Breast Feeding

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Dr. Kalpana MallaMD Pediatrics

Manipal Teaching Hospital

1)Milk secretion initiated by prolactin

2) Oxytocin reflex (let down reflex or milk ejection reflex) from post. pit - contraction of neuroepithelial cells surrounding alveoli - ejection of milk.

Varying composition of Breast Milk

• Colostrum• Transitional milk • Mature milk• Fore milk• Hind milk• Preterm milk

Colostrum

• Thick, yellowish milk secreted in the first several days (5-7 days) after delivery

• Alkaline • Amount - approximately 100 cc's / 24-hour• More rich in protein (2.3gm/dl) but less CHO or

fat

Composition

• Antibody ( Ig A) rich – protects against infection and allergy

• Purgative( Laxative effect) - enhances GIT motility - reducing enterohepatic circulation - clears meconium helps prevent NNJ

• Growth factors – help intestine to mature , prevents allergy & intolerance

• Vit A rich – reduces severity of infection

Composition

- Antibacterial – (lactoalbumin, lactoferin ) - Rich in cholesterol , Na , K , Cl , Zinc , Copper ,

leucocytes ( macrophages , lymphocytes

• Transitional milk - is secreted between about four days and ten days postpartum

• It is intermediate in composition in between colostrum and mature milk

• The volume increases during this time

• Mature milk is produced from approximately ten days after delivery up until the termination of the breastfeeding

Mature milk contains on average:

• Energy (750 kcal / liter)

• Lipids - main lipids - triacyl-glycerols, phospholipids, and fatty acids including essential fatty acids, Cholesterol

Mature milk contains on average:

• Casein or curds - proteins with low solubility which complex with calcium - much lower concentration than in cow's milk

• Whey - The largest components are alpha-lactalbumen, lactoferrin, lyzozyme, albumen and immunoglobulins. Clear liquid left behind when clotted milk stands

Mature milk contains on average:

• Non protein Nitrogen - Peptides, such as epidermal growth factor, somatomedin - C and insulin are present in this fraction - play an important role in the immune system and protein synthesis

• Lactose (70 g / liter) -major carbohydrate in breast milk. It is composed of galactose and glucose

Breast milk - minerals:

• Major cations- sodium, potassium, calcium and magnesium

• Iron - low amounts but the percentage of iron absorption is very high

Breast milk - minerals:

• Zinc, selenium, chromium, manganese, molybdenum , copper and nickel are present in small amounts in breast milk

• Vit - K is low in breast milk - hemorrhagic disease of the newborn

• The vitamin D content of breast milk is less

• Hind milk - Fats and lipids are high at the end of the feeding (hind milk)

Preterm milk has more of the following

• Protein nitrogen• Immunologic factors• Medium chain fatty acids• Sodium• Chloride• Iron• This difference lasts approximately 4 weeks.

Less of

• Calories• Protein• Calcium/phosphorus• Trace minerals

Composition human milk Vs animal milk

Per 100ml Human Buffalo Cow

Energy 70 Kcal 88 Kcal 67 Kcal

Protein 1.3 gm 3.3 gm 3.4 gm

Fat 4.2 gm 6.7 gm 3.9 gm

Lactose 7gm 4.6gm 4.6 gm

Vitamin D 0.81 μg – 0.18 μg

Composition human milk Vs animal milk

Per 100ml Human Buffalo Cow

Vit C 3.8mg 3.8mg 1.5mg

Vit B 12 0.01 μg – 0.31 μg

Calcium 35mg 210mg 124mg

Folic acid 5.2 μg 5.6 μg 5.2 μg

Iron 0.08 mg 0.05 mg 0.05 mg

Composition human milk Vs animal milk

Per 100ml Human Buffalo Cow

Water 89.7g 83g 90.2g

Cholesterol – 275/100gm 330/100gm

Retinol 60 μg 72 μg 31 μg

Sodium 15mg 50 mg 52 mg

Potassium 60mg 150mg 155mg

Phosphorus 15 mg 90 mg 98 mg

Breast feeding Reflexes

• Rooting reflex• Sucking reflex• Swallowing reflex

Advantages of BF

1. Normal temperature2. Economical3. Convenient4. Balanced diet5. Anti-anaemic 6. Anti-allergic7) Anti-ricketic8) Anti-infective

7) Anti-ricketic8) Anti-infective

1)Balanced diet: A) Protein: 70% soluble ; easily digested.

B) Fat: essential fatty acid - for brain develop. C) High cholesterol: myelination of nervous

system brain growth E) High lactose F) Colostrum: increasing zinc - prevent NEC

G) Low phosphate - prevent neonatal hypocalcemic convulsions

2) Anti-anaemic:

- Lower risk of iron deficiency anemia - first 6 months of life because:

A) Higher iron content (1.5 times cow's milk) B) Better iron absorption due to acidic medium and due to

presence vitamins C,E and copper

3) Anti-allergic

It protects against - infantile eczema , allergic rhinitis , asthma and other allergies

Mechanism:• In the intestinal tract there are minute pores - high

molecular protein can directly pass into the circulation leading to antibodies formation

• Breast milk has secretory IgA - which coats the GIT – pores closed - prevents leakage of lactoproteins into the circulation and no formation of antibodies

4) Anti-ricketic

A) higher content of biologically active vit. D.

B) Ideal Cal/phosph ratio - helps optimal absorption of both. (Ca/P ratio = 2:1)

C) higher lactose content enhances calcium absorption from the gut

• Biochemical aspect-- Protein

Whey protein (80%)

Casein (20%)

Lactalbumin

Lactoferrin

-Non protein nitrogen level is high - immunity-Solutes load is low.-Lactose promotes Ca & Mg absorption

Microbiological aspect

- Sterile milk with less chance of contamination- Lactoferrin (iron-binding protein) absorbs iron from

bacteria - inhibits growth of E. coli by depriving it from iron.

• B.S.S.L( bile salt stimulated lipase) kills amoeba and giardia

- Lactose and bifidus factor promote growth of protecting flora (lactobacilli)

Immunological aspect:

• Safe , non-allergic

• Milk B-lymphocytes secrete IgA

• Milk T-lymphocytes involved in cell-mediated immunity

• Milk macrophages synthesize complement , lysozyme and lactoferrin

Psychological factor-• Emotional bonding

• Maternal benefits- less risk of ovarian/ breast ca. , involution of uterus

• Epidemiology- 14 times less risk of diarrhoea- 4 times less risk of A.R.I- 2.8 times less risk of infections.

Technique of breast feeding:-

1- Both hands and nipple should be clean

2- Baby should be , warm ; not wet

3- Mother relaxed (sitting or lying on her side)

4- Support of the breast during feeding

Criteria of good position:-

1 Baby’s body is close to the mother

2 Baby’s body is turned to the mother

3 Baby’s whole body is supported (not only head or neck).

4 Baby’s neck is straight or bent slightly back

4 Criteria of good attachment:

1) Baby’s chin is touching the breast

2) Baby’s mouth is widely open

3) Lower lip is turned outwards

4) More areola tissue above than below the mouth

5) No pain while breast feeding

Criteria for Adequate Breast feeding

Baby feeds at least 8 times \ 24 hrs Baby is calm satisfied after feeds Baby sleeps well 2-4 hours after feeding Normal motion no constipation Normal amount of urine :- 6 or more / 24 hours Normal weight gain (20-30 gm/ day or 150-210 gm

/ week

II) Criteria of under feeding

• Wt gain ; slow• Decreased amount of urine• Crying unsatisfied after feed• Suckling of fists between the feeds• Sleeplessness or v. short sleep• Air swallowing colics, vomiting, • Constipation or hunger stool ( frequent, small,

green color)

Criteria of overfeeding

• Frequent regurgitation , vomiting colics• Large bulky stools undigested curds• Abdomen distesion• Skin eruption sore buttocks• Polyuria• Excessive sweating at head• Baby over weight

Burping - Method

• Baby put on left shoulder ; support with mother’s left hand

• Right arm- supports the buttocks & give gentle pat on baby’s back.

Burping - Method

2. Alternative method• Baby placed prone in mother’s lap• Gentle tap given on back.

Breast feeding- BFHI

• BFHI- Baby friendly hospital initiative.- Global programme organised by unicef.- Launched in 1992- WABA- World Alliance for breast feeding

action ; global agency for promotion of breast feeding

- World breast feeding week- 1st -7th august

10 steps of BHFI

1.Written breast feeding policy given to all health care staff

2.Training of all health care staff3.Inform mother about benefit and

management of BF4.Help mother initiate BF within an Hour of

birth5.Show how to BF even if separated from

infant

10 steps of BHFI

6.Unless medically indicated- no food or drink should be given to infant

7.Practice rooming-in ; allows mother & child to be together 24hrs a day

8.Encourage BF on demand9.No artificial teats or pacifiers to breast feeding

infants10.Establish BF support group and refer mothers

to them.

OPERATIONAL GUIDELINES on BF.(Source : IAP’s Policy on infant feeding)

Contact points Activity

Antenatal check up Motivate exclusive breast feeding, undertake physical examination of breast & nipples

Delivery room Initiate BF soon after delivery, discourage prelacteal feeds, practise rooming in & bedding in

Primary immunization sessions Confirm exclusive BF, Sort out practical problems

Measles immunization Confirm continuation of BF & weaning foods

Booster immunization/ pulse polio/ any illness

Ensure BF & adequate food intake

Absolute Contraindication of BF

1. Congenital lactose intolerance2. Galactosemia, phenylketonuria3. Intake of anti-malignant drugs -

cyclophosphomide methotrexate ; cyclosporine

4. Antithyroid drugs5. Antipsychotic drugs

Relative Contraindication for BF

I) Maternal causes :- a) Maternal hepatitis B b) Maternal HIV/AIDS,TB c) Intake of dugs - cocaine, Anticoagulants, Thiouracil ; lithium ; bomocriptine;

chloramphenicol ; tetracycline d) Breast abscess, crack & soreness of nipple

Relative Contraindication for BF

II) Baby causes ; premature – unable to suck congenital structural defect – cleft palate

Artificial feeding

when:

- Mother is critically ill- Mother is unavailable- Or mother is dead.

Process of artificial feeding

• Formula feedingFull strength (1:1) prepared by adding - One level measure of powder- One ounce of 30 ml water

• Alternative to Formula feeding is Cow’s milk-1st week of life – 1:1 dilution- 2nd week – 2:1 dilution- 3rd week – 3:1 dilution- 4th week onwards – undiluted milk

* Adverse effect – diluted cows milk has low nitrogen and calories so more chances of malnutrition.

Adverse effects of artificial feeding

1. Malnutrition due to dilution2. More diarrhea and respiratory infections due

to contamination3. More allergy & milk intolerance 4. Salt sensitive hypertension5. Hypercholesterolemia6. Coronary artery disease and cerebrovascular

disease

7. Iron deficiency anemia8. High incidence of diabetes mellitus9. Lowered IQ10.Protein intolerance11.Hypocalcemia - Tetany , Convulsion12. Vitamin A deficiency13.Overweight14. Interferes with bonding

Average Feeding levels

- Average daily number of feeds0 to 1 week – 6 to 10 times per day1wk to 1 month- 6 to 8 times per day1-3 months - 5 to 6 times per day3 to 7 months – 4 to 5 times per day4 to 9 months – 3 to 4 times per day8 to 12 months – 3 times per day

• Average quantity of milk per feed- 1st to 2nd week- 60 to 90 ml- 3rd week to 2nd month – 120 to 160 ml- 2 to 3 months - 150 to 180 ml- 3 to 4 months - 180 to 210 ml- 6 to 12 months - 210 to 240 ml

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