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Breastfeeding and Human Milk Properties

Breastfeeding and Human Milk Properties. AAP Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2005;115;496-506. WHO: Breast Feeding http://www.who.int/topics/breastfeeding/en/.

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Breastfeeding and Human Milk Properties

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  1. Breastfeeding and Human Milk Properties AAP Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2005;115;496-506. WHO: Breast Feeding http://www.who.int/topics/breastfeeding/en/

  2. ( وَالْوَالِدَاتُ يُرْضِعْنَ أَوْلادَهُنَّ حَوْلَيْنِ كَامِلَيْنِ لِمَنْ أَرَادَ أَنْ يُتِمَّ الرَّضَاعَةَ )

  3. Learning Objectives Describe why breast feeding is the best source of nourishment for infants and young children Describe the quantity and quality of components in breast milk Describe the beneficial impact on infant’s health, maternal condition, and socio-environment Describe the few contraindications and common challenges of breast feeding, which could be faced in clinical practice by parents and clinicians

  4. Content Breast feeding - definition, goal & rates Human milk Composition Functional components Benefits Relative contradictions Support system

  5. Definition & Goal Exclusive breast feeding is defined as the consumption of human milk with no supplementation of any type except for vitamins and medications Breast feeding is the bestnutrition and health protection for the first 6 months of life Breast feeding with complementary foods for at least 12 months is the ideal feeding pattern for infants Exclusive breast feeding rate target in the US: 75% at initiation 50% at 6 months 25% at 12 months Agostoni C, et al. J Pediatr Gastroenterol Nutr 2008;46:99-110.http://www.healthypeople.gov/document/HTML/Volume2/16MICH.htm

  6. Breast Feeding Rates From 1970 through 1990 breast feeding dropped More mothers stepped into the workplace Easier access to commercial infant formula Misunderstandings of breast feeding Since 2000: Recognition of the benefits of breast feeding by the public and by health professionals made breast feeding initiation rates increase gradually

  7. Global Breast Feeding Rates At 4 months: 66% in Norway 41% in Japan 28% in Vietnam At 6 months: 33% in the US Breast feeding rate in Taiwan is unsatisfactory In 2004: Immediately postpartum, 50% of mothers breast fed At 1 month, 29%-33% exclusively breast fed At 6 months,13% exclusively breast fed & 20% supplemented breast feeding with formula feeding WHO Global Data Bank on Breastfeeding and Complementary Feeding http://apps.who.int/research/iycf/bfcf/

  8. Structure of the Human Breast • The Human breast are modified sweat glands responsible for lactation (milk production). • The breast contains adipose tissue and fibrous connective tissue. • Different hormones are responsible for the development of the breast and changes that occur during pregnancy. • The major hormones affecting breast development and enlargement are estrogen, progesterone and prolactin.

  9. Structure of the Human Breast (Cont’d) • Each breast contains about 20 lobes, each lobes contains several lobules which at the end have alveolar in which milk is produced. • Milk production and secretion are responsive to two major hormones – prolactin and oxytocin; and the sucking reflex. • After production of milk in the alveolus, the milk moves through the ducts and are stored in the lactiferous sinus. When the infant latches on the breast, milk is expressed from the sinuses.

  10. Suckling Hormonal Reflex Arc (Cont’d) • The sucking reflex arc is a hormonal positive feedback mechanism. • The sucking of the breast by the infant stimulates the nipple; this sends messages to the spinal cord and subsequently to the brain. • Prolactin is released from the anterior pituitary for milk production and oxytocin from the posterior pituitary for the milk let down. • Prolactin receptors are established within the first eight days of delivery. • Suckling at breast increases prolactin levels, so at each feeding, levels rise, hence more milk production.

  11. Physiology of lactation • Lactation and milk production goes into 3 stages: • Lactogenesis  I  • Lactogenesis II • Lactogenesis III • Lactogenesis ( I & II )  milk supply is hormonally driven endocrine control system. • Lactogenesis III  switch to the autocrine (or local) control system.

  12. Physiology of lactation

  13. Physiology of lactation • The mother will start making colostrum about halfway through pregnancy (Lactogenesis I), but high levels of progesterone inhibit milk secretion. • At birth, the delivery of the placenta results in a sudden drop in progesterone/estrogen levels. progesterone/estrogen Prolactine • Lactogenesis II

  14. Physiology of lactation • After Lactogenesis II, there is a switch to the autocrine (or local) control system (Lactogenesis III ) • Milk removal is the primary control mechanism for supply. • Under normal circumstances, the breasts will continue to make milk indefinitely as long as milk removal continues. Maintenance stage of milk production

  15. Neonatal feeding reflexes:- 1) Rooting reflex: touching the check or circumaural area leads to turning the head to the side of the stimulus leading to opening the mouth seeking for the nipple.2) Suckling reflex: tactile stimuli of the nipple or aereolar tissue filling the mouth leading to milking action by tongue against hard palate.

  16. 3) Swallowing reflex: follows suckling or allows interruption to breathing to prevent choking during swallowing.

  17. Facts about babies and newborns. • They are considered as immunocompromised due to there immature immunity. • Thy need a high amount of energy for growth and development. • There renal solute load is low. • There different organs and systems are still not 100% mature. Breast Milk is tailored to help coping with these different immaturity aspects

  18. Composition of breast milk:- Colostrum: Small amount during days 3 up to 5. Thin yellowish fluid, provide passive immunity to the baby. High in protein, immunoglobulins and minerals. Low in lactose and fat. Bright lemon yellow ; alkaline ; viscous fluid secreted during first 5-7 days : compared to mature milk it is : 1) More rich in protein (2.3gm/dl) but less CHO or fat.

  19. 2) Very rich in immunoglobulin especially IgA.3) rich in cholesterol , Na , K , Cl , Zinc , Copper , leucocytes ( macrophages , lymphocytes )Antibacterial ( lactofissin , lactofirrin )more rich in Vit.A than mature milk.

  20. 4) Laxative effect by enhancing GIT motility leading to prevention of meconium blood formation which is the most common cause intestinal destruction. 5) reducing enterohepatic circulation and prevent hyperbilirubinaemia.

  21. Milk composition: • Transitional milk: • produced during days 4 to10 • High in fat, lactose • Lower in protein and minerals

  22. Milk composition: • Mature milk: available by 2 weeks post-partum. • Milk yield: 750 ml/d • Provides 67 kcal/100 ml • 60-80% whey protein. • 7% Lactose  provides 40% of caloric need. • 4% fat  Provides 50% of the caloric need • Growth promoting factors • Low in vitamin D

  23. Breast feeding • Nowadays there is a world wide efforts to rise the awareness of the importance of breast feeding for the benefit of the baby, and better health for all humans. • WHO strongly recommends exclusive breastfeeding for the first six months of life. Exclusive Breast Feeding Breast milk ONLY, and no other foods or liquids. Not even water !!

  24. Signs of Effective Breastfeeding • Frequent feedings 8-12 times daily. • Intermittent episodes of rhythmic sucking with audible swallows should be heard while the infant is nursing. • Infant should have about 6-8 wet diapers in a 24 hour period once breast feeding is established. • Infant should have minimum of 3-4 bowel movements every 24 hours. • Stools should be about one tablespoon or larger and should be soft and yellow after day 3. • Average daily weight gain of 15 -30g. • Infant has regained birth weight by day 10 of life.

  25. Good Breastfeeding Techniques The baby should be properly positioned to achieve effective latching. The mother should wear comfortable apparel, with the breast well exposed for the infant to be able to latch. The infant’s mouth, chin and umbilicus should be lined up with the head in a neutral position. The infant is brought to the breast, with the nose touching or close to the breast. The gum line should overlap the areola, and the nipple straight back into the mouth. The tongue moves forward beyond the lower gum, cupped and forming a reservoir. Milk is removed for the lactiferous sinuses, the jaw moves down creating a negative pressure gradient that helped transfer milk to the pharynx.

  26. Good Breastfeeding Techniques

  27. Breastfeeding Positions Cradle Hold • This is the most common position used by mothers. • Infant’s head is supported in the elbow, the back and buttock is supported by the arm and lifted to the breast. Adapted from AAFP Journal September 2001

  28. Breastfeeding Positions Football Hold Position • The infant’s is placed under the arm, like holding a football • Baby’s body is supported with the forearm and the head is supported with the hand. • Many mothers are not comfortable with this position • Good position after operative procedures Adapted from AAFP Journal September 2001

  29. Breastfeeding Positions Side Lying Position • The mother lies on her side propping up her head and shoulder with pillows. • The infant is also lying down facing the mother. • Good position after Caesarean section. • Allows the new mother some rest. • Most mothers are scared of crushing the baby. Adapted from AAFP Journal September 2001

  30. Breastfeeding Positions Cross Cradle Hold Position • Ideal for early breastfeeding. • Mother holds the baby crosswise in the crook of the arm opposite the breast the infant is to be fed. • The baby's trunk and head are supported with the forearm and palm. • The other hand is placed beneath the breast in a U-shaped to guide the baby's mouth to your breast. Adapted from AAFP Journal September 2001

  31. Breastfeeding Positions Australian Hold Position • This is also called the saddle hold • Usually used for older infants • Not commonly used by mothers. • Best used in older infants with runny nose, ear infection. Adapted from AAFP Journal September 2001

  32. Breast Milk vs. Cow Milk

  33. Breast Milk Contains: • Macronutrients • Protein • Fat • Carbohydrate • Micronutrients • Minerals • Vitamins • Enzymes, hormones, growth factors, immune globulins, trace elements and cells

  34. Protein 75% of the nitrogen-containing compounds in breast milk: Aqueous whey Micellar casein Ratio varies considerably during lactation Non-protein nitrogen substances include urea, nucleotides, peptides, free amino acids, and DNA Colostrum: Protein: 2.5 gm/dl Rich in cells Provides numerous immune factors - secretory IgA and lactoferrin Relatively low fat

  35. Protein Lonnerdal B. Am J Clin Nutr. 2003 Jun;77(6):1537S. Markus CR. Am J Clin Nutr. 2002 Jun;75(6):1051-6.

  36. Fat About 50% of kcal More than 98% as triglycerides Oleic acid (18:1), palmitic acid (16:0) are the most abundant fatty acids Human milk: palmitic acid esterified to center or 2-position of the triglyceride Vegetable oil: palmitic acid esterified mainly at external or 1- & 3-positions Human milk has significant beneficial effects on intestinal absorption of fat and calcium in healthy term infants

  37. Long-Chain Polyunsaturated Fatty Acids (LC-PUFA) Fatty acids with chain length of 18 carbons or more and at least 2 double bonds They have a positive impact on cognitive function and visual development Arachidonic acid [20:4ω6] and docosahexaenoic acid [22:6ω3] are higher in plasma and erythrocytes in breast fed infants than in formula-fed infants Maternal supply of egg yolk lipid, fish oil or vegetable oil can increase human milk content of LC-PUFA

  38. Enzymes Human milk lipases Lipoprotein lipase Essential for formation of milk lipid in mammary gland Bile salt-stimulated lipase Stable at low pH Not affected by intestinal proteolytic enzymes Heat labile, inactivated by pasteurization Effective for optional vitamin A absorption Beneficial for newborn, premature infants

  39. Carbohydrates Lactose is the major carbohydrate Hydrolyzed to glucose and galactose Oligosaccharides About 10% of total milk carbohydrates Lactose-N-tetraose and monofucosylated derivatives Some have structures that mimic specific bacterial antigen ligands - prevent bacteria and toxins’ attachment to the host mucosa Production of beneficial short-chain fatty acids is increased by intestinal flora

  40. Minerals and Vitamins • Human milk calcium • Combined with phosphorus & bound to casein • High bioavailability • 0.2 g casein/100 g milk • 280 mg/L (41mg/100Kcal) • 3 forms of calcium: • Free or ionized • Combined with inorganic anions (eg, phosphate, citrate) • Bound to casein

  41. Iron • Infants born with abundant iron stores • Meet the infant’s requirement until 4 to 6 months • Low birth weight, preterm infants need supplementation • Iron absorption from a variety of foods is about 1% • Iron absorption from human milk is greater than 50% • At 6 months, breast fed infants need 1 mg iron supplementation/kg/day Dee DL, et al. Pediatrics 2008;122:S98-S104. American Academy of Pediatrics. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

  42. Vitamin K Transmitted poorly across the placenta and is in low concentrations in human milk A single intramuscular dose of vitamin K at birth to prevent hemorrhagic disease Vitamin D Vitamin D deficiency may harm bone growth and tooth enamel formation Adequate sun exposure may help vitamin D formation In 2008, the American Academy of Pediatrics (AAP) recommended that all infants have a minimum intake of 400 IU of vitamin D per day, beginning during the first few days of life Vitamins K and D www.pediatrics.org/cgi/doi/10.1542/peds.2008-1862.

  43. Selected Bioactive Factors in Human Milk

  44. Selected Bioactive Factors in Human Milk

  45. Breast Feeding: Benefits for Infants Preventing infectious diseases Bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, necrotizing enterocolitis, otitis media, urinary tract infection, and late-onset sepsis in preterm infants Reduced chronic diseases/conditions Sudden infant death syndrome, diabetes, lymphoma, leukemia, Hodgkin’s disease, obesity, hypercholesterolemia, atopy, asthma Neurobehavioral aspects Cognitive development Pediatrics 2005;115:496-506. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496).

  46. Breast Feeding: Benefits for Mothers Short-Term Decreased postpartum bleeding Uterine involution Decreased menstrual blood loss Increased child spacing Postpartum weight loss Long-Term Reduced risk of breast and ovarian cancer Decreased risks of hip fractures in menopause Pediatrics 2005;115:496-506. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496).

  47. Decreased annual health care costs Decreased public health program costs Decreased absenteeism Decreased loss of family income More time for siblings and family matters Decreased environmental burdens Breast Feeding: Benefits for Communities Pediatrics 2005;115:496-506. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496).

  48. Breast Feeding: Do NOT recommend when: Infants The baby is diagnosed with galactosemia, or other inborn errors of metabolism Mothers Infected with the human immunodeficiency virus (HIV) Those with human T-cell lymphotropic virus Herpetic lesions localized to the breast Untreated active pulmonary tuberculosis Is taking prescribed cancer chemotherapy agents, such as antimetabolites Is using or dependent upon an illicit drug Is taking antiretroviral medications Is undergoing radiation therapies

  49. Breast Feeding: Conditions that are NOT Contraindications Mothers who are infected with hepatitis B or hepatitis C virus Mothers who are seropositive carriers of cytomegalovirus (CMV) Mothers who are febrile unless cause is a contraindication previously outlined Mothers who have been exposed to low-level environmental chemical agents Tobacco smoking Breastfeeding mothers who use alcoholic beverages

  50. Counseling and FAQ … • A mother has mastitis, Does she continue breastfeeding or not ?! • Breast feeding is NOT contraindicated in mastitis. • What about breast abscess ?! • The mother can nurse form the contralateral breast.

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