Breastfeeding final version - nutrition

Breastfeeding
F2 Thanaporn Trangkanont M.D.

Introduction
Breastmilk is essential for infant’s growth and development
The World Health Organization and United Nations Children’s fund
recommend exclusive human breast milk feeding for at least 6
months after birth and continue for up to 2 years of age and beyond

Anatomy of breast
• Nipple
• Areola: the pigmented area around nipple
- montgomery's gland
• Mammary tissue
- milk-secreting cells > alveoli
- ducts
• Supporting connective tissue and fat
• Blood and lymphatic vessels
• Nerves
Breastfeeding: a guide for the medical profession. 8th ed. 2016

During pregnancy
• Mammogenesis or mammary growth
estrogen progesterone, placenta hormones:
growth and proliferation of mammary gland
• Lactogenesis I: begin mid-pregnancy 16 weeks of GA
Prolactin: prepare milk production
Progesterone and estrogen: block the action of
prolactin

After delivery
• Lactogenesis II: D1-2 after delivery
Placental removed: progesterone drop
Prolactin remain high level -> milk production
“colostrum and transitional milk”
Not depend on suckling by baby
• Lactogenesis III: galactopoiesis
Depend on milk ejection reflex and autocrine

Prolactin
- Secreted by anterior pituitary gland
- Milk secretion to alveoli
- Peak of the level at 30 min after feed: produce
milk for next feed
- More secreted at night
The more a baby suckles, the more milk is produced

Oxytocin
- Secreted by posterior pituitary gland
- Myoepithelial cell contract -> milk already fills in
breast flow for the current feed
“ let down reflex or milk ejection reflex”
- Conditioned to mother sensation and feeling:
touching, smelling, seeing, hearing or thinking
Stress, pain, and upset may inhibit this reflex

Autocrine
Feedback inhibitor of lactation (FIL)
active whey protein stopping milk
production when milk is not removed
from the breast
FIL enables the amount of milk
produced to be determined by how much
the babies takes

Stage of lactation
Colostrum D1-5
- deep yellow color
- small amount 40-50 mL/d
- protein, minerals and
fat-soluble vitamin
- white cell and antibody(sIgA)
- lactose, oligosaccharide, fat
water- soluble vitamin
Transitional milk D5-14 Mature milk D>14
- white color
- comprise all essential
nutrients
- bluish-white color
- larger amount 300-400 mL/d
- bride between colostrum
and mature milk

Specific gravity 1.030
Osmolarity 286 mOsm/L
Carbohydrate
Composition of breastmilk
Macronutrients
Water
7%
88%
1%
4%
Protein
Fat
Typical mature milk contains 65-70 kcal/100 mL
Fat 50%, CHO 40% of TC

Carbohydrates
Human milk oligosaccharides
Lactose
• Easily digested by lactase from apical
surface of infant enterocyte
• Increase in mature milk
• Constant level of lactose throughout
the day
• Galactose-> galactolipid(cerebroside)
are essential to CNS development
• 20% of breastmilk carbohydrate
• Only produced in lactating mammary glands
• 200 structures of HMO have been described
• Non-digestible and non-nutritional CHO
- prebiotic role: development of gut microbiota
- production of SCFA: energy source of
enterocytes
- reduce the duration of diarrhea
- regulate direct immune response

Protein
Whey
Micellar, presented in form of clots or curd
- Result of heat, pH changes or enzymes:
Caseinate-calcium phosphate complex(insoluble)
Casein
Colostrum
90:10
Liquid form and is easy to digest
• Alpha-lactalbumin: 40% of whey component in BM
• Lactoferrin
• lysozyme
• Secretory IgA
Mature milk 60:40
Late lactation 50:50
Total protein 0.6-1.4 g/dL, protein concentration is not affected by maternal diet

Alpha lactalbumin
Role : synthesis lactose in mammary gland
absorption of mineral and trace element
Immune system and antibacterial properties
Bovine milk/cow milk contain beta-lactoglobulin
Which is absent from breast milk and to which infant
can become intolerant

Lactoferrin
• Iron binding protein
• Role: Inhibit growth of iron-dependent bacterial in GI tract
Cell growth regulation
NK cell activation
Antimicrobial, antiviral and antitumor function
Lysozyme
• Specific protein and basic polypeptide with lytic properties
• Role: Bacteriolytic against Enterobacteriacea
and gram-positive bacteria
Development and maintenance of specific intestinal flora

Immunoglobulin
• IgA and IgG are derived from serum and synthesis in mammary gland
• IgA> IgG
• IgA are very high in colostrum then decline rapidly, disappearing
almost completely by 14 day
• Role: protective defense against infection by keeping virus and
bacteria from invading the mucosa

Non protein nitrogen

Fat
Second greatest constituent in human milk, consist of
1. Triacylglycerols 97.5-98%: 2 essential fatty acid(ALA,LA)
2. Phospholipids and sphingolipids 0.7%
3. Cholesterol 0.5%
Provided major energy for infant and involved in CNS development
Fat concentration is closely related to maternal diet and weight gain during pregnancy

Fatty acid composition
• 43% SFA > 35% cis-MUFA > 20% PUFA > 1-7% trans-MUFA
• Predominant fatty acid are palmitic(C16:0), stearic(C18:0), oleic(C18:1,n-9),
linoleic(C18:2,n-6)
Fatty acid synthesized from
- Mammary gland: saturated fatty acid with
C10-14,inc. proportion in woman consuming
high CHO and low fat diets)
- Maternal circulation: long chain fatty acid(>C16)
Human milk triglyceride contained
palmitic acid primarily in sn-2 position
Nutrition in pediatric. 5th ed. 2016

Digestion and absorption of fat in human milk is more efficient than fat in infant
formula
- Presence of bile salt stimulating lipase(BSSL): complementary to pancreatic lipase
- Stereospecific position of fatty acid: contain palmitic acid in sn-2 position
Whereas infant formula fat blends contain palmitic acid in sn-1 and sn-3 position
Free palmitate may form soap with calcium
è Hard stool and loss both fatty acid and calcium
Pancreatic lipase selectively hydrolyzes
triglyceride in sn-1 and sn-3 positive
Nutrition in pediatric. 5th ed. 2016

Essential fatty acid
• DHA and ARA play very important roles in
early brain and eye development,
inflammatory response, immune function
• Recommended take upto 300 mg of DHA
per day to maintain sufficient amount of
DHA in breastmilk
Components of human breast milk: from macronutrient to microbiome and microRNA. Clin Exp Pediatr. 2020 Aug;63(8):301-309.

Milk fat globule membrane
• Within mammary epithelial cell, milk fat is packed
with other lipophilic compounds and secreted into
milk as milk fat globule
• Each globules is surrounded by bipolar milk fat
globule membrane(MFGM)
MFGM
- Emulsified milk fat
- Contain bioactive lipids, proteins and CHO
include lactadherin and MUC1 which play
role in host defense

Factors influence fat in human milk
Factor Influence
Duration of gestation Shortened gestation increase the long chain PUFA secreted
Stage of lactation Phospholipid and cholesterol contents are highest in early lactation
Parity High parity is associated with reduced endogenous fatty acid synthesis
Volume High volume is associated with low milk fat content
Feeding Human milk fat content progressively increase during a single nurse, hindmilk
Maternal diet A diet low fat increase endogenous synthesis of medium-chain fatty acid(C6-10)
Maternal energy status A high weight gain in pregnancy is associated with increase milk fat

Bioactive component
• Bioactive component come from variety of sources
- Mammary epithelial
- Cell carried within the milk
- Maternal serum: carried across epithelial by receptor-
mediated transport
Human milk composition: nutrients and bioactive factors, Pediatr Clin North Am(2013); 60(1):49-74

Growth factors
Bioactive Functions Note
Epidermal growth factors
- Maturation and healing of intestinal
mucosa
Preterm > term
Dec. over lactation
Neuronal growth factor
- brain-derived neurotrophic factor
- glial cell-line derived neurotrophic factor
- Maturation of enteral nervous system
- Enhanced peritalsis
- Inc. neuron survival and outgrowth
Insulin-like growth factor(IGF) - Survival of enterocyte following intestinal
damage by oxidative stress
Preterm=term (except
IGFII ) Dec. over lactation
Vascular endothelial growth factor(VEGF) - Angiogenesis Preterm< term(ROP)
Erythopoietin(Epo) - Inc. red blood cells, prevent anemia
- Tightens intestinal junctions
Calcitonin and somatostatin - Growth-regulating hormone
Adiponectin and other hormones: leptin,
resistin, ghrelin
- Regulate metabolism and suppress
inflammation
- Dec. incidence of overweight and obesity

Oligosaccharides
Acquired and innate factors
Cell of human milk Cytokines and chemokines
Immunological factors
macrophages, T cells,
stem cells, lymphocytes
- TGF
- TNF
- G-CSF
- Interleukin
- Interferon gamma
- Immunoglobulin: IgA,IgM,IgG
- Lactoferrin
- Milk fat globules: lactadherin
- Bile salt stimulating lipase
- Human milk
oligosachhcarides(HMOs)

Minerals
Content of milk is species-specific and parallels the growth and body structure
Cations: Na, K, Ca, Mg
Anions: P, Cl, citrate
Monovalent ions is inversed
proportion to lactose centent to
maintain osmolality close to serum
Most of mineral decrease over the first 4 months old Breastfeeding: a guide for the medical profession. 8th ed. 2016

Sodium and potassium
• K are much higher than Na, which are similar in intracellular fluid
• They can pass through the secretory membrane in both direction
-> equal level between intracellular, plasma and alveolar milk
• Independent with maternal diet, restriction of sodium did not
influence milk level

Calcium/phosphorus ration
• Ca:P ratio 1.8-2.4:1 in human milk, ratio appear to be critical to
efficient untilization
• Ratio differ to cow milk which Ca:P ratio 1:4
• Maternal serum calcium increases, although mother’s dietary intake
was below DRI
• Supplementation of calcium did not affect levels in human milk

Trace elements
- There are variation of iron in breast milk, < 0.1 – 1.6 mg of iron/mL
- Iron absorption from human milk is more efficient 49 % of iron,
compared with cow milk iron and iron fortified formula
> Inc. absorption: high amount of vitamin C, lactose (human milk)
> Dec. absorption: calcium, phosphorus and high protein
Iron
Zinc - Zinc absorption 41% from human milk, more than cow milk and
formula
- No correlation was found between zinc concentration in breast milk
and maternal dietary zinc and maternal plasma zinc

Vitamins
• Vitamin is influenced by diet in lactating women, in most cases, it contains
enough to ensure normal growth of infant
• Vitamin D and vitamin K is not insufficient in infants who are exclusively
breastfeeding
- Vitamin D is influenced by sun exposure in lactating mother or stored during
pregnancy, as well as maternal diet
-> recommended lactating mother and infants to take vitamin D supplement 200-
400 IU/day in maintenance dose, 2000 IU/day in deficiency
- Vitamin K transferred from mother to fetus in limited amounts
-> recommended vitamin K supplement in every infant after birth

Effect of mother’s diets on nutrients in breast milk
Nutrients which influenced by maternal diet
ü Fatty acid
ü Iodine
ü Manganese
ü Selenium
ü Vitamin B
ü Vitamin C
ü Folate
ü Fat soluble-vitamin
ü Protein and non protein nitrogen(in severe malnutrition)

Summary of breastmilk nutrients
Overview of Nutrients in Human Milk. Adv Nutr. 2018 May 1;9(suppl_1):278S-294S

Benefits for baby
Unclear
- Cognitive performance: confounding factor
- Cardiovascular disease: needs further investigation
• Reduction of risk for disease
- Acute otitis media - Atopic dermatitis
- Gastrointestinal infections - Lower respiratory tract disease
- Asthma - Obesity
- Type II diabetes - Childhood leukemia
- Sudden infant death syndrome(SIDS)

Benefits for mother
Unclear
- Osteoporosis
- Return to prepregnancy weight
• Reduction of risk for disease
- Type II diabetes
- Breast cancer
- Ovarian cancer
- Postpartum depression
• Postpartum recovery
• Suppress ovulation and menstruation

Contraindication of breastmilk/ breastfeeding
• Infant is diagnosed with classic galactosemia
• Mother has HIV
- is not on antiretroviral therapy
- is on ART but has not achieved sustained viral suppression during pregnancy or
time of delivery
• Mother is using illicit drug such as opioids, PCP or cocaine
(exception: alcohol, cigarettes)
• Mother has suspected or confirmed Ebola virus disease, untreated brucellosis

Contraindication of breastmilk/ breastfeeding
TB infection
Contraindication until
completion of approximately
2 week of appropriate
maternal therapy
Varicella-zoster infection
Infant should not have direct
contact active lesions
Herpes simplex infection
Contraindicated with active
herpetic lesion of the breast

อันตรายของสาร BPA เมื2อเข้าสู่ร่างกาย
สาร BPA ที*ปนเปื/อนมากับผลิตภัณฑ์พลาสติกและอาหารส่งผลกระทบต่อสุขภาพของผู้บริโภคทั/งในเด็กและ
ผู้ใหญ่ ซึ*งเด็กทารกที*ได้รับสาร BPA สะสมเข้าสู่ร่างกาย จะส่งผลกระทบที*รุนแรงกว่าในผู้ใหญ่ ซึ*งจะส่งผลต่อ
ร่างกายดังนี/
อันตรายต่อเด็ก
1.หากเด็กได้รับสาร BPA เข้าสู่ร่างกาย จะส่งผลต่อการสร้างเซลล์สมอง ระบบประสาท ความทรงจําและการ
เรียนรู้ของเด็ก
2.มีผลต่อฮอร์โมนการเจริญเติบโต และการสืบพันธุ์ ทําให้เด็กเป็นหนุ่มเป็นสาวเร็วเกินไป รวมถึงเด็กมีแนวโน้มที*
อาจจะเป็นโรคอ้วน และไฮเปอร์แอคทีฟหรือที*เราเรียกกันว่าโรคสมาธิสั/น ก่อให้เกิดความเสี*ยงโรคเบาหวาน และ
โรคหัวใจ ยิ*งสะสมในร่างกายมากเท่าใด ก็จะยิ*งไปลดศักยภาพการทํางานของร่างกายมากขึ/น
BPA ย่อมาจาก Bisphenol A เป็นสารเคมีประเภทโพลีคาร์บอเนต (Polycarbonate Plastic) เป็นวัตถุดิบ
สําคัญที2นํามาใช้ในการผลิตพลาสติก มีคุณสมบัติช่วยให้ผลิตภัณฑ์พลาสติกมีความแข็งแรง ใส ไม่แตก
ง่าย แต่ข้อเสียคือ BPA เป็นสารก่อมะเร็งและสร้างความผิดปกติให้กับเซลล์ในร่างกาย หากผลิตภัณฑ์
พลาสติกพวกนีdโดนความร้อน จากการต้ม นึ2ง สเตอริไลซ์ หรือการตากแดดเป็นเวลานาน

—Someone Famous
Breastmilk storage guideline

Impact of storage and pasteurization
Nutrient loss
• Vitamin C occur rapidly even during express breast milk
• Pasteurization of donor milk: high temperature heating
è Reduce concentration and functionality of its bioactive
component, esp. protein.
è Vary by pasteurization method(less damaging: flash-heat)
- sIgA, lysozyme, BSSL, cytokines, lipase, TGF and adiponectin
• Long term storage and freeze thaw cycles: significant
degradation of multiple milk components

Nutrients loss from breastmilk storage
Macronutrient Analysis of Human Milk according to Storage and Processing in Korean Mother. Pediatr Gastroenterol Hepatol Nutr. 2019 May;22(3):262-269.
• Human milk collected from 119 mothers was analyzed for macronutrients and caloric
• Subdivided into 9 groups for analysis, each containing 5-10 mL
1. Fresh milk, analyzed immediately
2. Fresh milk, microwave heating for 1 minutes
3. Stored at room temp 10-20oC for 1 week, rewarmed by bottle warmer
4. Stored at 2oC for 1 week, rewarmed bottle warmer
5. Stored at -20oC for 1 week, rewarmed bottle warmer
6. Stored at -20oC for 1 week, rewarmed at room temp
7. Stored at -20oC for 1 week, rewarmed in microwaved 1 minutes
8. Stored at -20oC for 1 month, rewarmed bottle warmer
Different storage temp

Different defrosting method

Different storage period

Microwave heating
Macronutrients analysis of sample after immediate microwave heating for
1 minutes was statistically different from fresh milk
Increasing in content may not be indicated of actual nutrient value but may have
reflected structural change in nutrients that were increased by heating
Heat-> nutrients are denatured or polymerized-> structural change
They considered the change itself rather than inc. or dec. the results

Different storage temperature
Under frozen storage all macronutrient were statistically significant difference
Stored 1 week, rewarmed by bottle warmer
Previous study
- Denaturation of protein has been noted after freezing 20oC and thawing
- Fat loss due to adherence of breastmilk to container wall, lipolysis or lipid peroxidation
- Lipolysis occur more in higher temperature

Different defrosting method
• No statistically significant difference in protein and CHO content of
defrosting breastmilk by room temperature
• No statistically significant difference in fat content of defrosting breastmilk
by microwave thawing
Stored at – 20oC 1 week, different defrosting method
Thatrimontrichai et al. measured fat content stored at -20oC for 30 days, defrosting refrigerated thawing
VS water bath thawing(N=90) -> Both showed significantly difference in fat content(refrigerated loss less )

Different storage period
• N= 105, 14 sample loss during storage
• Change in nutrient content were observed compared to fresh human milk
• Storage for 2 months protein content were no significantly difference
Stored at – 20oC different period, defrosting by bottle warmer
Bertino et al. measured fat content in 4o
C refrigeration human milk for 96 hr: no change in fatty acid
composition upto 96 hr(N=17)
-> Suggest maximum appropriate refrigerated shelf life is 4 days, need further study

Recommended feed fresh human
milk to their baby without storing

Nutrition in lactation women
DHA
Energy
Calcium
Micronutrients
0-6 months + 500 kcal/day
6-11 months + 300 kcal/day
0-6 months + 19 g/day
6-11 months + 13g/day
Protein Fishes + 2-3 serving/week
Inc. requirement of vitamin A,
B, C, iodine, zinc, selenium
Adequate calcium 800-1000 mg/day
ปริมาณสารอาหารอ้างอิงทีcควรได้รับประจําวันสําหรับคนไทย พ.ศ. 2563 . เอ.วี. โปรเกรสซี; 2563

Nutrition in lactation women
- Eat a variety of fish, avoid fish contained amount of mercury which have adverse effect
on brain and nervous system
- More 2-3 servings of fish a week(1 serving = 4 ounces of fish)
What is a serving: as a guide use a
palm of your hands

A picture is worth a
thousand words

A relaxed environment is
important in breastfeeding
Images reveal large amounts of data, so remember: use an
image instead of a long text. Your audience will appreciate it

Jupiter's rotation period
9h 55m 23s
333,000
The Sun’s mass compared to Earth’s
386,000 km
Distance between Earth and the Moon

Mercury is the closest
planet to the Sun and the
smallest one
Venus has a beautiful
name and is the second
planet from the Sun
Despite being red, Mars is
actually a cold place. It’s
full of iron oxide dust
How long do mothers usually breastfeed?
55% 20%
25%
12 months 24 months 6 months

Computer mockup
You can replace the image on the screen
with your own work. Just right-click on it
and select “Replace image”

Tablet mockup

Phone mockup

You can speak a bit about this
person here
You can speak a bit about this
person here
Sofia Hill
Kaliyah Harris
Doctors specializing in breastfeeding

Mercury
planet to the Sun
Mars
Despite being red,
Mars is a very cold
Venus
Venus is the second
planet from the Sun
Countries with laws that protect
breastfeeding

Quantity of milk a baby needs
80 - 150 ml
Jupiter is the biggest
planet of them all
22 - 27 ml
planet to the Sun
45 - 60 ml
Despite being red, Mars
is a very cold place
5 - 7 ml
Venus is the second
planet from the Sun
Month 1
Day 2 Week 1
Day 1

Proteins
Jupiter is the biggest planet
Composition of breast milk
Carbohydrates
Mercury is the smallest planet
Water
Mars is actually a very cold place
Fats
Venus has very high temperatures
Micro-nutrients
Saturn is a gas giant with rings

Baby's weight gain during the first year
0- 6 weeks 13 - 30 gs/day
< 4 months
113 - 227 gs/week
4 - 6 months 85 - 142 gs/week
7 - 12 months 42 - 85 gs/week

Sources of information on breastfeeding
Physicians
Mercury is the
smallest planet
Family
Jupiter is the
biggest planet
Nurses
Venus is the second
planet from the Sun
Midwives
Saturn is a gas giant
with rings
Follow the link in the graph to modify its data and then paste the new one here. For more info, click here
47%
27%
22%
4%

Caffeine
- Dose not affect the infant when mother consumes low to moderate amounts
< 300 mg/day: 2-3 cups of coffee
- Irritability, poor sleeping patterns, fussiness, and jitteriness have been reported in
infants of mother with very high intake of caffeine(> 10 cups of coffee)
- Preterm and younger newborn break down caffeine more slowly, consuming less
Drinks Caffeine content
8 Oz of coffee 80-100 mg
8 Oz of energy drinks 40-250 mg
8 Oz of black tes/ green tea 30-50 mg
12 Oz of caffeinated soft drink 30-40 mg

Recommended books for breastfeeding
Breastfeeding nutrition
Mother's milk
Breastfeeding
Milk of life

Objectives of world breastfeeding week
Firmly anchor
planet to the Sun
Promote
Despite being red, Mars is
a very cold place
Participate
Jupiter is the biggest
planet of them all
Inform
Venus is extremely hot,
even more than Mercury

Breastfeeding monitoring chart
Time Breast Duration Humor
13:35 h Left 20 minutes Quiet
:
:
Baby’s name Write here… Date Write here…
Pee Poop

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