time. Supplemental bottle-feedings to achieve weight gain should be limited because these may compromise attempts at breast-feeding.
Although the difference between breast and bottle nipples may confuse the infant, this is usually not a serious problem. It is perfectly satisfactory to have the mother pump her breasts and feed the infant breast milk via a bottle for the 1st 1–2 wk. Then, when she is relaxed and less anxious, she can attempt breast-feeding 1 or 2 times daily until she and the infant have achieved a successful nursing routine. The additional pumping will usually increase milk production, thereby helping to ensure an adequate supply. Even after nursing is well established, it may be appropriate for the mother to pump extra milk and store it (in a home freezer for up to 1 mo or in a refrigerator for up to 24 hr) for use when she is not available. This allows the mother some freedom and, at the same time, allows the father or other caregivers to be more involved in the infant’s feeding and care.
Lactation usually is not well established before the mother is discharged from the hospital, and the excitement of going home may impede an initially successful in-hospital nursing experience. It is wise to anticipate this possibility and discuss it with the mother. Providing her with enough formula for a few feedings may prevent discouragement that might prejudice further nursing.
No factor is more important for successful breast-feeding than the mother’s happy, relaxed state of mind. Mothers may worry that their infants are abnormal when they cry, are drowsy, sneeze, or regurgitate milk. They are often upset by any suggestion that their milk may be lacking in quantity or quality, and they may be disturbed by the scanty supply of colostrum, nipple tenderness, and the fullness of the breasts on the 4th or 5th day after delivery. Many mothers do not feel comfortable when trying to nurse in an open ward, or even with another person in the room. Many also may worry about what is going on at home while they are in the hospital or what is going to happen when they return home. An alert physician recognizes and appreciates these worries, particularly if the infant is a firstborn, and provides tactful reassurance and explanations that minimize worry and enhance the likelihood of successful breast-feeding. The support plan for individual mothers, of course, must include consideration of social and cultural factors.
HYGIENE.
Proper hygiene will help prevent irritation and infection of the nipples caused by prolonged initial nursing, maceration from wetness of the nipple, or rubbing of clothing.
The breasts should be washed at least once a day. If soap appears to dry the nipple and areolar area, a milder, non-drying soap should be substituted or the use of soap should be temporarily discontinued. The nipple area should be kept as dry as possible.
Many mothers are more comfortable wearing a properly fitted brassiere day and night. If this is done, plastic liners should be removed and a commercially available absorbent pad or clean cloth should be placed inside the brassiere to absorb any leaked milk.
MATERNAL DIET AND OTHER FACTORS.
The breast-feeding mother’s diet should contain enough calories and other nutrients to compensate for those secreted in the milk as well as for those required to produce it. A varied diet sufficient to maintain weight and generous in fluid, vitamins, and minerals is important. Weight-reducing diets should be avoided, particularly while the infant is exclusively breast-fed. Milk is an important component of the mother’s diet, but it should not replace other essential foods. If the mother is allergic to milk or dislikes it, her diet should be supplemented with
Ingestion of some foods (berries, tomatoes, onions, members of the cabbage family, chocolate, spices, condiments) by the mother may occasionally cause the infant to have gastric distress or loose stools. However, no food need be withheld from the mother unless it is known to cause, or is strongly suspected to cause, distress to the infant.
Nursing mothers should not take drugs unless they are absolutely necessary (see Chapter 94 ). Many preparations are harmful to the neonate; many have not been evaluated. Antithyroid medications, lithium, anticancer agents, isoniazid, recreational drugs, and phenindione are contraindicated for the breast-feeding mother. If the mother requires any of these agents, diagnostic radiopharmaceuticals, chloramphenicol, metronidazole, sulfonamides, and/or anthraquinone-derivative laxatives, temporary cessation of breast-feeding should be considered. Nursing mothers should limit intake of fish from waters contaminated with polychlorinated biphenyls or other substances (mercury). Smoking cigarettes and drinking alcoholic beverages should be discouraged during breast-feeding. It is important for the breast-feeding mother to avoid fatigue. She should exercise sufficiently to promote her sense of physical well-being.
TECHNIQUE OF BREAST-FEEDING.
Breast-feeding sometimes becomes impossible because the attending physician fails to recognize that the difficulties are in the feeding technique. It is important to review the technical aspects of breast-feeding with the mother, particularly the mother who has not breast-fed before (see Chapter 94 ).
At feeding time, the infant should be hungry, dry, and neither too cold nor too warm. He or she should be held in a comfortable, semi-sitting position to prevent vomiting with eructation. The mother, too, should be comfortable and completely at ease. A moderately low chair with an armrest is preferable, and a low stool for resting her foot and raising her knee on the nursing side is helpful. The infant should be supported comfortably with the face held close to the mother’s breast by 1 arm and hand while the other hand supports the breast, making the nipple easily accessible to the infant’s mouth without obstructing nasal breathing. The infant’s lips should engage considerable areola as well as nipple.
Success in breast-feeding depends, in large part, on the adjustments made during the 1st few days of life. Difficulties often result from attempts to adapt the infant to a nursing procedure rather than designing a procedure that satisfies the infant. Most problems can be avoided by conforming to the infant’s spontaneous pattern. If the infant is breast-fed when hungry and his or her appetite is satisfied, the fundamental requirements are met.
Several reflexes or behavior patterns that facilitate breast-feeding are present at birth. These include the rooting, sucking, swallowing, and satiety reflexes. The rooting reflex is the 1st to come into play. When the infant smells milk, he or she moves the head in an attempt to find the source of the smell. If the cheek is touched by a smooth object (the mother’s breast), the infant will turn toward that object and open his or her mouth in anticipation of grasping the nipple (rooting with the mouth for the nipple). The infant’s rooting reflex brings the entire areolar area into the infant’s mouth and contact of the nipple against the infant’s palate and posterior tongue elicits sucking, while the buccal fat pads help keep the nipple in place. This sucking reflex is a process of squeezing the sinuses of the areola rather than simply sucking on the nipple, as is required for bottle-feeding. Finally, milk in the infant’s mouth triggers the swallowing reflex.
The breast-feeding infant’s sucking results in afferent impulses to the mother’s hypothalamus and then to both the anterior and the posterior pituitary. Prolactin release from the anterior pituitary stimulates milk secretion by the cuboidal cells in the acini or alveoli of the breast, whereas secretion of oxytocin by the posterior pituitary results in contraction of the myoepithelial cells surrounding the alveoli deep in the breast. This, in turn, “squeezes” milk into the larger ducts, where it is more easily available to the sucking infant. When this “let down” or milk ejection reflex functions well, milk flows from the opposite breast as the infant begins to nurse. The reflex is often absent or erratic during periods of pain, fatigue, or emotional distress. This is thought to be a common cause of milk retention in women who are unsuccessful at breast-feeding.
Mothers should know that the infant who is not hungry will not search for the nipple or suck. Most infants are usually sleepy for several days after birth; hence, they are not avid suckers. By the 3rd day of life, when there has been some weight loss, many mothers become anxious if the infant seems uninterested iursing. It reassures them to learn that most healthy infants “wake up” and become good nursers by the 4th or 5th day of life. Infants whose mothers were sedated during labor usually suck at lower rates and pressures and also consume less milk than infants of non-sedated mothers.
Some infants will empty a breast in 5 min; others will nurse at a more leisurely pace, sometimes for 20 min or longer. Most of the milk is obtained early in the feeding (50% in the 1st 2 min and 80–90% in the 1st 4 min). Unless the mother has sore nipples, the infant should be allowed to suck until satisfied. If the infant does not “unlatch” from the breast after a reasonable period, a finger can be inserted into the corner of his or her mouth to decrease suction and facilitate removal. The infant should not be pulled from the breast.
At the end of the nursing period, the infant should be held erect over the mother’s shoulder or on her lap, with or without gentle rubbing or patting of the back to assist in expelling swallowed air. This “burping” procedure often is necessary 1 or more times during the feeding as well as 5–10 min after the infant has been returned to the crib. It is an essential procedure during the early months of life, but should not be overdone.
The infant should empty at least 1 breast at each feeding; otherwise, the breast will not be stimulated sufficiently to refill. Both breasts should be used at each feeding during the early weeks to encourage maximal milk production. After the milk supply is established, the breasts may be alternated at successive feedings. The infant will usually be satisfied with the amount obtained from 1 breast. If milk secretion becomes too great, both breasts may be offered at each feeding but incompletely emptied, thereby decreasing milk production.
DETERMINING THE ADEQUACY OF MILK SUPPLY.
If the infant is satisfied after each nursing period, sleeps 2–4 hr between feedings, and gains weight adequately, the milk supply is sufficient. Infants who are “light sleepers” usually require considerable body contact with the mother during the 1st months of life; hence, it should not be assumed automatically that mothers of such infants have a poor milk supply. On the other hand, if the infant nurses avidly and completely empties both breasts, but appears unsatisfied afterward (does not go to sleep after nursing or sleeps fitfully and awakens after 1–2 hr) and fails to gain weight satisfactorily, the milk supply is probably inadequate. The
In general, weighing the infant before and after every nursing to judge the adequacy of the milk supply is neither necessary nor desirable. The amount of milk an infant takes at a single feeding ranges from 1 to several oz throughout a 24 hr period and, hence, is usually unimportant with respect to daily intake. Small gains may worry the mother and, in turn, may diminish her milk supply. In addition, she may give the infant a bottle to reassure herself that the infant is getting enough to eat, and the better result with the “test bottle” may discourage breast-feeding, even if she has an adequate milk supply.
Three possibilities should be excluded before assuming that a mother cannot produce sufficient milk: (1) errors in the feeding technique; (2) remediable maternal factors related to diet, rest, or emotional distress; (3) physical disturbances of the infant that interfere with nursing or weight gain. Infrequently, infants who seem to be nursing well may not thrive because of inadequate milk supply. In such cases, more frequent feedings may be indicated. However, nursing more often than every 2 hr may inhibit prolactin secretion and further decrease milk production. This usually is not a problem with feeding at 2 hr intervals. Other aids include stimulation of prolactin secretion by small doses of chlorpromazine for a few days and the use of feeding tube devices attached to the nipple, such as the Lact-Aid, which supplement the infant’s intake.
EXPRESSION OF BREAST MILK.
Expression of breast milk is useful to relieve engorgement of the breasts. Although convenient and more effective than manual expression, battery-operated and electric breast pumps may be prohibitively expensive for many mothers. Nonetheless, pumping increases milk production. It also relieves sore nipples because it does not cause as much nipple irritation as suckling. Pumped breast milk can be safely stored in the freezer or refrigerator and used for feeding the infant at a later time.
SUPPLEMENTAL FEEDINGS.
Most mothers who are returning to work plan to pump enough milk while at work to feed their infant while they are at work. However, because of stress and time constraints at work and at home, this often is impossible. These mothers should be reassured that it is acceptable to feed the infant a commercial formula during the day and to continue nursing in the evening. Breast milk production will gradually decrease so that the mother is not plagued by engorged, leaking breasts, but most will continue to produce enough milk for 2–3 feedings/day for several months.
If formula or stored breast milk is to be given after the infant has completed a breast-feeding, the bottle containing the milk should be available so that it can be offered immediately after the infant has been “burped.” The holes in the nipples should not be so large that the infant gets this portion of food without effort; if this happens, he or she may quickly abandon any efforts to nurse adequately at the mother’s breast. Some employers provide child care at the workplace or provide convenient facilities for pumping. These enable mothers to continue nursing successfully and, hence, should be commended and encouraged.
WEANING FROM BREAST-FEEDING
Between 6 and 12 mo of age, after they become accustomed to solid foods and liquids by bottle and/or cup, most infants decrease the volume and frequency of breast-feeding ( Table 42-2 ). As the infant demands less milk, the mother’s supply gradually diminishes without causing discomfort from engorgement. Weaning can be initiated when mutually desired by the mother and infant by substituting formula by bottle or cup for part and, subsequently, all of a breast-feeding. Breast-feeding is eventually replaced with formula-feeding, at which time the infant is weaned completely. Occasionally, an infant takes a cup as readily as a bottle. If so, the intermediate transfer from breast to bottle before transferring from bottle to cup can be avoided. These changes should be made gradually and should be a pleasant experience, not a conflict, for both the mother and the infant.
TABLE 42-2 — Important Principles for Weaning
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When cessation of nursing is necessary at an early age, use of a tight breast binder and application of ice bags may help decrease milk production. Restriction of the mother’s fluid intake and small doses of estrogen for 1–2 days also may help decrease milk production.
CONTRAINDICATIONS TO BREAST-FEEDING.
Provided the mother’s milk supply is ample, her diet is adequate, and she is not infected with HIV, there are no disadvantages of breast-feeding for the healthy term infant (see Chapter 94 ). Allergens to which the infant is sensitized can be conveyed in the milk, but the presence of such allergens is rarely a valid reason to stop breast-feeding. Rather, an attempt should be made to identify the allergen and remove it from the mother’s diet.
There also are few maternal contraindications to breast-feeding. Markedly inverted nipples may be troublesome, as may fissuring or cracking of the nipples, but the latter can usually be avoided by preventing engorgement. Mastitis usually can be alleviated by continued and frequent nursing on the affected breast to keep it from becoming engorged, but local heat applications and antibiotics may occasionally be necessary. Acute maternal infection may contraindicate breast-feeding if the infant does not have the same infection; otherwise, there is no need to stop nursing unless the condition of either the mother or the infant necessitates it. When the infant is unaffected, the breast may be emptied and the milk given to the infant by bottle or cup. Mothers with septicemia, active tuberculosis, typhoid fever, breast cancer, or malaria should not breast-feed. Substance abuse and severe neuroses or psychoses also are contraindications to breast-feeding. Infants with galactosemia should not be breast-fed, but should receive a non–lactose-containing formula
Counseling the Breastfeeding Mother
Overview
Breastfeeding always has been the criterion standard for infant feeding. Prior to the advent of commercial formulas, breastfeeding was, in truth, the only way to feed an infant. The 20th century brought with it a dramatic change in the way an infant could be fed; for the first time in the evolution of man, nonhuman milk formulas were created and mass produced in such a way that allowed infants to survive and reach adulthood.
In the 21st century, despite marked improvements in the composition of such formulas, breastfeeding remains the superior form of infant nutriture and also serves as an extrauterine directive of immune development.The issues relevant for lactation success have changed as the world has changed. The ability to counsel breastfeeding women significantly impacts her success. A Cochrane Database review of 52 studies of 56,451 mother-infant pairs supports this claim. Results of the review show that all forms of extra support showed an increase in the length of time women continued to breastfeed and the length of time women breastfed without introducing any other types of liquids or foods. Both professional and lay supporters had a positive impact on breastfeeding outcomes. Face-to-face support was significantly more effective compared with telephone support.
With the reemergence of breast milk as the ideal source of infant nutrition, more women are choosing to breastfeed. However, a lack of community knowledge about breastfeeding and shorter hospital stays has led to more breastfeeding failures, a phenomenon that continues to this day.
Women and their infants are now being discharged earlier (12-24 h postdelivery); therefore, the tradition of the first follow-up at age 2 weeks must be replaced with earlier, more carefully planned assessments of the breastfeeding mother–infant dyad. Such early follow-up makes lactation success more likely and leads to a healthier infant. Successful follow-up depends on the healthcare provider’s knowledge of the mechanics of breastfeeding, the evaluation of successful lactation, and the interventions required if difficulties develop.
A 2012 Cochrane review recommended exclusive breastfeeding for the first six months of life in both developing and developed countries.
This article reviews the mechanics of breastfeeding, correct breastfeeding techniques, and sufficient versus insufficient milk supplies. A discussion of early follow-up of the breastfeeding mother–infant dyad and the warning signs of difficulties in that dyad are also included. Emphasis is placed on assessing the breastfeeding neonate and determining wheeonatal jaundice, more common in breastfed infants, is pathologic. Finally, common breastfeeding problems are discussed, with emphasis on their early recognition and management.
For more information about the physiology of lactation and about the structure and biochemical features of human milk, please see the Medscape Reference article Human Milk and Lactation.
Mechanics of Breastfeeding
Understanding the actual mechanism of how babies get milk into their bodies is important. Suckling and breastfeeding are often areas that are taken for granted because of their seemingly instinctive nature. However, the mechanics should not be forgotten or deemphasized because they are essential for a successful and uncomplicated breastfeeding experience. This understanding is helpful in ensuring the use of proper breastfeeding technique.
Initiation of the breastfeeding cycle
When breastfeeding begins, the nipple, surrounding areola, and underlying breast tissue are brought deeply into the infant’s mouth, with the baby’s lips and cheeks forming a seal (see the image below).
During feeding, the suction created within the baby’s mouth causes the mother’s nipple and areola mammae to elongate to 2-3 times their resting length and to form a teat. The nipple and areola extend as far as the junction between the baby’s hard and soft palates. The baby’s jaw then moves his or her tongue toward the areola, compressing it. This process causes the milk to travel from the lactiferous sinuses to the infant’s mouth. The baby then raises the anterior portion of the tongue to complete the process.
Afterward, the baby depresses and retracts the posterior portion of his or her tongue in undulating or peristaltic motions. This motion forms a groove in the tongue that channels milk to the back of the oral cavity and stimulates receptors that initiate the swallowing reflex. This backward movement creates a negative pressure, allowing milk to travel into the baby’s mouth. Throughout the suckling cycle, the nipple should not move in the infant’s mouth if it is correctly positioned.
Swallowing during the breastfeeding cycle
When the volume of milk is sufficient to trigger swallowing, the back of the infant’s tongue elevates and presses against the posterior pharyngeal wall. The soft palate then rises, closing off the nasal passageways. The larynx then moves up and forward to close off the trachea, allowing milk to flow into the esophagus. The infant then lowers his or her jaw, the lactiferous sinuses refill, and a new cycle begins. A rhythm is created in which a swallow typically follows every 1-3 sucks.
Differences between suckling and sucking
Distinct differences between suckling from a breast and sucking from an artificial nipple are important to note. Suckling from the breast is an active process that involves participation of both the mother and her infant. In contrast, bottle-feeding is a more passive activity that results in the creation of a partial vacuum in the infant’s mouth through sucking. The artificial teat taken into the infant’s mouth has a distinct oral/tactile stimulation. When an infant sucks on an artificial nipple, the nipple fills his or her mouth and prevents the peristaltic tongue action that occurs with suckling at the breast. Milk flows from the artificial nipple into the mouth without tongue action; flow occurs from the rubber nipple even if the baby’s lips are not sealed around the nipple. Because of these differences, an infant is more likely to have a desaturation episode during bottle-feeding than during breastfeeding.
Phenomenon of human imprinting
Lawrence and Lawrence (2005) discuss the phenomenon of human imprinting or stamping, which occurs early in the postnatal period.Comfort sucking and the formation of a nipple preference are genetically determined behaviors that affect imprinting to the mother’s nipple. The baby’s initial recognition of his or her mother involves the distinctive features of the nipple. If an infant who is learning to breastfeed receives supplementation via a bottle or a pacifier, the nipple-recognition signals are mixed. Although some dispute the existence of nipple confusion, numerous documented cases support its existence. Certainly, studies have shown that supplementation and the introduction of a foreign nipple, such as a pacifier, are associated with decreased rates of continued breastfeeding.
Correct Breastfeeding Techniques
Before the common breastfeeding positions and techniques are reviewed, an understanding of the importance of timing in initiating breastfeeding is essential. Studies show that a woman’s likelihood of continuing breastfeeding beyond the first month is related to the initiation of breastfeeding immediately after delivery.
Oxytocin levels at 15 minutes, 30 minutes, and 45 minutes after delivery are significantly elevated, coinciding with the expulsion of the placenta. Studies have linked maternal bonding and oxytocin levels. Therefore, encouraging the mother to have contact with her infant at a time when suckling is paired with high oxytocin levels and better letdown seems appropriate. In addition, the infant is alert soon after delivery and has not entered the deep sleep period that ensues approximately 6-12 hours after birth. Finally, personnel are more available to assist the mother in initiating breastfeeding during this immediate postpartum period.
Successful latch-on of the infant during this period enhances a mother’s confidence that she can breastfeed. If a mother received narcotic analgesics during delivery, the infant may be sleepy and less able to breastfeed; if so, the mother may need to wait until the infant is in a more alert state. The use of relaxation techniques during labor and other forms of anesthesia, such as epidural anesthesia, allows the infant to be delivered in a more fully awake state. This early breastfeeding session typically helps instill confidence in the mother. Early problems can be identified, and the mother can be offered assistance to facilitate the lactation process.
A 2012 review supports the practice of early initiation of breastfeeding that includes skin-to-skin contact between the mother and infant. Skin-to-skin contact is associated with a higher success of breastfeeding in the first one to four months. In addition, it is associated with improved infant homeostasis in the immediate postpartum period as well as decreased crying behavior.
Breastfeeding environment
The mother and infant should be allowed to breastfeed in a relaxed and supportive environment. Personnel should be readily available to facilitate the process. Constant interruptions and a deluge of visitors may disrupt the early breastfeeding experience. The father’s assistance and support are strongly associated with the success of breastfeeding. In a study of 224 mothers who were interviewed regarding their feeding choice, the father was a key factor in the initiation of breastfeeding.When the father supported breastfeeding, more than 75% of the mothers chose to breastfeed; in contrast, when the father did not support breastfeeding, only 2% of the mothers chose to breastfeed.
Often, the father can assist the mother with the positioning of the infant, particularly if she is recovering from a cesarean delivery. Thus, the father’s approval and involvement in the breastfeeding process is helpful in creating a supportive environment. Grandparents who support breastfeeding also facilitate the process; however, if they are not supportive of breastfeeding, their attitude can adversely affect the breastfeeding mother. Therefore, the mother who is breastfeeding and learning to know her newborn should be surrounded by a supportive caring team of healthcare providers and family members.
Positioning the infant
Positioning the infant is one of the most fundamental components to successful breastfeeding. If no maternal or neonatal contraindications (eg, heavily medicated mother, low Apgar scores, known congenital anomalies of the GI tract, respiratory distress, prematurity) are present immediately after birth, the mother should be helped into a comfortable position. This position may be lying on her side on the hospital bed or sitting in a comfortable chair. The most common position involves cradling the infant next to the breast from which he or she will feed, with his or her head propped up by the mother’s arm. The infant should be placed with his or her stomach flat against the mother’s upper abdomen, in the same plane. This close contact also helps the infant maintain a normal body temperature. As noted above, skin-to-skin contact is associated with a greater chance of successful breastfeeding.
Another holding position is the football hold, in which the infant is cradled in the mother’s arm with his or her head in the mother’s hand and the feet oriented toward the mother’s elbow. Mothers recovering from cesarean delivery may prefer this position because less pressure is placed on her abdomen. The mother then presents her breast to the infant, and the suckling process is initiated.
Presenting the breast to the suckling infant
Two basic hand positions that the mother typically uses are the palmar grasp or C-hold and the scissor grasp. With the palmar grasp, the mother places her thumb above the areola, and she places her remaining fingers under the breast to form a “C” or “V.” The scissor grasp involves the placement of her thumb and index finger above the areola with the remaining 3 fingers below. The mother should ensure that the nipple is not tipped upward when she presents it to the infant because improper latch-on and nipple abrasion may result. In addition, the grasp should not impede the infant’s ability to place a sufficient amount of the areola into his or her mouth, which is necessary for adequate latch-on and suckling.
Achieving latch-on
Infants instinctually open their mouths wide when the nipple touches their upper or lower lip. The tongue extends under the nipple, and the nipple is drawn into the mouth, initiating the suckling reflex. The mother’s nipple and areolar should be maneuvered to the infant’s open mouth instead of pushing the infant’s head toward the breast. Although this maneuver may appear simple, it may seem impossible to a first-time mother. Care should be taken to assist the mother not only with the positioning of her infant relative to her breast but also with understanding the importance of putting the nipple and areola into the infant’s mouth when it is open.
The suck-swallow pattern should be evaluated while the infant is breastfeeding. Proper latch-on is evident by the infant’s suckling and then swallowing. One can hear an infant’s feeding rhythm, which produces a characteristic sound. During the early postpartum period, the mother typically reports that she feels her uterus contracting while her infant is breastfeeding.
Feedback from the mother during the breastfeeding process
Simply asking a mother if breastfeeding is going well is not enough. Many women report that everything is fine, but when further questioned about nipple pain, hearing the infant suckle, or the frequency of breastfeeding, problems often surface. The best way to know if breastfeeding is going well is to observe the mother-infant dyad. This observation allows the staff to assist the mother with immediate feedback and corrective measures wheecessary. The observation checklist by Lawrence and Lawrence (2005) is adapted below.
Key observation checkpoints of the breastfeeding mother-infant dyad include the following:
- Observe the position of the mother, her body language, and her level of tension. Offer pillows to support the mother’s arm or the infant. Help reposition the mother if necessary.
- Observe the position of the infant. The mother and infant should be positioned ventral surface to ventral surface (ie, stomach to stomach). The infant’s lower arm, if not swaddled, should be around the mother’s thorax. The infant cannot swallow if he or she has to turn to face the breast because the infant’s grasp of the areola is poor in this position. The infant’s head should be in the crook of the mother’s arm and moved toward the breast by the mother’s arm movement.
- Observe the position of the mother’s hand on the breast and ensure that it is not impeding proper grasping by the infant.
- Observe the position of the infant’s lips on the areola. Typically, the lips should be 1-
1.5 inches (2.5-3.8 cm ) beyond the base of the nipple. - Observe the lower lip. If folded in, suckling does not occur. The lips should be flanged.
- Observe the presentation of breast to the infant and the mother’s assisting the infant to latch-on.
- Observe the response of the infant to lower lip stimulus. The infant should open his or her mouth wide to allow the insertion of the nipple and areola.
- Observe the motion of the masseter muscle during suckling, and listen for sounds of swallowing.
- Observe the mother’s comfort level, and ensure that she is not having breast pain.
One should reinforce a mother’s own physiologic cues during breastfeeding. A mother’s letdown is the interplay of her physiologic response to suckling and her emotional state. Prolactin, the hormone responsible for letdown, is inhibited by stress (mediated by dopamine, norepinephrine, and epinephrine). The mother’s relaxation ensures adequate letdown and the continued adequacy of breastfeeding.
Putting the infant to breast 8-12 times a day during the first 4-5 days after birth ensures the creation of an adequate milk supply, which the infant’s use later regulates. A mother who responds to her infant’s cry with letdown and who breastfeeds her infant on demand (ie, unrestricted breastfeeding) is more successful with continued lactation than the mother who breastfeeds according to the clock. The recommendation for mothers to use systematic or controlled timed feedings to help regulate the baby’s cycles is fraught with misinformation. A mother should be empowered to follow the internal schedule that is appropriate for her and her baby.
Factors Affecting the Maternal Milk Supply
True difficulties in supplying milk to the infant are most commonly related to the irregular or incomplete removal of milk. In the human mammary gland, lactation is under autocrine control, in which the frequency and degree of milk removal appears to regulate an inhibitory peptide present in the milk. In other words, if the milk is not removed, this inhibitory peptide accumulates and subsequently decreases the synthesis of milk. If the milk is frequently removed, this inhibitory peptide does not accumulate, and milk synthesis increases.
Although most women are capable of producing more milk than their infants require, more than half of breastfeeding mothers perceive that their milk supply as inadequate. A mother may state that her milk is not “in” and that her infant is not getting enough milk. This misperception is most common during the immediate postpartum period. The neonate’s requirements for fluid gradually increase over the first few days; ideally, the neonate frequently ingests milk in small volumes. As the baby’s GI tract becomes more regulated and functional and as the stomach volume increases, the baby’s milk intake increases.
The composition changes of the milk from colostrum to mature milk, which has a higher energy density (ie, caloric density) because of its higher fat content. Mothers should be encouraged to breastfeed at least 8-12 times during the immediate postpartum period to increase their milk supply. If a mother breastfeeds only 4-5 times during those early days, her milk production is delayed. Infrequent breastfeeding is associated with neonatal jaundice (referred to as breastfeeding jaundice or dehydration jaundice) and the early cessation of breastfeeding.
Another perception of inadequate milk supply is related to the infant’s growth spurts. During periods of enhanced growth, the infant may be more irritable and may seek the breast more often. These growth spurts usually resolve in about 1 week. Growth spurts should be explained to the mother to prevent undue stress or interruptions in breastfeeding.
Near-term infants, those 35-38 weeks’ gestation who are mature enough to be discharged with mother, may not feed well initially; however, once breastfeeding is established, they may seem to feed “on the hour.” If an infant has increased milk intake (eg, during periods of catch-up growth), the breast should be emptied fully to allow the transfer of hind milk, with its higher fat content. Those infants who receive only foremilk receive higher concentrations of lactose, which allow the infant to grow well but may lead to gaseous distension and irritability, with explosive, watery stools. This phenomenon is sometimes called hyperlactation syndrome.
As mentioned above, one should counsel the mother to empty her breast fully. A feeding with pumped milk that has both the fore and hindmilk in combination may also alleviate some of the gastrointestinal symptoms. During such potentially stressful times for both the mother and infant, consultation with a breastfeeding medicine expert is warranted.
Because the milk supply is directly related to its removal and ongoing synthesis, factors that hinder milk removal affect milk production. Factors that could disrupt the complete removal of milk are numerous (see Recognition and Management of Common Breastfeeding Problems). For example, stress and fatigue in both parents may have an impact on the mother’s milk production. Evaluating for these risk factors in the mother-infant dyad is essential to ensure that the milk supply is sufficient and that breastfeeding difficulties are not perpetuated.
If an infant is ill, a mother typically uses a breast pump to remove and store her milk. Early on, the mother may have difficulty extracting colostrum using a breast pump. Manual expression is seen as a viable option in the days following delivery, with a transition to the use of electric breast pumps. Premature infants who are first learning to breastfeed may be ineffective at milk removal.
Some infants have neurologic disabilities or suck-swallow incoordination (common among premature infants born at < 34 weeks’ gestation). In those situations, a mother may need to pump her breasts after breastfeeding to maintain adequate lactation while her infant learns to more effectively breastfeed. By facilitating complete removal of the milk by using a pump, the mother’s supply remains abundant and thus easier for the infant to consume. Marianne Neifert, MD, uses this simile: “With an increase in a mother’s milk supply, feeding is like drinking from a fire hydrant; the infant cannot miss.”
In summary, factors affecting maternal milk supply include the following: (1) irregular or incomplete milk removal, (2) growth spurts, (3) maternal fatigue and stress, and (4) the infant’s medical condition (eg, prematurity, neurologic injury).
Early Follow-up of the Breastfeeding Mother and Her Infant
In accordance with recommendations from the American Academy of Pediatrics, breastfed neonates should be evaluated for breastfeeding performance within 24-48 hours after delivery and again at 48-72 hours after they are discharged from the hospital. At this follow-up visit, the newborn’s weight and general health assessment are determined. The assessment of breastfeeding performance includes a direct observation of the baby latching on and suckling. The neonate should be evaluated for jaundice, adequate hydration, and age-appropriate elimination patterns when he or she is aged 5-7 days.
The key elements of early follow-up are summarized below. For excellent patient education resources, visit eMedicineHealth’s Pregnancy Center. Also, see eMedicineHealth’s patient education article Breastfeeding.
Follow-up of breastfeeding infants
- Evaluate the infant’s breastfeeding performance in the hospital within 24-28 hours after delivery, as well as before the newborn is discharged.
- If the infant was born late preterm (between 35-37 weeks’ gestation), the mother-infant dyad must be closely followed to ensure adequate hydration and breastfeeding to prevent breastfeeding jaundice. This group is particularly at risk for developing hyperbilirubinemia. Therefore, if discharged from the hospital at 24 hours after delivery, these infants require a follow-up visit at 48 hours for a weight and bilirubin check.
- For term infants, follow-up with telephone contact or an office visit 48-72 hours after the neonate is discharged from the hospital. is essential
- Visually inspect the mother breastfeeding her newborn.
- Check the baby’s weight.
- Assess the neonate’s general health status.
- Ask the mother if latch-on and suckling at breast are good.
- Ask the mother if she has sore or painful nipples.
- Ask the mother about support or help at home.
- Follow-up with an office or clinic visit when the neonate is aged 5-7 days.
- Evaluate baby for jaundice, adequate hydration, and age-appropriate elimination patterns.
- Assess maternal well-being. For example, evaluate for fatigue, stress, postpartum depression, sore nipples, and engorgement.
The options for early follow-up assessment of the breastfeeding mother-infant dyad are numerous and can include a home health visit, a consultation with a lactation specialist, a hospital follow-up program, or an appointment at a doctor’s office or clinic. Telephone counseling should be viewed as an additional support, but it should not replace a visit in person.
This degree of follow-up may seem excessive, but ensuring the well-being of the breastfeeding mother-infant dyad is imperative. Such follow-up helps eliminate the rare but tragic cases of death caused by dehydration secondary to inadequate breastfeeding. Most morbidity associated with poor breastfeeding, such as failure to thrive, hypernatremic dehydration, and jaundice can be prevented with early follow-up and an assessment of maternal and neonate risk factors for inadequate feeding. This follow-up also increases the rate of successful breastfeeding.
Warning signs of ineffective breastfeeding
Numerous warning signs of ineffective breastfeeding are noted. For example, if milk production is inadequate secondary to poor latch-on or infrequent breastfeeding, the infant may become dehydrated with a concurrent increase in the sodium level. Prolonged hyperbilirubinemia may accompany the dehydration. Dehydration may occur over days, depending on the milk supply and the frequency of breastfeeding. In rare cases, the sodium concentration may be as high as 180 mmol/L. Nothing may be inherently wrong with the mother’s milk, but if it is not adequately removed from her breasts, either by suckling or by pumping, the milk becomes weaning milk with a higher sodium concentration. Another sign of dehydration in the newborn is listlessness, decreased tone and activity, and increased sleepiness.
The main reason that the sodium level increases in the infant is volume contraction secondary to dehydration and insufficient transfer of milk to the infant. Human milk is 87% water, but its composition changes if an insufficient amount of milk is removed from the breast. The treatment of an infant with hypernatremic dehydration is to replace the free water losses slowly because an abrupt decrease in the sodium level can trigger seizures secondary to cerebral edema and the rapid flux of sodium concentrations. This treatment involves giving the infant intravenous fluid with decremental concentrations of sodium to achieve a normal serum sodium level.
Another warning sign of ineffective breastfeeding is failure to thrive in the breastfeeding infant, which also results from an insufficient milk supply. An infant can have both hypernatremic dehydration and failure to thrive. These disorders occur along a spectrum depending on whether the milk produced is adequate to maintain the infant’s hydration state but insufficient to allow adequate growth. The primary care provider must assess the growth of the breastfeeding infant over time. Neonates typically regain their birth weight by 2 weeks of age, and their weight should increase by 50% at age 6-8 weeks. At 4-5 months of age, the baby’s weight should be double his or her birth weight. Also, the infant’s head circumference and length should be assessed. The monitoring of subcutaneous fat deposition also aids the clinician in assessing the adequacy of growth. An infant’s growth should follow the growth curve.
Failure to thrive in an infant should not be attributed to breastfeeding without an exploration of other differential diagnoses. The mother whose infant is failing to thrive should be encouraged to breastfeed with close assistance and, possibly, short-term supplementation. Daily visits for weight checks and overall health assessments are ofteecessary. In rare cases, hospitalization may be indicated.
Assessment of the Neonate
General principles
The assessment of the breastfed infant includes an evaluation of its voiding and elimination patterns; feeding routines; jaundice; and, most importantly, weight. In addition, the mother should be examined for pain or irritation of her breast and nipples and for signs and symptoms of undue stress or fatigue.
Healthy breastfed neonates should not lose more than 5-10% of their birth weight and should regain birth weight by the time they are aged 10-14 days. One factor that may impact initial weight loss in the first 24 hours is maternal intravenous fluid just prior to delivery. Some infants have a brisk diuresis if mother was given fluid over the course of several hours. The weight at 24 hours may be more reflective of the true “birth weight.” However, care must be taken to ensure that weight loss is not from poor feeding and lack of milk transfer, especially in late preterm infants (35-37 weeks’ gestation).
Newborns should have a minimum average weight gain of 20 g/d between age 14 days and 42 days. The average weight gain during this time is 34 g/d for girls and 40 g/d for boys. In addition, breastfed neonates tend to gain weight faster than formula-fed neonates for the first 2-3 months, and the rate begins to slow at 6-12 months. Breastfed infants also tend to have leaner bodies than those of formula-fed infants. In preterm, formula-fed infants, a recent study concluded that preterm formula aided growth and mineralization better than term formula.
In the first 48 hours after birth, the neonate may void as infrequently as a couple times a day. Once the mother’s milk supply is established, the baby voids after most feedings, usually 6-8 times a day.
As the mother’s milk supply is established, the infant’s stool changes from green-black meconium to yellow yogurtlike stools with seedy curds. This transition usually occurs by the infant’s fifth day of life. Compared with formula-fed infants, breastfed infants tend to have more frequent and higher-volume bowel movements during their first 2 months of life. At weeks 4-6, an infant should pass at least 3 yellow stools of sufficient volume per day; if not, the possibility of inadequate milk intake must be considered. The number of stools gradually decreases after this time; by 2-3 months, several days or a week may pass before an infant has a stool.
As discussed in Factors Affecting the Maternal Milk Supply, incomplete breast emptying frequently causes insufficient milk production. An inadequate frequency or duration of breastfeeding is a common preventable cause of decreased milk production and thus intake. The expected frequency of breastfeeding iewborns is once every 2-3 hours. Breastfeeding should last approximately 10-15 minutes per breast and should include active suckling with short pauses and frequent audible swallows.
Essentials of early follow-up
Early follow-up of the mother-infant dyad supports breastfeeding and the continued good health of the neonate. Although assessing the infant’s weight and state of hydration (skin turgor, capillary refill, hydration of mucous membranes) is vitally important, the interaction between infant and mother must also be assessed. Early breastfeeding is fatiguing and possibly overwhelming, especially for the primiparous mother. In addition to the physiologic assessment of the infant, the staff should encourage the mother and discuss ways to decrease her fatigue (eg, napping when the infant is napping, waking the infant during the day if his or her day-night cycle is switched, taking walks, talking with other mothers and friends).
Postpartum depression may occur in the early postpartum period. Early recognition is essential for appropriate treatment. Women often do not see their obstetricians until 6 weeks after delivery; therefore, the physician who is caring for the infant and mother becomes an important link in the care of the infant and mother. A mother who has depression often has difficulties with her daily activities, including breastfeeding. The early follow-up visit helps with the early identification of problems and with the initiation of appropriate intervention.
Neonatal Jaundice
Hyperbilirubinemia occurs iearly all newborns and can be classified in several categories, including pathologic jaundice, physiologic jaundice of the newborn, breastfeeding jaundice, and breast milk jaundice.
Pathologic jaundice
Jaundice in the first 24 hours after birth is not normal and causes, such as sepsis and blood type incompatibility, should be sought.
Physiologic jaundice
Physiologic jaundice is due to a higher erythrocyte circulating volume, a larger amount of precursors that undergo early degeneration, and a shorter life span of the newborn’s erythrocytes. In addition to these physiologic considerations, the newborn hepatic uptake and conjugation of bilirubin are reduced, and the reabsorption of bilirubin is relatively enhanced due to a process called enterohepatic recirculation. These factors can lead to an early elevation in unconjugated bilirubin levels, which typically become normal adult values when the neonate is aged 2-3 weeks.
Breastfeeding jaundice
In addition to physiologic jaundice, breastfeeding jaundice or dehydration jaundice may develop in infants who breastfeed. Breastfeeding jaundice is due to inadequate milk intake, regardless of the cause. This condition occurs in the neonate’s second or third day of life, usually before the mother’s milk supply is in. The treatment is to put the infant to the breast more frequently, and the mother-infant dyad should be observed for proper latch-on. Maternal pumping with supplementation should be considered only if increasing the breastfeeding frequency does not lead to an increased milk supply. Evaluation of the overall nutritional status and breastfeeding technique of the mother-infant dyad is essential for successful lactation and the resolution of breastfeeding jaundice.
Breast milk jaundice
Breast milk jaundice is different from breastfeeding jaundice in that unconjugated bilirubin levels in the serum continue to increase during the first 2 weeks. With breast milk jaundice, the unconjugated bilirubin level typically peaks between days 5 and 15 after birth, and they usually returormal levels by the end of the third week. However, elevated levels that persist into the third month are not uncommon.
Interrupting breastfeeding in an otherwise healthy infant is not recommended unless the serum bilirubin concentration exceeds 20-22 mg/dL. The cause of breast milk jaundice is still not clear. Potential causes include an inhibitor of hepatic glucuronyl transferase and/or an increase in the enterohepatic circulation of bilirubin. The differential diagnosis includes glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, especially in black and Asian infants. Other more rare forms of unconjugated hyperbilirubinemia, such as Crigler-Najjar syndrome (ie, glucuronyl transferase deficiency), should be considered if the bilirubin level remains elevated after the infant’s first month of life.
Recognition and Management of Common Breastfeeding Problems
Risk factors for breastfeeding difficulties
Mother-infant pairs who are at risk for breastfeeding difficulties should have closer follow-up care. Risk factors in the mother include a history of poor breastfeeding with a previous newborn, flat or inverted nipples, abnormal breast appearance, previous breast surgery, previous breast abscess, extremely sore nipples, minimal prenatal breast enlargement, failure of the milk to come in abundantly after delivery, and chronic or severe medical problems, including diabetes. Breastfeeding risk factors in the infant include small size or prematurity, poor sucking, any oral abnormality, multiple gestation, medical problems, or neurologic or muscle-tone problems.
Risk factors in the infant include premature birth, neurologic abnormalities, hyperbilirubinemia (sleepy baby), shortened frenulum (“tongue-tie”), and having been fed with a bottle prior to breastfeeding.
Common breastfeeding problems and solutions
Common breastfeeding problems and their solutions include the following:
- Engorgement: The treatment is prevention with frequent breastfeeding.
- Areolar engorgement: Treatment involves the manual expression or pumping of milk to soften the areola and allow better latch-on
- Mammary vascular engorgement: Treatment involves frequent breastfeeding around the clock, the application of cabbage leaves, and manual or electric pumping.
- Sore nipple: This problem is commonly associated with improper latch-on. Help the mother with positioning and encourage her to insert the areola and nipple into the infant’s open mouth.
- Cracked nipple: The mother should begin the breastfeeding session on the less-affected side. Placing a drop of milk on each nipple and allowing this to air dry after breastfeeding may help. The use of high-grade lanolin or nipple shields should be considered if bleeding occurs. Correcting the cause of the cracked nipple, such as incorrect positioning/latch or contact of the nipple with coarse fabric or use of a bra with a seam (as opposed to a nursing bra), is essential.
- Mastitis: This problem is more common in engorged breasts. If engorgement is not effectively treated, the mother is at greater risk of developing mastitis in one or both breasts. If diagnosed with mastitis, the mother should continue to breastfeed while taking antibiotics. Common antibiotics include cephalosporins and dicloxacillin. Frequent emptying of the breast is essential for relief and recovery. The mother may also take acetaminophen or ibuprofen for relief. Mastitis can present with flulike symptoms, with fever, malaise, and chills. However, evaluation of the mother’s breasts relieves the main cause of symptoms.
- Abscess: This problem typically requires surgical incision and drainage, as well as antibiotics. The mother should continue to breastfeed on the unaffected side and pump the affected side to relieve pressure and facilitate recovery. The infant may be breastfed on the affected side when the breast is no longer painful to touch. Analgesia is essential for mother’s comfort.
- Yeast infection of the breast: Candida albicans, which causes thrush in infants, may infect the nipple and intraductal system. Complaints of the mother include pain during breastfeeding or a diminution of her milk supply. Culture samples obtained from the skin. Treatment may begin with topical nystatin, but systematic therapy may be required for eradication.
- “Nipple confusion:” So-called nipple confusion is really flow confusion. The infant becomes accustomed to receiving milk from a bottle, with immediate flow of milk upon sucking. With breastfeeding, especially in the beginning, the infant must “work” to achieve milk let-down. Have the mother pump or use hand expression for a few minutes prior to putting the infant to breast. If the infant is frantic and hungry, a caregiver may feed the infant a few milliliters of expressed milk via syringe or cup to calm the infant. The mother should then put the infant to breast with a syringe of milk handy to place droplets of her milk on her nipple to facilitate latch.
- Premature infants: Preterm infants lack the fat pads in the mouth that allow a good seal around the nipple and areola. They also have difficulties with suck, swallow, and breath. Putting an infant to an emptied breast first to learn to suckle without a deluge of milk may be necessary. Gradually, as the infant matures over days to weeks, the mother can pump her breasts less and put the infant to breast earlier. Some infants benefit from the use of a nipple shield (silicon) that creates a negative pressure around the nipple facilitating milk flow and latch. As the infant develops oral motor control, the nipple shield is discontinued.
- Infants with neurological issues: Infants with neurological issues may require an approach similar to that of the preterm infant. Unlike the preterm infant who is likely to gain oral motor skills over time, some infants with neurological issues do not show oral motor improvement. Each case must be assessed to adapt the breastfeeding process to the skills of the infant and mother.
- Shortened frenulum: As more women have chosen to breastfeed, the importance of a shortened frenulum has surfaced. Older physicians who were skilled at frenotomy (“clipping” the frenulum) are training a new generation of physicians to perform this simple technique. In areas where no one is skilled at this procedure, an ear, nose, and throat specialist may be consulted.
Engorgement
Engorgement is a common breastfeeding problem, and its prevention is important. A mother should be encouraged to breastfeed several times a day to establish her milk supply and to ensure relief after her milk has come in. If a mother’s breasts are so distended that the nipple is obscured, the infant may have difficulty in latching on. A mother may manually express or pump her milk to relieve the tension and distortion of the breast, which makes the nipple available for suckling by the infant. The mother should continue this cycle frequently as her breasts regulate to the requirements of her infant.
Cabbage leaves, either whole or as a minced paste, have been shown to relieve the swelling and pain of engorgement within 12-24 hours of application. The use of lanolin is not helpful in engorgement. Recommending that the mother discontinue breastfeeding is not appropriate because breast milk is the preferred source of nutrition for the infant and because the mother has shown that she desires to breastfeed with her action of initiating breastfeeding.
Insufficient milk supply
The misperception of an insufficient milk supply is common, particularly with first-time mothers. A mother who plans to breastfeed should undergo a prenatal assessment to evaluate her breast development during pregnancy: Does she have sufficient glandular tissue? Are her breasts tubular? Do you see milk veins and pigment changes in the nipples/areola? Is colostrum visible at the nipple when pressed by 20-24 weeks’ gestation? One should assess the condition of her nipples (eg, are they inverted?) and discuss strategies to achieve successful lactation. These strategies include frequent breastfeeding every 1.5-2 hours during the first few days. If a mother does not breastfeed frequently enough, her milk production is delayed.
The first-line treatment for an insufficient milk supply is to have the mother breastfeed frequently because any milk removed is quickly replaced. If a mother has been too ill to breastfeed or pump her milk or if her infant is too ill to breastfeed, the mother may have an insufficient milk supply. Again, the mother should be encouraged to breastfeed, if her infant is able, or to pump her breasts to stimulate milk production.
Women who have had breast reduction surgery are at greater risk of insufficient milk supply, especially if the innervation to the nipple has been compromised. Along with the excised fat tissue of the breast, the woman have also lost a fraction of her ductules/ducts, decreasing the potential production of milk. Despite the history, a woman should be supported to attempt breastfeeding. If her milk supply is insufficient, she may still breastfeed with the use of a supplemental nursing system.
Women who have undergone breast augmentation typically fare better than those who have had breast reduction—as long as the nipple and areolar have not been surgically altered. If a woman had insufficient glandular tissue to begin with, then she would still be at risk of a lower milk supply. Every attempt should be made to support these mothers and optimize breastfeeding for that woman.
Galactagogues
Galactagogues or milk production enhancers may facilitate milk production. Probably the best known agent with the fewest adverse effects is fenugreek, a herb used in Indian curries and cooking. It is well tolerated by most women. It can be taken as a tea (2-3 cups of tea per day) or as a capsule (two 500-mg capsules 3 times daily for a total of 6 caps per day). Milk production should increase within 48-72 hours.
Other herbal remedies include fennel seeds brewed as a tea (1 tsp boiled in water and steeped for 10 min, served 2-3 times per day), milk thistle, and goat’s rue. Contraindications to these herbal remedies include the current use of antiepileptic agents, Coumadin, or heparin because the herbs may affect drug levels or clotting parameters.
Medical therapy
Metoclopramide (Reglan) acts as a potent stimulator of prolactin release and has been used to treat lactation insufficiency. Although the US Food and Drug Administration (FDA) has not approved metoclopramide for this indication, a dose of 10 mg orally 3-4 times daily has been shown to increase milk production. An increase of milk letdown response was experienced by as many as 60% of women within 3-7 days. Limit use to a maximum of 10-14 days, with a gradual taper. Rarely, a woman may experience a dystonic reaction early on. Prolonged use is associated with clinical depression in some women, but differentiating this from postpartum depression may be difficult. Coadministration of opioid analgesics with metoclopramide may increase CNS toxicity.
Domperidone is used as a galactogogue worldwide. It is not approved for use in the United States, and the FDA cautions against its use because of reports of arrhythmias when intravenously administered. Despite this caution, thousands of women acquire the drug at local pharmacies where the drug is compounded. Many women report fewer side-effects with domperidone because it does not cross the blood-brain barrier and its prolonged use is not associated with postpartum depression. Documentation in the medical record must state why the drug is prescribed and that the potential risks have been discussed with the mother. The dose prescribed is the same as metoclopramide (ie, 10 mg orally 3-4 times daily for 3-7 d and then gradually tapering the regimen over days to weeks).
Large trials of galactagogues are lacking. Available data come from small studies and case reports.
Need for Vitamin D Supplementation in Breastfed Infants
The American Academy of Pediatrics (2008) recommends universal vitamin D supplementation (400 IU/d) starting a few days after delivery.This recommendation follows in the wake of widespread vitamin D deficiency in the United States and other countries in all age groups. The reason that breastfed infants are deficient in vitamin D is not because human milk is deficient in vitamin D per se but because mothers who are deficient in vitamin D have vitamin D–deficient milk, which leads to vitamin D deficiency in the infant.
Studies are underway to determine if higher maternal vitamin D supplementation doses will safely and effectively increase milk vitamin D levels that will lead, in turn, to optimal vitamin D status in the breastfeeding infant.In this way, both mother and infant could be replete. Until such studies are completed and published, a safe alternative is for infants to receive a vitamin D-only supplement to provide 400 IU vitamin D/d.
Human Milk and Lactation
Background
Breast milk is thought to be the best form of nutrition for neonates and infants. The properties of human milk facilitate the transition of life from in utero to ex utero. This dynamic fluid provides a diverse array of bioactive substances to the developing infant during critical periods of brain, immune, and gut development. The clinician must be familiar with how the mammary gland produces human milk and how its properties nourish and protect the breastfeeding infant.
Clinicians play a crucial role in a mother’s decision to breastfeed and can facilitate her success in lactation. Although a mother may not be aware of the evidence indicating that breast milk contributes to her baby’s short-term and long-term well-being, she has developed certain attitudes and cultural beliefs about breastfeeding. The issue of bonding between mother and newborn may be a strong factor; however, stronger cultural or societal barriers may result in the decision to formula feed. Such issues must be understood for successful counseling. The mother makes her decision regarding breastfeeding prior to delivery in more than 90% of cases; therefore, her choice of infant nutrition should be discussed starting in the second trimester and continue as part of an ongoing dialogue during each obstetric visit.
This article reviews the development of the mammary gland (mammogenesis), the process through which the mammary gland develops the capacity to secrete milk (lactogenesis), the process of milk production (lactation), and the specific properties of human milk that make it unique and appropriate for human infants. In a related article titled Counseling the Breastfeeding Mother, the mechanics of breastfeeding and evaluation of the breastfeeding mother-infant dyad are discussed. Such articles are intended to be overviews. For a more in-depth treatise, please refer to textbooks by Lawrence and Lawrence (2005)and the American Academy of Pediatrics (2006).Guidelines for breastfeeding and the use of human milk have been established by the American Academy of Pediatrics.
Pathophysiology
Mammogenesis
The breast begins to develop in utero, undergoing the first of many developmental changes necessary for proper breastfeeding to occur. A bulb-shaped mammary bud can be discerned in the fetus at 18-19 weeks’ gestation. Inside the bud, a rudimentary mammary ductal system is formed, which is present at birth. After birth, growth of the gland parallels that of the child until puberty. The normal anatomy of the mammary gland following pubertal development is shown in the images below.
The basic unit of the mammary gland is the alveolus or acinus cell that connects to a ductule. Each ductule was believed to independently drain to a duct that, in turn, emptied into lactiferous sinuses. These lactiferous sinuses drain to 15-25 openings in the nipple, allowing milk to flow to the recipient infant.
More recently, researchers such as Ramsay et al (2005) have questioned the existence of lactiferous sinuses.Extensive real-time ultrasonography of 21 fully lactating women provided better understanding of the anatomy of the lactating human breast, as shown below.
The ducts can be traced from the base of the nipple back into the parenchyma. The meaumber of main ducts greater than
At puberty, released estrogen stimulates breast tissue to enlarge through growth of mammary ducts into the preexisting mammary fat pad. Progesterone, secreted in the second half of the menstrual cycle, causes limited lobuloalveolar development. The effects of estrogen and progesterone facilitate the formation of the characteristic structure of the adult breast, which is the terminal duct lobular unit. However, full alveolar development and maturation of epithelium requires the hormones of pregnancy.
Lactogenesis
In lactogenesis, the mammary gland develops the capacity to secrete milk. Lactogenesis includes all processes necessary to transform the mammary gland from its undifferentiated state in early pregnancy to its fully differentiated state sometime after pregnancy. This fully differentiated state allows full lactation. The 2 stages of lactogenesis are discussed below.
Stage 1 occurs by mid pregnancy. In stage 1, the mammary gland becomes competent to secrete milk. Lactose, total protein, and immunoglobulin concentrations increase within the secreted glandular fluid, whereas sodium and chloride concentrations decrease. The gland is now sufficiently differentiated to secrete milk, as evidenced by the fact that women often describe drops of colostrum on their nipples in the second or third trimester. However, high circulating levels of progesterone and estrogen hold the secretion of milk in check.
Stage 2 of lactogenesis occurs around the time of delivery. It is defined as the onset of copious milk secretion. In stage 2, blood flow, oxygen, and glucose uptake increase, and citrate concentration increases sharply. Increased milk citrate is considered a reliable marker for the second stage of lactogenesis. Progesterone plays a key role in this stage. Removal of the placenta (ie, the source of progesterone during pregnancy) is necessary for the initiation of milk secretion; however, the placenta does not inhibit established lactation. Work by Haslam and Shyamala reveals that progesterone receptors are lost in lactating mammary tissues, thus decreasing the inhibitory effect of circulating progesterone.In addition, maternal secretion of insulin, growth hormone (GH), cortisol, and parathyroid hormone (PTH) facilitates the mobilization of nutrients and minerals that are required for lactation.
The stages of lactation can be summarized as follows (adapted from Riordan and Auerbach, 1998):
- Mammogenesis: Mammary (breast) growth occurs. The size and weight of the breast increase.
- Lactogenesis
- Stage 1 (late pregnancy): Alveolar cells are differentiated from secretory cells.
- Stage 2 (day 2 or 3 to day 8 after birth): The tight junction in the alveolar cell closes. Copious milk secretion begins. Breasts are full and warm. Endocrine control switches to autocrine (supply-demand) control.
- Galactopoiesis (later than 9 d after birth to beginning of involution): Established secretion is maintained. Autocrine system control continues.
- Involution (average 40 d after last breastfeeding): Regular supplementation is added. Milk secretion decreases from the buildup of inhibiting peptides.
Lactation
- Two essential hormones (prolactin and oxytocin)
- During the second stage of lactogenesis, the breast becomes capable of milk production. For the ongoing synthesis and secretion of human milk, the mammary gland must receive hormonal signals. These signals, which are in direct response to stimulation of the nipple and areola (mammae), are then relayed to the central nervous system. This cyclical process of milk synthesis and secretion is termed lactation. Lactation occurs with the help of 2 hormones, prolactin (PRL) and oxytocin. Although PRL and oxytocin act independently on different cellular receptors, their combined actions are essential for successful lactation.
- Prolactin
- Milk synthesis occurs in the mammary gland epithelial cells in response to PRL activation of epithelial cell PRL receptors. PRL, a polypeptide hormone synthesized by lactotrophic cells in the anterior pituitary, is structurally similar to GH and placental lactogen (PL), which appear to have cytokine functions. The secretion of PRL appears to be both positively and negatively regulated; however, its main locus of control comes from hypothalamic inhibitory factors, the most important of which is dopamine, acting through the D2 subclass of dopamine receptors present in lactotrophs. PRL stimulates mammary glandular ductal growth and epithelial cell proliferation and induces milk protein synthesis.
- Research during the past several decades has led to a deeper understanding of PRL’s role in the body. PRL-related knockout models support PRL’s pivotal role in lactation and reproduction, which suggests that most of PRL’s target tissues are modulated rather than dependent on PRL.
- The significance of PRL can be seen in the inhibition of lactogenesis using bromocriptine and other dopamine analogues, which are PRL inhibitors.
- Oxytocin
- The other important hormone involved in the milk ejection or letdown reflex is oxytocin. When the neonate is placed at the breast and begins suckling, oxytocin is released. The suckling infant stimulates the touch receptors that are densely located around the nipple and areola. The tactile sensations create impulses that, in turn, activate the dorsal root ganglia via the intercostals nerves (4, 5, 6). These impulses ascend the spinal cord, creating an afferent neuronal pathway to both the paraventricular nuclei of the hypothalamus where oxytocin is synthesized and secreted by the pituitary gland. The stimulation of the nuclei causes the release of oxytocin down the pituitary stalk and into the posterior pituitary gland, where oxytocin is stored.
- The infant’s suckling creates afferent impulses that stimulate the posterior pituitary gland. This releases oxytocin in a pulsatile fashion to adjacent capillaries, traveling to the mammary myoepithelial cell receptors that, in turn, stimulate the cells to contract. Oxytocin causes the contraction of the myoepithelial cells that line the ducts of the breast. These smooth muscle–like cells, when stimulated, expel milk from alveoli into ducts and subareolar sinuses that empty through a nipple pore.
- Milk secretion directly correlates with synthesis
- The regulation of milk synthesis is quite efficient. Milk synthesis remains remarkably constant at approximately 800 mL/d. However, the actual volume of milk secreted may be adjusted to the requirement of the infant by feedback inhibitor of lactation, a local factor secreted into the milk; therefore, the rate of milk synthesis is related to the degree of breast emptiness or fullness. The emptier breast produces milk faster than the fuller one.
- Milk production is responsive to maternal states of well-being. Thus, stress and fatigue adversely affect a woman’s milk supply. The mechanism for this effect is the down-regulation of milk synthesis with increased levels of dopamine, norepinephrine, or both, which inhibit PRL synthesis. Relaxation is key for successful lactation.
Biochemistry of human milk
Human milk is a unique, species-specific, complex nutritive fluid with immunologic and growth-promoting properties. This unique fluid actually evolves to meet the changing needs of the baby during growth and maturation. Milk synthesis and secretion by the mammary gland involve numerous cellular pathways and processes (summarized in the table below).
The processing and packaging of nutrients within human milk changes over time as the recipient infant matures. For example, early milk or colostrum has lower concentrations of fat than mature milk but higher concentrations of protein and minerals (see the image below). This relationship reverses as the infant matures.
Important biochemical points are discussed below.
- Fore and hind milk (important differences)
- In addition to the changes from colostrum to mature milk that mirror the needs of the developing neonate, variation exists within a given breastfeeding session. The milk first ingested by the infant (fore milk) has a lower fat content. As the infant continues to breastfeed over the next several minutes, the fat content increases. This hind milk is thought to facilitate satiety in the infant. Finally, the diurnal variations in breast milk reflect maternal diet and daily hormonal fluctuations.
- Specific enzymes to aid neonatal digestion
- Human milk contains various enzymes; some are specific for the biosynthesis of milk in the mammary gland (eg, lactose synthetase, fatty acid synthetase, thioesterase), whereas others are specific for the digestion of proteins, fats, and carbohydrates that facilitate the infant’s ability to break down food and to absorb human milk. Certain enzymes also serve as transport moieties for other substances, such as zinc, selenium, and magnesium.
- Three-dimensional structure of human milk
- Under a microscope, the appearance of human milk is truly amazing. Although it is a fluid, human milk has substantial structure in the form of compartmentation. Nutrients and bioactive substances are sequestered within the various compartments of human milk. The most elegant example of this structure involves lipids. Lipids are enveloped at the time of secretion from the apical mammary epithelial cell within its plasma membrane, becoming the milk-fat globule. Certain proteins, growth factors, and vitamins also become sequestered within this milk-fat globule and are embedded within the membrane itself.
- The membrane acts as a stabilizing interface between the aqueous milk components and compartmentalized fat. This interface allows controlled release of the lipolysis products and transfer of polar materials into milk serum (aqueous phase). The bipolar characteristics of the membrane are also necessary for the emulsion stability of the globules themselves; thus, the structure of human milk provides readily available fatty acids and cholesterol for micellar absorption in the small intestine.
- Proteins, carbohydrates, and designer fats for optimal brain development
- Human milk provides appropriate amounts of proteins (primarily alpha-lactalbumin and whey), carbohydrates (lactose), minerals, vitamins, and fats for the growing term infant. The fats are composed of cholesterol, triglycerides, short-chain fatty acids, and long-chain polyunsaturated (LCP) fatty acids. The LCP fatty acids (18- to 22-carbon length) are needed for brain and retinal development. Large amounts of omega-6 and omega-3 LCP fatty acids, predominately the 20-carbon arachidonic acid (AA) and the 22-carbon docosahexaenoic acids (DHAs), are deposited in the developing brain and retina during prenatal and early postnatal growth.
- An infant, particularly a preterm infant, may have a limited ability to synthesize optimal levels of AA and DHA from linoleic and linolenic acid. Therefore, these 2 fatty acids may be considered essential fatty acids.
- Many infant formulas in the United States have added AA, DHA, or both. The amount of AA and DHA in breast milk varies with the maternal diet.The unique blend of fatty acids in the breast milk has been linked to the development of innate and adaptive immune regulation.
- Prior to routine fortification of formulas with DHA and AA, infants who received breast milk demonstrated better visual acuity at age 4 months and slightly enhanced cognitive development than formula-fed infants. This has not been a universal finding, and some have continued to doubt the benefits of DHA and ARA.
- However, in a most recent study of children at age 5 years who were breastfed and whose mothers were given a modest DHA supplement until 4 months postpartum, there was a significant improvement in sustained attention when compared to children whose mothers were not given DHA.
- A recent study compared growth and bone mineralization in very low birth weight infants fed preterm formula with those who received term formula; the conclusion was that preterm formula better aided in growth and development.
- One study examined maternal dietary manipulation of fatty acid concentration and neurodevelopmental differences in human milk.Despite higher levels of AA and DHA in the heavily supplemented maternal groups, no differences were observed in the neurodevelopmental outcomes of the 3 groups. This finding supports a more global effect of human milk as opposed to a single agent that renders developmental differences.
- Thus, whether healthy term infants benefit from the addition of DHA and AA to formula remains unclear because they are able to convert very LCP fatty acids to DHA and AA. Ill term infants and those born prematurely are most likely to benefit from formulas enriched with DHA, AA, or both.
- Rather than producing better vision or greater intelligence, breast milk may somehow protect the developing neonatal brain from injury or less optimal development by providing necessary building materials and growth factors that act synergistically rather than in isolation.
Immunologic properties of human milk
Through the years, knowledge about the immune properties and effects of human milk has grown. A recommended comprehensive review by one of the pioneers in the field, Dr. Armand Goldman, appeared in Breastfeeding Medicine (2007).Below are the highlights of just some of many known immune properties and functions of human milk.
- Human milk immunoglobulins
- Human milk contains all of the different antibodies (M, A, D, G, E), but secretory immunoglobulin A (sIgA) is the most abundant. Milk-derived sIgA is a significant source of passively acquired immunity for the infant during the weeks before the endogenous production of sIgA occurs. During this time of reduced neonatal gut immune function, the infant has limited defense against ingested pathogens. Therefore, sIgA is an important protective factor against infection.
- Assuming that the mother and her infant, who are closely associated, share common flora, the antigenic specificity of the mother’s sIgA in her milk is directed against the same antigens in the neonate. Maternal immunoglobulin A (IgA) antibodies derived from the gut and respiratory immune surveillance systems are transported via blood and lymphatic circulations to the mammary gland, ultimately to be extruded into her milk as sIgA. The packaging of IgA with a secretory component unique to the mammary gland protects the sIgA from stomach acids, allowing it to reach the small intestine intact.
- Other immunologic properties of human milk
- In addition to antibodies, human milk has numerous factors that can affect the intestinal microflora of the baby. These factors enhance the colonization of some bacteria while inhibiting the colonization by others. The immunologic components include lactoferrin, which binds to iron, thus making it unavailable to pathogenic bacteria; lysozyme, which enhances sIgA bactericidal activity against gram-negative organisms; oligosaccharides, which intercept bacteria and form harmless compounds that the baby excretes; milk lipids, which damage membranes of enveloped viruses; and mucins, which are present on the milk-fat globule membrane. Mucins adhere to bacteria and viruses and help eliminate them from the body. Interferon and fibronectin have antiviral activities and enhance lytic properties of milk leukocytes.
- Our understanding of the interactional effect of these bioactive constituents, the impact of microbiota on gut function, and development (and role of human milk in that development) is just beginning to be understood.These constituents clearly have profound effects of the health status of individuals throughout life, particularly during infancy.
- Human milk leukocytes
- Macrophages comprise 40-60% of the cells in colostrum, with the remainder of cells primarily consisting of lymphocytes and polymorphonucleocytes. Extruded into the milk are rare mammary epithelial cells and the plasma membrane-bound lipid droplets referred to as milk-fat globules. By 7-10 days postpartum, with the transition from colostrum to mature milk, the percentage of macrophages then increases to 80-90% at a concentration of 10 -10 human milk macrophages per milliliter of milk. Milk leukocytes can tolerate extremes in pH, temperature, and osmolality. They have been shown to survive for as long as a week in baboons and lambs.
- Passive immunity from mother to recipient breastfeeding infant
- While awaiting endogenous maturation of the baby’s own immunologic systems, various immunologic and bioactive milk components act synergistically to provide a passive immunologic support system from the mother to her infant in the first days to months after birth. Ingested milk passively immunizes the neonate. Numerous studies have clearly documented this scenario and its clinical benefit, demonstrating decreased risk for gastrointestinal and respiratory infections, particularly during the first year of life.
- Evidence is increasing that these immune and bioactive substances prime the neonatal GI and immune systems in their selective recognition of antigens and development of cellular signaling. This may explain the decreased risk of intestinal and respiratory allergy in children who have been breastfed and the lower-than-predicted risk of autoimmune diseases in the breastfed population. Direct effects are difficult to prove given the multifactorial nature of such diseases; however, when taken together, the data support the beneficial nature of human milk for the developing infant.
Bioactive properties of human milk
Human milk also contains growth modulators, such as epidermal growth factor (EGF), nerve growth factor (NGF), insulinlike growth factors (IGFs), and interleukins. Transforming growth factor (TGF)–alpha, TGF-beta, and granulocyte colony-stimulating factor (G-CSF) are also identified in human milk. These growth modulators are produced either by the epithelial cells of the mammary gland or by activated macrophages, lymphocytes (mainly T cells), or neutrophils in the milk. EGF and TGF-alpha were found at higher concentrations in the milk of mothers who delivered prematurely compared with those who delivered at term. EGF, TGF-alpha, and human milk stimulate fetal small intestinal cell proliferation in vitro, with the greatest increase in cell proliferation seen following exposure to human milk.
Certain bioactive substances and live cells in milk appear to influence neonatal gut maturation and growth through their transfer of developmental information to the newborn. Although most of these biosubstances have been identified in mother’s milk in quantities that exceed maternal serum levels, their exact role in human newborns is uncertain; most current information is from animal models whose development may significantly differ.
Conclusion
Human milk, in addition to its numerous nutrients that make it an ideal food source for the growing term infant, is a bioactive fluid that evolves from colostrum to mature milk as the infant matures. This bioactive fluid contains numerous factors and live cells that, in concert, promote the growth and well-being of the breastfeeding infant. Oliver Wendell Holmes said it best when he stated, “A pair of substantial mammary glands has the advantage over the two hemispheres of the most learned professor’s brain, in the art of compounding a nutritious fluid for infants.” With the ever-expanding knowledge resulting from current research, commercial formula clearly cannot replicate all of the valuable properties that are inherent in human milk.
References
а) Basic
1. Manual of Propaedeutic Pediatrics / S.O. Nykytyuk, N.I. Balatska, N.B. Galyash, N.O. Lishchenko, O.Y. Nykytyuk – Ternopil: TSMU, 2005. – 468 pp.
2. Kapitan T. Propaedeutics of children’s diseases and nursing of the child : [Textbook for students of higher medical educational institutions] ; Fourth edition, updated and translated in English / T. Kapitan –
3. Nelson Textbook of Pediatrics /edited by Richard E. Behrman, Robert M. Kliegman; senior editor, Waldo E. Nelson – 19th ed. – W.B.Saunders Company, 2011. – 2680 p.
b) Additional
1. Denial Bernstein. Pediatrics for medical Students. – Second edition, 2012. – 650 p.
2. Jam W. Ball, Ruth G. Bindler Pediatric Nursing. Caring for Children. – Third edition, 2011. – 984p.
3. Guidelines on HIV and infant feeding 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. World Health Organization, 2010.
4. WHO/ Breastfeeding
5. www.bookfinder.com/author/american-academy-of-pediatrics
6. www.emedicine.medscape.com
7. http://www.nlm.nih.gov/medlineplus/medlineplus.html
