Breast feeding and breast care

Breast care As part of preventive medicine for women, the breast and breast disease, both benign and malignant, must be evaluated and thoroughly understood The breast is dynamic organ throughout a woman’s life, from puberty to menopause concern about breast and breast symptoms are common complaints

Breast cancer is the most common cancer in women. It is the second only to lung cancer as the most frequent type of cancer death.

The medico legal system holds the gynecologist as a primary care provider, responsible for breast assessment and detection of breast cancer.

 

Guidelines for preventive breast care

 

Self breast examination monthly beginning at age 20 years

Clinical breast examination annually beginning at age 18years

Screening mammography baseline between age 35 and 40 years

Every 1 to 2 years from ages 40 to 50

Annually after 50 years

Breast anatomy.

Contained in ectodermal ridges that form on the ventral surface of the

embryo and extend laterally from forelimb to hindlimb.

Except for one pair in the pectoral region that eventually develops into

the two mammary glands.

Formation of 15to 25 secondary buds that provide the basis for the duct

system and each secondary bud elongates into a cord, bifurcates, and

differentiates into two concentric layers of cuboidal cells and a central

lumen.

Continued . . .

. . . . Continued

The inner layer of cells eventually gives rise to the secretory

epithelium,

which synthesizes the milk. The outer cell layer becomes

myoepithelium,

which provides the mechanism for milk ejection

Each mature mammary gland is composed of 15 to 25 lobes that arose

from the secondary buds. The lobes are arranged radially and are

separated from one another by varying amounts of fat.

From embryo to puberty, the breasts of human male and female are the

same,both functionally and histologically.

Thelarche is the onset of rapid breast growth that begins about the time

of puberty when estrogen production rises.

Estrogen involved with growth and development of mammary ducts and

fat deposition. Progesterone stimulates development of the alveoli for

future lactation.

Every alveolus is provided with a small duct that joins others to form a

single larger duct for each lobe. These lactiferous ducts open separately

upon the nipple, where they may be distinguished as minute but distinct

orifices.

. . . . Continued

Pregnancy initiates the complex maturation of the breast. There is

reversal of the stromal_glandular relation, which causes the breast

to be composed almost completely of glands with a small amount

of surrounding stroma.(lactogenesis stage 1)

. . . . Continued

BREAST FEEDING

 

LACTATION. Colostrum is the deep lemon-yellow colored liquid

secreted initially by the breasts and expressed from the nipples by the

second postpartum day.

 

COLOSTRUM. More minerals and protein, globulin, less sugar and fat.

Colostrum secretion persists for about 5 days( lactogenesis stage 2)

its content of immunoglobulin A may offer protection for the newborn

against-enteric pathogens.

Complement, macrophages, lymphocytes, lactoferrin, lactoperoxidase,

and lysozymes.

MILK. (lactogenesis stage 3)_suspension of fat and protein in a

carbohydrate-mineral solution.

Easily makes 600mL of milk per day.,isotonic with plasma, lactose

accounting for half of the osmotic pressure. & lactalbumin, β-

lactoglobulin, and casein, are also present.

Essential amino acids are derived in part from blood or synthesized in

the mammary gland.

Lactose synthesis from glucose in alveolar secretory cells is

catalyzed by lactose synthase. Fatty acids are synthesized in the

alveoli from glucose and are secreted by an apocrine like process.

All vitamins except vitamin K are found in human milk, maternal

dietary supplementation increases the secretion of most of these.

Vitamin K administration to the infant soon after delivery is required to

prevent hemorrhagic disease of the newborn.

Human milk contains a low iron concentration and maternal iron

stores do not seem to influence the amount of iron in breast milk.

Endocrinology of lactation.

The precise humeral and neural mechanism involved in lactation are

complex.

Progesterone, estrogen, and placental lactogen, as well as prolactin,

cortisol, and insulin, stimulate the growth and development of the milk-

secreting apparatus of the mammary gland

An abrupt and profound decrease in the levels of progesterone and

estrogen, which removes the inhibitory influence of progesterone on the

production of lactalbumin by the rough endoplasmic reticulum &

lactalbumin serves to stimulate lactose synthase

The intensity and duration of subsequent lactation are controlled,

in large part, by the repetitive stimulus of nursing.

The neurohypophysis, secretes oxytocin. This stimulates milk

expression from a lactating breast by causing contraction of

myoepithelial cells in the alveoli and small milk ducts.

Milk ejection, or “letting down,” is a reflex initiated especially by

suckling;

Immunological consequences of breast feeding.

The predominant immunoglobulin in milk is secreatory IgA. It has

been suggested that IgA exerts its effect by

• preventing bacterial adherence to epithelial cells surfaces,

thus preventing tissue invasion

Human milk also provides protection against rotavirus infections,

which cause up to 50 percent of cause of gastroenteritis among

infants.

Nursing. Human milk is ideal food for neonates. It provides

species- and age-specific nutrients for the infant.

Immunlolgical factors, and antibacterial properties, human milk

contains factors that act as biological signals for promoting

cellular growth and differentiation.

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 narcotizing enterocolitis.

Protective effect of human milk feeding against sudden infant

death syndrome, insulin-dependent diabetes mellitus, Crohns

disease, ulcerative colitis, lymphoma, allergic diseases, other

chronic digestive diseases.

Cognitive development

Milk transfer to the infant is the key physiologic principle to

lactation. the initial step

good latch__on

• light tactile stimulation of the cheek and lateral angle of the mouth

• nipple is tilted slightly downwards using “c_hold”,or palmar grasp.

• Infant brought firmly to the breast by the supporting hand

• The nipple and the areola are drawn in to the mouth as far as the

areola breast line.

• The buccal mucosa and tongue mold around the teat,leaving no

space.

Proper technique for positioning infant during nursing

WAIT until the baby’s mouth is

WIDE open

Jeanette Panchula - BSW, RN, PHN, IBCLC - Solano County Health and Social Services

Nose very close or touching breast

Chin deeply into breast

Observe to make sure:

•Cheeks DO NOT suck in

•Breast moves toward the mouth and not away

Lips flanged

Jeanette Panchula - BSW, RN, PHN, IBCLC - Solano County Health and Social Services

Mother’s eye view can make her think

the baby can’t breathe

Jeanette Panchula - BSW, RN, PHN, IBCLC - Solano County Health and Social Services

Observe for signs of milk transfer• Sustained suck/swallow pattern with

occasional pauses• Audible swallowing• Relaxed arms and hands• Moist mouth• Satisfied after feeding

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Contraception. Contraception is not needed in the first 3 weeks

postpartum because of a delay in return of ovulation in all women.

Progestin_only mini pills,depo medroxyprogesteron and levonorgestrel

implants do not affect the quality of milk and increase, only very slightly

the volume of milk;

Recommendation for hormonal contraception if used by breast

feeding mothers

 

Progestin only oral contraceoptives started 2_3 weeks postpartum

DMP initiated 6 weeks postpartum

Hormonal implants inserted 6weeks postpartum

Cocp after 6 weeks postpartum *

 Contraindications.

• Women who take street drugs or do not control alcohol use;

• have an infant with galactosemia,

• have HIV infection*

• have active; untreated tuberculosis;

• active herpetic lesion.

 

Care of the breasts and nipples.

Dried milk is likely to accumulate and irritate the nipples, cleaning of

the areola with water and mild soap is helpful before and after nursing.

Nipple shield for 24 hours or longer.

Inverted or retracted nipples may be troublesome; teased out by gently

pulling with the finger and thumb. This is best done during pregnancy

Drugs secreted in milk.

• The concentration of drugs in plasma,

• Degree of protein binding,

• Plasma and milk pH,

• Degree of ionization,

• Lipid solubility,

• Molecular weight.

  

Milk –to-plasma drug-concentration ratio.

Most drugs have a mild –to-plasma ratio of 1 or less; about

25 percent have ratios of more than 1,and about 15 percent

have ratios greater than 2

Nutritional Requirement

Outline for nutritional requirement

• Feeding during the 1st 6 month of life – BF• Feeding during the second 6 month of life• Feeding problems during the 1st year of life• Feeding during second year of life• Feeding during later childhood

Objective

• At the end of this lecture the students should be able to– Describe the nutritional requirement of infants

and children– Identify common problems encountered during

feeding of infants

Breast feeding• Feeding should be initiated as soon after birth as

possible unless contraindicated.– maintains normal metabolism during transition– Promotes maternal infant bonding

• The time required for an infant stomach to empty may vary from 1-4 hrs – 6 – 9 feedings in 24 hrs– Most infants take 80-90ml per feed

• Satisfactory feeding – No more wt loss at the end of 1st week– Started to gain wt at the end of 2nd week

Advantage of BF• Always available at a proper temperature and

requires no preparation time• Fewer feeding difficulties, low incidence to allergy• Contains bacterial and viral antibodies

– High conc. Of secretary IgA– Substances that inhibit growth of many common viruses– Macrophages synthesize complement, lysozyme and

lactoferrin– Lower incidence of diarrhea as well as otitis media,

pneumonia, bacteremia, and meningitis

Continued…– Contains bile salt-stimulated lipase, which kills giardia lamblia and

enteameba histolytica• Supply all necessary nutrients except flouride and after

several months vit. D• The psychological advantage of BF to the mother and the

infant – well known• Establishing and maintaining the milk supply

– Empting of the breast – most important stimulusSuckling – afferent to hypothalamus –pituitary – prolactin and oxytocin– Tender or sore nipples- nursing more frequently, manually expressing

milk, nursing in diffirent conditions, and keeping the breast dry– Less relaxed anxious mother – express milk feeding

Maternal diet• Should contain enough calories and other nutrients

– To compensate those secreted in the milk and those required to produce it

– Role – to maintain wt and generous in fluid, minerals and vitamin– Milk is an important component of the diet– No food need to be withheld from the mother– Should not take drugs– Antithyroid medications, lithium, anticancer agent, INH,

chloramphenicol, metronidazole– Smoking cigarettes and drinking alcohol- discouraged

Feeding during the second 6 month of life

• By 6 month of age infants capacity to– Digest and absorb a variety of dietary components– Metabolize, utilize and excrete the absorbed products of digestion is

near adult capacity– Teeth are beginning to erupt– Begin to explore his surrounding

• Addition of other foods is recommended ( weaning)• Complementary foods – additional foods including formulas,

given to breast fed infants• Replacement foods – foods other than formula given to

formula fed infants

• Weaning should be stepwise to both breast fed and formula fed infants– Cereals, a good source of iron, usually should be the first

food– Vegetable & fruits are introduced next– Meats follows shortly – finally eggs– One new food should be introduced at a time– Additional new foods should be spaced by 3-4 days

• Adverse reactions (families with food or other allergies)

• Either home prepared or manufactured complementary foods can be used

• The latter are more convenient and likely to contain less salt – have supplemental nutrients ( eg Iron)

• Egg containing products should be delayed• Food should be served 3 -5 time per day including

night • With this most infants receive adequate nutrients

Feeding problems during the 1st year of life

• Underfeeding– Suggested by restlessness and crying– Failure to gain wt– Possible causes

• Check frequency of feeding, mechanics of feeding• Abnormal mother infant bonding• Possible systemic disease

– Rx – instructing mother about the art of BF and psychological support

_ specific management of systemic illnesses

• Overfeeding– Regurgitation and vomiting

• Reg. –return of small amount of swallowed food• Vomiting – more complete emptying of stamach

– Too high in fat – delay in gastric emptying, cause abd. distention and Discomfort,

– Too high in CHT- distention and flatulance• Loose stools

– Milk stool – loose, greenish yellow containing mucus with freq. of 6-8 times/24hrs

– All diarrhea - infectious

• Constipation – Consistency rather than freq. is the basis for diagnosis– Perform PR exam– Aganglionic megacolon, tight or spastic anal sphincter– May be caused by an insufficient amount of food or fluid – From diets that are too high in fat or protein or deficient in

bulk– Functional constipation – the most common– Enemas and suppositories – temporary use

• Colic – infantile colic– Common in infants younger than 3 month– The attack usually begins suddenly with a loud

continuous cry– Etiology is not usually apparent– Holding the infant upside helps and burping– Occasionally sedation for prolonged attack

Feeding during the 2nd year of life

• By the end of 1st year- 3 meals a day plus 1-2 snacks• Changes in eating behavior

– Reduced food intake –rate of growth declines– Lack of interest in food – temporary– Never force feed– Self selection of diets – should be respected– Self feeding by infant

• Basic daily diets– Grains, fruits, vegetables, meats and dairy products-balanced diet

with – Snacks between meals- orange or other fruit juice with biscuit– Vegetarian diet – vitamin B12 and trace mineral deficiency

Feeding during later childhood

• After the age of 2 years– The child's diet – the same as family diet– Emphasis on grains, fruits, and vegetables

• Restriction of dietary fat to 30% of total energy• Saturated fatty acid -< 10%• Cholesterol – not more than 100mg/1000kcal• Poly unsaturated fatty acid -7-8% of energy• Unsaturated fatty acid – 12-13% of energy

– Such diet support normal growth of children

Food guide pyramid to 2-6 year old children

• These servings usually meet the daily requirement of 1600kcal (less active child) and 2800kcal ( more active child)