Breast Feeding Dr. Kalpana Malla MD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
1)Milk secretion initiated by prolactin2) 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 ccs / 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 cows 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, molyb denum , 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 milkPer 100ml Human Buffalo CowEnergy 70 Kcal 88 Kcal 67 KcalProtein 1.3 gm 3.3 gm 3.4 gmFat 4.2 gm 6.7 gm 3.9 gmLactose 7gm 4.6gm 4.6 gmVitamin D 0.81 μg – 0.18 μg
Composition human milk Vs animal milkPer 100ml Human Buffalo CowVit C 3.8mg 3.8mg 1.5mgVit B 12 0.01 μg – 0.31 μgCalcium 35mg 210mg 124mgFolic acid 5.2 μg 5.6 μg 5.2 μgIron 0.08 mg 0.05 mg 0.05 mg
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 growthE) High lactoseF) Colostrum: increasing zinc - prevent NECG) 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 cows milk) B) Better iron absorption due to acidic medium and due to presence vitamins C,E and copper
3) Anti-allergicIt protects against - infantile eczema , allergic rhinitis , asthma and other allergiesMechanism:• 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-ricketicA) 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%) Lactalbumin Lactoferrin Casein (20%)-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)
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 clean2- Baby should be , warm ; not wet3- 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 mother2 Baby’s body is turned to the mother3 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 breast2) Baby’s mouth is widely open3) Lower lip is turned outwards4) More areola tissue above than below the mouth5) 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 - Method2. 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 BHFI1.Written breast feeding policy given to all health care staff2.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 BHFI6.Unless medically indicated- no food or drink should be given to infant7.Practice rooming-in ; allows mother & child to be together 24hrs a day8.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 ActivityAntenatal check up Motivate exclusive breast feeding, undertake physical examination of breast & nipplesDelivery room Initiate BF soon after delivery, discourage prelacteal feeds, practise rooming in & bedding inPrimary immunization sessions Confirm exclusive BF, Sort out practical problemsMeasles immunization Confirm continuation of BF & weaning foodsBooster immunization/ pulse polio/ Ensure BF & adequate food intakeany illness
Relative Contraindication for BFI) 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 BFII) Baby causes ; premature – unable to suck congenital structural defect – cleft palate
Artificial feedingwhen:- 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 feeding1. Malnutrition due to dilution2. More diarrhea and respiratory infections due to contamination3. More allergy & milk intolerance4. 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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