Breastfeeding Making The Difference In

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Breastfeeding Making The Difference In

  1. 1. REV. HOSP. CLÍN. FAC. MED. S. PAULO 58(1):49-60, 2003 BREASTFEEDING: MAKING THE DIFFERENCE IN THE DEVELOPMENT, HEALTH AND NUTRITION OF TERM AND PRETERM NEWBORNS Maria Beatriz Reinert do Nascimento and Hugo Issler NASCIMENTO MBR do et al. - Breastfeeding: making the difference in the development, health and nutrition of term and preterm newborns. Rev. Hosp. Clín. Fac. Med. S. Paulo 58(1):49-60, 2003. Breastfeeding is the natural and safe way of feeding small infants, providing nutritional, immunological, psychological and economic recognized and unquestionable advantages. These qualities are especially important in premature infants, because of their vulnerability. Despite highly desirable, there is, in general, little success in breastfeeding preterm infants, especially in special care neonatal units. There are evidences that a high supportive hospital environment, with an interdisciplinary team, makes possible to these infants to be breastfed. In this article, the authors present an up-to-date review about the components of human milk and its unique characteristics, as well as describes aspects that make the breast milk particularly suitable for feeding the premature newborn. DESCRIPTORS: Infant feeding. Breastfeeding. Human milk. Newborn. Premature infant. INTRODUCTION tional and immunological needs of the The transitional phase lasts from child1,3,8. the seventh to the tenth day, up to two Maternal breastfeeding is the most Lactation progresses through three weeks post partum, during which the natural and safe way to feed a small well-identified periods, i.e., the stages composition of colostrum changes, child. Breastfeeding provides a unique of colostrum, transition milk and ma- with a decrease in the concentration of combination of proteins, lipids, carbo- ture milk4. Colostrum is a yellowish immunoglobulins and proteins and an hydrates, minerals, vitamins, enzymes fluid of high density and small volume increase in lactose and fat levels and and living cells, as well as known and that fills the alveolar cells during the in energy content, until reaching the unquestionable nutritional, immuno- last trimester of gestation1. Its high con- characteristics of mature milk10. logical, psychological and economic tent of proteins and minerals, in addi- Mature human milk is a homog- benefits1-6. tion to low concentrations of fat and enous mixture consisting of three frac- The nutritional composition of lactose, reflects the needs of the new- tions: emulsion (fat droplets), suspen- breast milk, which possesses the exact born during the first week of life8. Co- sion (casein micelles) and solution (wa- proportion of nutrients for good devel- lostrum provides 67 kcal/dl, is rich in ter soluble components)4,11. Different opment of the human brain, differs immunoglobulins, lactoferrin and energy contents have been described to from the milk of other mammals, such leukocytes, and facilitates the growth mature milk in the literature, ranging as rabbit milk which contains large of Lactobacillus bifidus in the from 65.7 kcal/dl12, 71 kcal/dl13 to 75 amounts of protein for rapid growth of gastrointestinal tract and the elimina- kcal/dl10. Variations in the nutritional the species, or from whale milk which tion of meconium9,10. components of human milk exist, which is rich in fat in order to guarantee sur- depend on the stage of lactation, the vival in cold water7. Human milk is a From the Department of Pediatrics, Hospital time of day, period of feeding, mater- das Clínicas, Faculty of Medicine, University complex species-specific biological of São Paulo. nal nutrition and age, and gestational fluid, adapted throughout human ex- Received for publication on age of the infant, as well as individual April 23, 2002. istence to perfectly satisfy the nutri- aspects of each lactating mother5,8,10. 49
  2. 2. Breastfeeding: making the difference REV. HOSP. CLÍN. FAC. MED. S. PAULO 58(1):49-60, 2003 Nascimento MBR et al. NUTRITIONAL COMPOSITION human milk is perfectly adequate, with concentration being higher in OF HUMAN MILK a reduced amount of phenylalanine breastfeeding infants than in those fed and tyrosine. The newborn shows a re- artificial milk5. There is evidence show- With respect to the biochemical duced capacity of metabolizing these ing the beneficial effect of a higher composition of human milk, maternal aromatic elements which, at high cholesterol concentration during this milk contains 88% of water and its os- plasma levels, can cause lethargy13. phase of life based on its better molarity is similar to that of plasma2. Taurine, important for the develop- bioavailability to the developing brain Therefore, exclusive breastfeeding on ment of the retina and for the stability and for maintaining low and appropri- demand, without water supplementa- of cell membranes, is found in human ate blood levels of cholesterol during tion, keeps the nursing infant perfectly but not in cow’s milk14. The ratio of adult life1,10,14. hydrated1,11. the sulfur-containing amino acids me- Digestion of triglycerides in the The total protein content of human thionine/cystine in human milk is neonate is facilitated by a combination milk is the lowest among all mammals close to one, a ratio seven times lower of enzymes, such as lingual lipase due to the relatively slow growth of than that found in cow’s milk10. The which initiates hydrolysis in the diges- the child14. The real amount is about enzyme cystathionase, which is re- tive tract, gastric lipase, pancreatic li- 0.8 to 0.9 g/dl, including a high frac- sponsible for the transformation of me- pase and, especially, bile-stimulated tion of non-protein nitrogen corre- thionine to cystine, is absent in the lipase provided by the human milk fat sponding to 20 to 25%1,3. However, brain and liver of premature newborns, droplets themselves and activated by many of the properties beneficial to and thus cystine becomes essential for bile salts in the duodenum3,11. the nursing infant can be attributed to these children1. Human milk also con- Human milk represents the best the protein compartment, such as tains carnitine, a protein of high source of essential fatty acids. A great defense factors, digestive enzymes, bioavailability, which is vital during difference between human and artifi- hormones and growth factors4. immediate post-natal life for the deg- cial milk concerns the concentration Milk proteins include casein and radation of long-chain fatty acids, of long-chain polyunsaturated fatty lactalbumins, or serum proteins10, and since newborns show a reduced capac- acids, which are essential for the nor- are not completely available for nutri- ity to synthesize carnitine 8,14,15. The mal development of nursing infants, tional use by the nursing infant, since decrease in protein content during the with emphasis on docosahexaenoic those with a defense function against course of lactation leads to the fact acid which is important for the devel- infections appear intact in the feces and that human milk, without the use of opment of the brain and retina, and are not absorbed4. Casein forms stable additional components, is not com- arachidonic acid as a precursor of conglomerates with calcium and phos- pletely adequate for the feeding of pre- prostaglandins and leukotrienes17. The phorus, thus favoring the transport of mature newborns16. reserves of these fat elements are lim- these minerals11,13. The main serum Fat is the most variable component ited at birth, especially in premature proteins include a-lactalbumin, impor- of maternal milk, corresponding to 3- newborns, and rapidly decrease when tant for the synthesis of lactose, and 4 g/dl13, and represents the main en- lacking in the diet18. Several clinical protective factors such as lactoferrin, ergy source for the newborn, provid- studies have demonstrated that enrich- lysozyme and immunoglobulins. ß- ing 35 to 50% of its daily needs1. Al- ment of industrialized infant milk with Lactoglobulin, which is highly aller- most all lipids in human milk are long-chain polyunsaturated fatty acids, genic, is predominantly found in present in the form of droplets, which simulating the composition of human cow’s milk, and is only detected in permit stabilization of the emulsion milk, improves visual and cognitive small amounts in human milk where it and increases the bioavailability of li- functions in term and preterm probably originates from cow’s milk posoluble components1. Lipid compo- newborns19. However, further studies ingested by the breastfeeding nents include triglycerides, phospho- are needed to determine the long-term mother4,14. The serum protein/casein lipids and cholesterol, as well as free beneficial effects of this supplementa- ratio in human milk reported in differ- fatty acids, and are derived from cir- tion and its side effects17,19. ent studies ranges from 80/20 to 60/ culating fat originating from the diet The main carbohydrate of human 40, a fact that results in the formation and from maternal body reserves, or are milk is lactose, whose concentration is of a smoother gastric curd, reducing synthesized from glucose in the breast about 7 g/dl and which is metabolized the time of gastric emptying and facili- itself 5. into galactose, the primary source of tating digestion1,8,10. Human milk shows a high concen- the white matter of the growing The amino acid composition of tration of cholesterol, with its plasma brain1,8. Lactose facilitates the absorp- 50
  3. 3. REV. HOSP. CLÍN. FAC. MED. S. PAULO 58(1):49-60, 2003 Breastfeeding: making the difference Nascimento MBR et al. tion of calcium3,14 and supports the tion from human milk is five times The predominant immunocompetent presence of a fecal flora protective higher than absorption from cow’s cells in human milk are macrophages against bacteria and of feces of ad- milk and is facilitated by the presence (40-50%) and polymorphonuclear equate consistency 20. Other sugars, of lactose and vitamin C, as well as by neutrophils (40-50%), which have such as glycolipids, glycoproteins and low levels of protein and phosphorus phagocytic capacity and exert bacte- oligosaccharides, exist which play an in maternal milk3,8. ricidal and fungicidal actions25. In ad- important role in the defense against All water soluble vitamins are dition, macrophages synthesize the C3 infections3,4. found in breast milk, and the concen- and C4 complement components, lys- The concentration of minerals in tration of vitamin C is eight to ten ozyme and lactoferrin, and are a vehi- maternal milk is about one-third lower times higher than in the mother’s cle for the transport and storage of than in cow’s milk13. This fact, together plasma. Vitamin B 12 levels are fre- immunoglobulins10. Lymphocytes rep- with the reduced protein content, leads quently low in the milk of mothers resent 5 to 10% of white cells of milk, to a lower solute load which is ad- consuming vegetarian diets, a fact that and are mainly formed by T equate for the newborn’s immature kid- might lead to deficiency of this com- lymphocytes which exert a cytotoxic ney8. The total mineral content of hu- pound in the nursing infant5. Of the li- action on microorganisms and stimu- man milk is generally constant and in- posoluble vitamins, vitamin A and E late the immunological system of the cludes minerals such as sodium, potas- contents are adequate in human milk. nursing infant, while B lymphocytes sium, chloride, calcium, magnesium However, vitamin K supplementation are responsible for the production of and phosphorus, and the trace ele- is required for all newborns since its specific antibodies against numerous ments iron, fluor, zinc, copper, manga- endogenous production by enteric bac- pathogens8. nese, selenium, and iodide5. teria only starts some days after birth. When a pathogen in the respiratory Several studies have demonstrated The low vitamin D concentration in or digestive tract of the maternal or- a high bioavailability of minerals and human milk requires the use of exog- ganism is captured by a macrophage, their relationship with other nutrients enous vitamin supplements in the case the antigenic information is passed on present in human milk, which facili- of nursing infants who are not regularly to T lymphocytes and then to B tates their absorption, metabolism and exposed to the sun3,18. lymphocytes, which, upon transforma- excretion3. Although present in small tion into plasma cells, release specific amounts in human milk, calcium is antibodies directly into the breast. The well absorbed and its concentration is IMMUNOLOGICAL enterobronchomammary system as- sufficient in term newborns, with a cal- COMPOSITION OF HUMAN sures that any pathogen threatening cium/phosphorus ratio of 2:18. How- MILK the mother stimulates the production ever, the calcium and phosphorus con- of specific antibodies which are found centrations are too low to satisfy the One of the most valuable aspects in maternal milk1. requirements of bone mineralization in of human milk is the presence of The specific soluble factors are preterm infants20. defense elements which, together with represented by immunoglobulins (Ig). The sodium content of human milk the perfect composition and purity of The main immunoglobulin is secre- declines during the course of lactation. this milk14, guarantee a protective ef- tory IgA, which corresponds to 10% of This reduced concentration, together fect in terms of child morbidity and milk protein and prevents the adhe- with the high potassium content, mortality6,21-24. sion of microorganisms to the intesti- seems to be beneficial to the nursing The protective components of hu- nal surface, in addition to acting infant; however, it does not satisfy the man milk conferring active and pas- against diverse infectious agents such needs of premature newborns who re- sive protection on the newborn and as rotavirus, respiratory syncytial vi- quire large amounts of this mineral16. nursing infant can be divided into spe- rus, Escherichia coli, Vibrio cholerae, The high bioavailability of zinc in hu- cific and nonspecific cellular and hu- Shigella, Salmonella, Clostridium man milk compensates for its low con- moral factors10. Cellular defense ele- difficile, Giardia lamblia and centration, with zinc deficiency being ments include live leukocytes, which Campylobacter. Secretory IgA in- rare, thus preventing enteropathic ac- are present in high numbers at the be- cludes dimeric IgA bound to poly- rodermatitis in breastfeeding infants1,8. ginning of lactation9 and are known to meric immunoglobulin receptors (J Iron deficiency is a rare disorder in exert activity in the gastrointestinal chain) and conjugated to a glycopro- breastfeeding infants since, even in the tract of the nursing infant, inducing a tein produced in epithelial cells, which case of a low iron content, its absorp- local and systemic immune response. represents the secretory component25. 51
  4. 4. Breastfeeding: making the difference REV. HOSP. CLÍN. FAC. MED. S. PAULO 58(1):49-60, 2003 Nascimento MBR et al. The milk of mothers of low detergent action of free fatty acids and proteases, interleukins, prostaglandins, birthweight newborns contains larger monoglycerides released by the hy- acetylhydrolase of platelet activating amounts of IgA than the milk of moth- drolysis of triglycerides mediates the factor, secretory IgA, and antioxidants ers of term infants, conferring greater lysis of bacteria, viruses and such as vitamins and peroxidases. Hor- protection during a period when the protozoans27. mones and growth factors also play an child is more susceptible to infec- Oligosaccharides promote the de- important role by promoting gastro- tion26. velopment of the bifid flora which, intestinal maturation and by contribut- With respect to the other antibod- through a decrease in pH, impairs the ing to the development of the neonate’s ies of the different immunoglobulin multiplication of enterobacteria such own defenses31. classes, IgD participates in the immune as Shigella, Salmonella and E. coli, response in the mammary gland. IgE, and inhibits the adhesion of bacteria together with antigens in the intesti- such as Pneumococcus to mucosal sur- THE MAIN ADVANTAGES OF nal lumen, releases chemical mediators faces, thus playing an important role BREASTFEEDING that increase vascular permeability, fa- in the prevention of infectious diseases cilitating the liberation of IgG to per- in newborns4. Based on the anti-infectious, anti- form its opsonizing activity on bacte- Evidence indicates the existence of inflammatory and immunomodulatory ria and viruses. IgG also mediates the numerous other protective factors in properties of human milk described activation of the complement system, addition to those described earlier, for earlier, breastfeeding offers protection while IgM is important for the initial example, gangliosides, resistance fac- against diverse pathologies8,32, with a protection of neonates exposed to ma- tor, interferon, fibronectin, glycosami- consequent reduction in the incidence ternal infections25. noglycans, and stimulated bile li- of hospital admissions21. Many nonspecific protective factors pase10,27,28. In addition to its anti-infec- Maternal milk confers protection are found in human milk. Lactoferrin is tious function, new studies have dem- against gastrointestinal and respiratory a protein that acts as a bacteriostatic onstrated that human milk can modu- infections23,24. Children who have not agent by depriving microorganisms of late the immune response in the nurs- been breastfed show a 17-fold higher iron, in addition to exerting bacteri- ing infant through immunomodulatory probability of being hospitalized due cidal, antiviral, anti-inflammatory and and anti-inflammatory substances that to pneumonia than those who exclu- immunomodulatory activities25,27. Lys- alter the host’s reaction to injury30. sively received human milk. This pos- ozyme is a protein component found in The immunomodulatory factors sibility is even higher in nursing in- large amounts in human milk, which present in maternal milk include prol- fants aged less than three months33. mediates bacterial lysis and can exert actin, lactoferrin, nucleotides and In developing countries, the main an immunomodulatory effect by releas- cytokines which, in addition to their causes of death in the pediatric age ing elements from the bacterial cell other biological and antimicrobial func- range are protein-calorie malnutrition wall25,27. tions, are able to actively regulate the and infectious diseases, especially The components of the complement synthesis and maturation of the immune gastroenterocolitis. Malnutrition is system are found in colostrum and ma- system of the neonate. This activity particularly observed in places where ture milk, but in smaller amounts than stimulates lymphocyte proliferation and the weaning diet has a low nutritional those observed in maternal serum or in the production of immunoglobulins, value. In these countries, the effect of the nursing infant, and protect against and increases cell activity. A direct anti- natural feeding on infant mortality is respiratory and enteric infections. Vita- inflammatory action of maternal milk significant34-36. The risk of death due min B12-binding protein prevents the has not yet been demonstrated in vivo, to diarrhea and acute respiratory infec- incorporation of this vitamin by E. coli but epidemiological studies have sug- tions increases 14.2- and 3.6-fold in and bacterioids, thus inhibiting their gested that the breastfeeding infant is weaned infants, respectively 22 . growth10. protected against infection, without the Breastfed infants show a greater pro- Some fat elements of human milk observation of evident lesion of the in- tection against death due to infection also show antimicrobial functions. testinal or respiratory mucosa due to an and, at a lower age, a higher mortality Among the components of the cell inflammatory response. This is the re- risk when not breastfed. The probabil- membrane of fat droplets, glyco- sult of a well-established anti-inflam- ity of death due to infectious diseases proteins such as mucins prevent the matory system in human milk and has during the first two months of life is binding of bacteria and viruses to the been discovered only recently. The anti- six times higher in non-breastfed in- intestinal mucosa27,28. In addition, the inflammatory factors include anti- fants6. 52
  5. 5. REV. HOSP. CLÍN. FAC. MED. S. PAULO 58(1):49-60, 2003 Breastfeeding: making the difference Nascimento MBR et al. Breastfeeding has been also asso- A recent meta-analysis has sug- with a greater benefit being observed ciated with a reduction in the inci- gested that breastfeeding is associated for low birthweight infants and with a dence of acute otitis media37, urinary with a 50% lower risk of sudden infant longer duration of breastfeeding56. tract infection 38 , and meningitis death syndrome, although the etiology Maternal breastfeeding has a caused by Haemophilus influenzae39. of this event is still not well estab- higher social impact in poor countries Allergic diseases are also less com- lished and the studies analyzed pre- where the use of human milk as a nu- mon and less severe in breastfed in- sented limitations50. tritional source is crucial due to its fants8. Artificial feeding has been as- The long-term effects of breast- economic value57. Breastfeeding leads sociated with a higher incidence of feeding include a reduced risk of obes- to significant savings for the family asthma, diarrhea, vomiting and pro- ity, since breastfeeding is associated since no money is spent on the acqui- longed colds 40. Around the third or with a lower rate of obese children (2.8 sition of maternal milk substitutes or fourth month of life, 62% of infants versus 4.5% of children who have medication, and for society as a whole. fed artificial milk present chronic na- never been breastfed). Thus, breast- Not breastfeeding increases the costs sal obstruction and diarrhea versus feeding represents a preventive meas- for the health system. For each one 13% of breastfed infants 41. A long- ure for reducing the incidence of car- thousand non-breastfed infants, there term follow-up study has demonstrated diovascular diseases and other disor- is an additional number of 2033 that the prevalence of atopic manifes- ders resulting from overweight51. pediatric visits, 212 days of hospitali- tations, including eczema and food Breastfeeding provides better con- zation, and 606 medical prescriptions and respiratory allergies, is higher in ditions for the development of the for the treatment of diarrhea, respira- the group of non-breastfed patients or mother-child bond. The psychological tory diseases and acute otitis, media patients breastfed for a short period of effects of breastfeeding on the mother compared to children exclusively time42. and the child have been widely recog- breastfed for at least three months. The action of human milk on the nized, since preparing the newborn for This additional demand generates an immune system of the nursing infant breastfeeding establishes a proximity extra cost of US$331 to US$475 for might explain the finding that allergic between them that is the optimal dis- each child during the first year of life58. disorders8,42 and insulin-dependent dia- tance for the infant to visualize its The act of breastfeeding corre- betes43 are less prevalent in breastfed mother’s face52. This affective connec- sponds to a significant part of the re- children, and that weaning has been de- tion leads to reciprocal feeding from productive life of a woman, generating scribed as a risk factor for Crohn’s dis- the psychological point of view53. The new sensations and improving her self- ease 44 , childhood lymphoma 45 , and early contact between the mother and esteem59. In addition, the beneficial ef- even for breast cancer during adult- her child since birth and during lying fects of breastfeeding on maternal hood46. This effect should also be con- in together can increase the incidence health are numerous. In the breast- sidered to explain the better response and duration of breastfeeding and re- feeding puerpera, adequate involution of antibody production after vaccine duce the occurrence of abuse, negli- of the uterus accompanied by a reduc- doses against poliomyelitis, tetanus gence and abandonment during child- tion in post-partum bleeding protects and diphtheria in breastfeeding infants hood54. the maternal iron reserves, thus lead- compared to those receiving artificial At the time the newborn is ing to lower rates of anemia2,11. milk47. breastfed, alterations occur in its cer- Maternal nutrition has a low effect Breastfeeding also has a beneficial ebral activity, which are characterized on the production and composition of effect on the development of the oral by a significant increase in the ampli- human milk, since the lactating mother cavity of the child, leading to ad- tude of its electroencephalogram in the is able to mobilize nutrients from her equate tooth alignment and rare cases posterior cortical areas of both hemi- own organism even in the presence of of malocclusion, thus reducing the spheres which are related to mecha- malnutrition. Under these conditions, need to use an orthodontic apparatus nisms involved in hunger, satiety, regu- the concentration of the human milk and the risk of sleep apnea during lation of affective satisfaction and components is conserved, except for adulthood48. Breastfed infants show a sleep cycle modulation55. the lipid fraction2,60. lower incidence of caries2, while in- Breastfeeding has been correlated Lactation is believed to cause rapid fants receiving bottles containing milk with the child’s cognitive prognosis. weight loss in the lactating mother, es- or juice rich in carbohydrates at night Breastfed infants show significantly pecially during the first month post show a higher risk of developing bot- better scores in developmental tests partum, and persists, to a lesser extent, tle caries49. than those receiving artificial milk, until the time of weaning61. There are 53
  6. 6. Breastfeeding: making the difference REV. HOSP. CLÍN. FAC. MED. S. PAULO 58(1):49-60, 2003 Nascimento MBR et al. also reports showing a lower risk of os- infants, valorization of the breast as a the rules of the “Ten Steps to Success- teoporosis in breastfeeding women62. sex symbol, lack of enthusiasm on the ful Breastfeeding”78. Breastfeeding has been suggested part of health professionals, and lack This set of measures started with to exert a protective function against of knowledge about the advantages of the preparation of health professionals breast cancer. The longer the duration breastfeeding on the part of the moth- who, from the prenatal period on, were of breastfeeding, the lower the risk of ers70. As a result of urbanization, the provided with correct information developing this type of tumor during extended family has been replaced by about the qualities of natural feeding the premenopausal period63. A nega- the nuclear family, with girls having and guidance to solve problems of lac- tive correlation between breastfeeding fewer opportunities to learn informally tation79,80. The latter aspect is as impor- and ovarian cancer has also been re- the art of breastfeeding71. tant as the former since most pregnant ported64. The contraceptive effect of In Brazil, this phenomenon was women, although recognizing the su- lactation, with a consequent increase correlated with economic transforma- periority of breastfeeding, lack knowl- in the interval between gestations, is tions that occurred at the beginning of edge about the art of breastfeeding81. important to reduce maternal morbid- the 20th century, accompanied by ur- The implementation of the strategy ity and mortality in developing coun- ban-industrial growth which favored “Baby-Friendly Hospital” has been re- tries65,66. the occurrence of the nuclear family lated to a significant increase in the The practicality of feeding maternal and a consumer society, leading to the duration of breastfeeding of term milk is unquestionable, since no mix- use of bottles and importation of in- newborns82; however, information re- ing, heating or sterilizing is required dustrialized milk11. National produc- garding its impact on the feeding of and the milk is always available at the tion of artificial milk, which was am- premature infants is still insufficient. adequate temperature, in an unbreak- plified at the beginning of the forties, able container and especially pro- and exaggerated advertising of mater- jected7. Therefore, breastfeeding is the nal milk supplements have stimulated USE OF HUMAN MILK IN ideal method for feeding newborns and early weaning11,72. PREMATURE INFANTS nursing infants and should be exclu- Awareness of this problem and its sively used until six months of age67. consequences, especially infant mor- The recommendation of breast- After this age, complementation food tality due to malnutrition and gastro- feeding for the premature newborn has should be offered, but breastfeeding enterocolitis34, led to the creation of been defended on the basis of the im- can be beneficially maintained until the National Program for the Encour- munological properties of human milk, two years or more67,68. agement of Breastfeeding (PNIAM) in its role in gastrointestinal maturation, 1981 by the Ministry of Health, which formation of the mother-child bond, represented an ample educational pro- and improvement in neurobehavioral BREASTFEEDING AND EARLY gram with the objective to rescue natu- performance, shown by breastfed chil- WEANING ral feeding72,73. dren83,84. Feeding of premature infants The decade of the eighties was char- with human milk has been suggested Despite the qualities of maternal acterized by the valorization of to have short-, medium- and long-term breastfeeding, a decline in the world- breastfeeding, with the development benefits85. Premature infants show a wide rates of breastfeeding was ob- of a worldwide movement on behalf of better suction-deglutition coordina- served at the end of the 19th century, the rescue of breastfeeding 74-77. In tion during breastfeeding. The transcu- at the time of the Industrial Revolution 1989, the World Health Organization taneous partial oxygen pressure levels, and was intensified after World War II. and UNICEF promoted a meeting in oxygen saturation and body tempera- This decrease started in the urban Florence, Italy, attended by representa- ture have been shown to be higher centers of developed countries and has tives of various countries, including than those observed during bottle feed- gradually spread to developing coun- Brazil, who signed the “Innocenti Dec- ing86-89, confirming that breastfeeding tries69. laration”78 which determined actions is a more physiological process. The reasons for this decline have to be implemented by health services Human milk exerts a protective ef- been attributed to processes of urbani- to facilitate breastfeeding. On this oc- fect on premature infants against necro- zation and industrialization, including casion, the “Baby-Friendly Hospital tizing enterocolitis. Lucas and Cole90 working mothers, occupation of Initiative” was created to stimulate observed a six to ten times higher in- women in modern society, the advent maternity hospitals to promote, protect cidence of this disorder in premature of milk products exclusive for nursing and support natural feeding, based on newborns who exclusively received 54
  7. 7. REV. HOSP. CLÍN. FAC. MED. S. PAULO 58(1):49-60, 2003 Breastfeeding: making the difference Nascimento MBR et al. artificial milk compared to those fed tween 7.5 and 8 years of age, in strategy, which results in a better human milk. Likewise, the incidence preterm children fed human milk. This weight gain of premature newborns, is of any infection, including sepsis and study was carried out with scientific to offer hindmilk that contains up to meningitis, has been found to be sig- rigor, with adjustment for factors such three times more fat than foremilk111. nificantly lower among very low as social class and educational level of The milk produced by mothers of pre- birthweight newborns fed human milk the mother, days of mechanical venti- mature newborns during the first four than among those receiving exclu- lation, and gender. Since most prema- weeks post partum contains a higher sively artificial milk91,92. ture newborns received milk by gav- concentration of nitrogen, proteins During the hospital stay of the age, there is evidence that the best psy- with immunological functions, total mother and the premature infant, the chomotor development was due to the lipids, medium chain fatty acids, vita- mother produces antibodies against milk itself and not to the quality of mins A, D and E, calcium, sodium, and nosocomial microorganisms that occur mother care, supporting the statement energy than the milk of mothers of at the neonatal unit, a fact important that human milk is the optimal diet for term infants. Therefore, milk obtained for the prevention of infection in the the developing brain102. from the milk bank pool might be nu- neonate during the hospital stay 93. Epidemiological evidence suggests tritionally inadequate for premature These data were confirmed by the ob- that feeding human milk is related to infants12,112. servation of a significant reduction in a lower incidence of rehospitalization Industrialized additives derived the incidence of severe infections in of premature infants, even after the in- from cow’s milk are available and rec- patients submitted to the Kangaroo troduction of food supplements. There- ommended by some sources in order Mother Care, in which the newborn is fore, even partial breastfeeding should to satisfy the nutritional needs of the maintained in a vertical position, in be encouraged in this population8,85,93. child16,113. A wide variety of human prone decubitus, against the mother, The biological benefits of mater- milk additives exists, most of them pre- leading to early and growing contact nal milk render it an excellent food for pared on the basis of protein, carbohy- between them94, compared to patients premature newborns, even when con- drates, calcium, phosphorus, magne- treated by the traditional method95,96. sidering that eventual losses of nutri- sium and sodium, which can also con- Maternal milk has been found to ents due to collection, processing and tain zinc, copper and vitamins114. The protect premature infants with a fam- storage and to the method used to of- addition of these nutrients of bovine ily history of atopy against allergy, es- fer human milk to patients of neonatal origin to human milk has guaranteed pecially in terms of the incidence of units83,103-107 might be responsible for appropriate growth rates for very low eczema. After 18 months of age, chil- the lower growth rate observed for birthweight newborns113,115, without af- dren who received artificial milk these newborns compared to those re- fecting gastric emptying or food tol- showed a higher risk of developing ceiving artificial milk 108. Although erance116. this type of reaction than those receiv- neonatal growth performance is better Neonatologists need not only to be ing human milk from a milk bank97. in preterm infants fed premature formu- convinced of the multiple advantages Omega 3 fatty acids are essential las, this is not true for measurements of breastfeeding and of the possibility for a normal development of the retina, of weight, height, head circumference to feed human milk to premature especially in very low birthweight and cutaneous fold around nine newborns, but should also integrate newborns98. These fatty acids, together months and eight years of age, which the management of lactation into the with antioxidant substances such as were found to be similar irrespective planning of therapeutic actions for vitamin E, ß-carotene and taurine, of whether the diet received was pref- these patients117. In view of the enor- might explain the protective effect of erentially maternal milk or exclusively mous advances in neonatology since human milk on the development of artificial milk109. the end of the sixties, especially the premature retinopathy, since the inci- The diet of choice for premature development of new support tech- dence and severity of this disease are newborns is the milk of their own niques for critically ill newborns, a significantly lower in premature in- mothers. In the case the child is unable population of premature very low fants exclusively fed with maternal to directly suck at the breast, it should birthweight newborns has arisen, milk or who ingested at least 80% of receive manually expressed milk. which, until recently, did not survive their milk in the form of human milk99. When necessary, this milk should be and which, due to treir immaturity and Lucas et al.100,101 observed advan- supplemented with nutrients that are clinical complications, is subject to tages in terms of cognitive perform- found in human milk itself (reformu- childhood malnutrition and rehospi- ance, assessed at 18 months and be- lated human milk)110. Another feeding talization118. Studies making breast- 55
  8. 8. Breastfeeding: making the difference REV. HOSP. CLÍN. FAC. MED. S. PAULO 58(1):49-60, 2003 Nascimento MBR et al. feeding viable for this risk population fied help and family support125. breastfeeding to the mother. This, in have unquestionable social importance Breastfeeding premature infants turn, requires training in health educa- since these children, due to their im- represents a challenge. The premature tion and a true revolution in the hab- munological impairment 119, would newborn shows physiological and its of clinical management and, con- particularly benefit from breastfeeding, neurological immaturity, muscle hypo- sequently, subsidies for the function- especially in Brazil, a developing tony and hyperreactivity to environ- ing of the program. country with high infant mortality rates mental stimuli, and remains alert for It is also compensatory to help and endemic malnutrition in various short periods of time only 126. How- mothers of premature infants, who fre- regions120. ever, despite its inadequate suction- quently experience feelings of guilt Although desirable, a low success deglutition-respiration control 127, a and anger, by showing that rate of breastfeeding has been observed premature newborn is able to feed at breastfeeding, in addition to being im- among mothers of premature neo- the breast as long as appropriate help portant for the health and development nates121, since many hospital barriers to is provided128. of the newborn, is a practical and posi- breastfeeding still exist122, especially in The success of the work of promo- tive way for the mother to cope with high risk neonatology services123, and tion, protection and support for the early birth of their child. weaning from the breast frequently oc- breastfeeding in premature infants de- Even better would be to permit that curs even before discharge of the pre- pends on an interdisciplinary team hospitalized premature newborns be mature newborn from the high risk nurs- consisting of neonatologists, nursing neither deprived of the presence of ery124. professionals, nutritionists, occupa- their mothers nor of breastfeeding. As During the stay at the neonatal tional therapists, physiotherapists, so- Colette Clark said: unit, many mothers perceive that nurs- cial assistants and phonoaudiologists, ing their child is the only thing that who should be prepared to integrate “The newborn has only three es- they can effectively do to collaborate the clinical hospital management of sential needs: the human warmth of in the recovery of the premature new- lactation within the routine function- the mother’s arms, the certainty of the born; however, only few mothers are ing of high risk nurseries. This team mother’s presence, and the milk of her able to initiate and maintain an ad- should be motivated and capable to breasts. Breastfeeding satisfies all equate milk production without quali- provide consistent information about three.” RESUMO NASCIMENTO MBR do e col. - Alei- cológicas e econômicas reconhecidas e o aleitamento nestas crianças. Neste ar- tamento materno: fazendo a dife- inquestionáveis. Estas qualidades ad- tigo, os autores apresentam uma revisão rença no desenvolvimento, saúde e quirem relevo especial em se tratando atualizada sobre os componentes do nutrição dos recém-nascidos de ter- de recém-nascidos pré-termo, por sua leite humano e suas características úni- mo e pré-termo. Rev. Hosp. Clín. maior vulnerabilidade. Apesar de alta- cas, bem como descrevem aspectos que Fac. Med. S. Paulo 58(1):49-60, mente desejável, observa-se, de modo tornam o leite materno particularmente 2003. geral, baixa incidência de êxito na adequado para a alimentação do recém- amamentação de prematuros, especial- nascido prematuro. O aleitamento materno é o modo mente em unidade neonatais de risco. natural e seguro de alimentação para a Há evidências de que uma postura hos- DESCRITORES: Alimentação criança pequena, proporcionando van- pitalar favorável, com apoio de uma infantil. Aleitamento materno. Leite tagens nutricionais, imunológicas, psi- equipe multiprofissional, torne possível humano. Recém-nascido. Prematuro. 56
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