9/10/2014

Best for Mother and Baby

According to the American Academy of Pediatrics and the

Academy of Nutrition and Dietetics, human milk is the
preferred source of nutrition for all infants, including
premature and sick newborns.
Breastfeeding is one of the most important contributors
to infant health. Breastfeeding provides a range of
benefits for the infants growth, immunity, and
development. In addition, breastfeeding improves
maternal health and contributes economic benefits to the
family, health care system, and workplace."
-Former United States Surgeon General David Satcher

Briefly review advantages of breastfeeding.

Identify key elements for promoting
breastfeeding in the hospital and in other
settings.
Discuss aspects of becoming Baby Friendly.
Review lactogenesis.
Describe how nutrient content of breastmilk
is affected by maternal diet.
Review how to support breastfeeding.
Discuss common problems and how to
address them.

Promotes good jaw development.

Breastfeeding strengthens the jaws and
encourages the growth of straight, healthy
teeth.
Nursing may have psychological benefits,
creating an early attachment between
mother and child. Infants as young as 1 week
prefer the smell of their own mother's milk.

shaming?
my breast is for my husband
bottle feeding may lead to
over feeding

breast-milk is not
sterile. Contains:

Mother:
Reduces risk of maternal diabetes
Reduces rates of certain breast and ovarian
cancers.
Child:
Reduces likelihood/incidence of allergies,
asthma, atopic dermatitis, eczema.
Reduces rates and severity of URI, colds, OM.
Reduces GI infections, NEC, type 1 DM.
Reduced risk of ALL/AML.
Lower infant mortality, SIDS.
Improved cognitive function/IQ.

Secretory IgA active against E coli, salmonella,

shigella, streptococcus, h influenzae, c difficile
IgM active against E coli, CMV, RSV, rubella
IgD active against E coli
IgG active against rubella, CMV, RSV
Complement effect unknown
Lactoferrin active against E coli
Lactoperoxidase active against streptococcus, E
coli, pseudomonas
Lysozyme active against E coli, salmonella
Produces both bacteriocidal and antiinflammatory action

Bifidobacteria - >700 species

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thickner added to
breast milk breaks
down due to:

Epidermal Growth Factor a major

growth-promoting agent in breast milk,
stimulates proliferation of intestinal
mucosa and epithelium and strengthens
the mucosal barrier to antigens
Human Growth Factors 1, 2 and 3:
stimulates DNA synthesis and cellular
proliferation
Insulin-like Growth Factor: thought to
have a growth-promoting role
CCK enhances digestion, sedation and
feeling of satiety

Lipase compensates for immature

pancreatic function and the absence of
amylase in neonates; active against
protozoa- giardia, trichomonas
Amylase necessary for the digestion of
starch
Biotinidase regulates the metabolism of
biotin

Human milk is the preferred food for all

premature and sick newborns, with rare
exceptions.
Breastfeeding women need consistent,
informed, and individual care in the
hospital and at home after discharge.
It is usually not necessary to discontinue
breastfeeding to manage medical problems
of the mother or infant.

Hospital support
Professional support
Mother-to-mother support
Legislation
Infrastructure (public facilities and
services)

Any medical decision to limit a mothers

breastfeeding must be justified by the fact that
the risk to her baby clearly outweighs the
benefits of breastfeeding.

Worldwide effort to improve maternity care.

Facility must meet Ten Steps to Successful
Breast feeding as outlined by the World health
Organization/UNICEF.
Facilities that implement the steps can be
recognized as Baby Friendly
Some states range from several small BFHI
health care facilities to one or two large ones to
none at all
Vary in size
Best way to measure impact is proportion of
births in a given state occurring at BFHI
facilities

Maintain a written breastfeeding policy that is

routinely communicated to all health care staff

Train all health care staff in skills necessary to

implement this policy

Inform all pregnant women about the benefits

and management of breastfeeding

Help mothers initiate breastfeeding within one

hour of birth

Show mothers how to breast feed and how to

maintain lactation, even if they are separated
from their infants

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Give infants no food or drink other than

breast milk, unless medically indicated

Practice rooming in-- allow mothers and

infants to remain together 24 hours a day

Encourage unrestricted breastfeeding

Give no pacifiers or artificial nipples to

breastfeeding infants

Foster the establishment of breastfeeding

support groups and refer mothers to them
on discharge from the hospital or clinic

There are 198 US hospitals and birthing

centers in 45 states and DC that are baby
friendly.
There are 7 in Texas. They are all Texas
Health Resources hospitals and located in
North Texas:
Bedford, Ft. Worth, Cleburne, Stephenville,
Arlington, Allen, Plano.

Parkland is working on attaining BF status.

https://www.babyfriendlyusa.org/find-facilities

Provide space and equipment for pumping.

Limit distribution of free formula.
Provide lactation support to hospitalized
babies/mothers.

International Board Certified Lactation

Consultants (IBCLCs)
Work in hospitals, physicians offices, public
health clinics and their own offices

Phone assistance & phone follow-up 1-3 days

Assist the mother-infant pair

Early follow-up visit (within 1 week of discharge)

Create and administer lactation programs

Problem solving by lactation counseling

Supportive attitude

Educate other health professionals about breast

feeding

Public health nurse referral for problems

La Leche League Groups

Community support groups for pregnant
women considering breastfeeding and mother
who are breastfeeding
http://www.llli.org/

Laws protecting breastfeeding in public

Laws supporting breastfeeding women who

return to work

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State

health department full-time equivalents

(FTEs) responsible for breastfeeding
State

breastfeeding coalition
http://www.txbfcoalition.org/
Coalition

Web site

Schools include breastfeeding in curricula for MD, RN, RD,

social workers, and other allied health professionals

Insurance reimburse for lactation support

Schools teach breast is best in health and parenting classes

Societal and cultural attitudes to change to be supportive

of the breastfeeding family

Churches and other groups support breastfeeding

Barriers be removed giving women full access to

breastfeeding support

http://www.nichq.org/our_projects/txbreastfeeding.html

During the first trimester, breast tissue

changes begin. There is an increase in the
mammary ducts.
Midway through pregnancy, large lobules
begin to form. Breasts enlarge, and fat
deposition is increased.
Some women may have some leakage of their
breasts during pregnancy, but for most, milk
production begins after birth.

All

programs in TDSHS
promote and support
breastfeeding
Medical community must be
breastfeeding friendly
Hospitals with maternity
services must be baby
friendly
Business community become
mother friendly

Non-pregnant woman: average size is 200 g

Pregnant: 400-600 g
Lactating: 600-800 g
Size of the breast does not affect ability to
breastfeed successfully.
Glandular tissue is more important than size.
However, women with large breasts may have
larger volumes available per feeding, whereas
women with smaller breasts may have to nurse
more frequently.

Prolactin: stimulates milk production.

Suckling stimulates prolactin (secretion doubles
during suckling).
Oxytocin: important in letdown (milk ejection
from the milk gland).
Letdown may be experienced as a tingling or
slight pain that lasts about a minute or less.
Also acts on the uterus, causing it to contract
and shrink in size (post partum).
Letdown can occur in response to suckling,
stress, a babys cry and other stimuli.

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Colostrum: first several days post-partum

Lower in energy
Higher in protein, fat soluble vitamins, minerals,
electrolytes

Transition Milk: 7-14 days postpartum

Immunoglobulins and proteins increase
Lactose, fat and energy increase

Mature Milk: 2 weeks postpartum

Continues to about 7-8 months

Extended Lactation: 7 months to 2 years

CHO, protein, and fat stable
Vitamins and minerals gradually decrease

Colostrum gradually changes to mature milk

by the 7th postpartum day.
Lower protein content.
Lactose content is increased.
Fat content is increased.
Energy content is increased.

Calories: 65-70 kcals per dL (67)

Protein: 0.9-1.2grams per dL (0.9)
Carbohydrates: provides about 40-50% of
calories (usually primarily lactose, small
quantities of oligosaccharides, galactose,
fructose).
Oligosaccharides may help to maintain beneficial
bacterial flora in the gut.
Lactose improves calcium absorption.

Fat: provides about 40-60% of calories

(Also contains DHA, ARA-may have benefit
for visual and mental acuity)

Thick, yellowish.
Small amounts produced: less than an ounce
per feeding in many cases.
Very high in immune properties: secretory
immunoglobulin A, lactoferrin, mononuclear
cells. Higher in sodium, potassium, chloride,
protein and lower in fat and lactose than
mature milk.
Usually days 1-3 postpartum.

Probably only exists in women giving birth

to an infant less than 26 weeks.
Probably lasts only 2-3 weeks.
Higher in protein content.
Higher in calcium and other minerals and
lower in lactose than term milk.
Is not nutritionally adequate for the preterm, very low birth weight or extremely
low birth weight infant. (needs
fortification; still a superior choice to
formula)

Protein:
Low protein diet or poor quality of protein does not
usually affect protein content of human milk.
Chronic maternal protein deficit may result in lower
protein in milk.

The protein present in human milk is species

specific and very well absorbed.

Carbohydrate:
No good evidence that the lactose content of human
milk can be modified by maternal diet.

Ballard O. Pediatr Clin N Am. 2013.

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Fat: most fat present in human milk is in the form

of triglycerides but phospholipids, cholesterol,
diglycerides, monoglycerides, etc. are also
present.
Fatty acid composition of human milk is very much
affected by diet.
May contain EPA, DHA, ARA if the mother consumes foods
rich in these fatty acids.
Trans fat can also be found in human milk.
Carnitine, which helps to transport LCFAs across the
mitochondrial membrane, also is present in human milk.

Usually respond well to good diet and supplementation.

Deficiency in human milk could occur in cases of maternal
deficiency.
Clinical deficiency of these nutrients rarely occurs in
breastfed infants.
Vitamin B6: MOST likely to be deficient in human milk and
does respond to maternal diet change.
B12 and folic acid: bound to whey proteins in the milk.
Less likely to be deficient because protein not usually deficient.
Deficiency of B12 in human milk has occurred in women who have
had gastric bypass, hypothyroidism, vegans, or those with
pernicious anemia.

Calcium:
Stable regardless of maternal intake.
Calcium content is low but is well absorbed.
If maternal intake is low, calcium may be taken
from bones
Bone status usually returns after weaning.

Zinc:
Deficiency has been described but is rare.
Zinc in human milk is highly bioavailable and well
absorbed.

Iodine and selenium content affected by

maternal intake.

Breastmilk levels of water soluble vitamins are

usually more affected by maternal diet than fat
soluble vitamins.
Vitamin D:
affected by maternal exposure to sunlight, maternal
diet and maternal supplementation.

Vitamin A:
affected by the quality and quantity of vitamin A in
the maternal diet.

Vitamin K:
produced by bacteria in the gut; not present in the
sterile infant gut (Vitamin K shot at birth is standard
practice). Also present in breast milk.

Minerals contribute to osmolality and renal

solute load. The comparatively low renal solute
load of human milk make it easy on the kidneys
of infants.
Mineral content decreases over first 4 months
postpartum.
However, minerals present in human milk are
highly bioavailable.
Despite low concentrations of iron in human
milk, most breastfed infants do not experience
anemia if exclusively breastfed to 6 months of
age.

Breast milk is NOT sterile.

>700 species of bacteria have been found in
breast milk.
May contribute to probiotic role of breast
milk.
Heavier women have fewer bacteria in their
breast milk.

http://www.sciencedaily.com/releases/2013/01/130104083103.htm.
Accessed 9/10/2014.

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Sore nipples
Letdown failure
Hyperactive letdown
Engorgement
Plugged duct
Infection
Jaundice

Infants should receive quick access to the

breast after birth:
The infants suckling reflex is strongest 45 minutes
to 2 hours after birth.
Quick access to the immune properties of breast
milk.
Peristalsis is stimulated, promoting elimination of
bilirubin and decreasing likelihood of jaundice.
Breast engorgement is minimized or prevented.
Lactation is accelerated.
Attachment and bonding are enhanced.

Cradle
Allow the baby to breastfeed frequently on
demand. May want to breastfeed initially as
often as every 2-3 hours, sometimes more
frequently.
Allow pt to move to the other breast when
the baby is finished with the first. Dont
artificially stop a breastfeeding after 5-10
minutes and have mother switch breasts.
Alternate which breast a feeding is started
with.

Cross Cradle

Football

before 6 weeks, babies do not use breast as pacifier

use safety pin to know which breast the baby was

C hold
V hold
Choosing which just depends on which is
most comfortable for the mother.

Audible swallowing/gulping during feeding.

6-8 wet diapers daily.
2-3 stools daily. (some may have more)
Pre and post weights.

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Hospital Grade versus Hand-pumps

Hand pumps may be effective if the need for
pumping is infrequent. They are very lightweight and easy to transport and inexpensive.
Electric pumps may be more practical for the
working woman who needs to pump frequently.
If pumping is to be the sole means or
establishing and keeping milk supply, hospital
grade pumps are necessary.

When the baby is not able to breastfeed

immediately, pumping should be started as soon
as possible after delivery.
Double electric pumps should be used whenever
possible. (commercial grade)
Hand pumps are not very effective for
establishing an adequate milk supply.
Mom should pump every 2-3 hours, not less than
5 times per day, ideally 6-8 times per day or
more.
Mom should use an appropriate level of suction
to remove milk, not be encouraged to use the
high or normal setting unless she is
comfortable with that.

Initially double pumping should last 15-20

minutes. Once moms milk has come in,
she should pump until she stops getting milk,
then approximately 1-2 minutes after to
ensure breasts are emptied.

Common Nipple: nipple protrudes on

stimulation
Flat Nipple: minimal protrusion on
stimulation
Inverted Nipple: No protrusion/inversion on
stimulation.
Treatment may be worse than the problem:
Hoffman technique and breast shells no
longer recommended; try a nipple shield.

Sore, cracked nipples.

After feeding, allow expressed breast milk to
dry on the breasts.
May use purified lanolin as well.
Do not use soaps, creams, etc. on the breast:
some may contain ingredients not healthful to
the baby or which may irritate or dry the
breast skin.
Do not toughen the nipples.
Keep nursing.

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Engorgement: Breast becomes excessively

full of milk, warm and enlarged. Baby may
not be able to latch.
Warm compresses applied to the breast.
Mother may shower and allow warm water to
run over the breast while she applies massage.
Cold compresses after pumping or nursing to
relieve pain.
Fresh cabbage leaves applied to the breast. (do
not overuse; this may also be used to dry up
milk supply)

Mastitis: infection in the breast

Flu-like symptoms in mother

Pain, redness, swelling in the breast
Often occurs in first 6 weeks postpartum
Mother may continue to breastfeed
Needs immediate medical attention:
antibiotics
Risk factors: insufficient emptying of the
breast, cracked skin, previous mastitis
Can affect milk supply.

http://www.webmd.com/parenting/baby/vi
deo/breastfeeding-dilemmas

Basic nutrient content and advantages, why

we breastfeed
How to assist with pumping
Basic breastfeeding positions and advice.
Optimal breastfeeding diet.

Nicotine:

Passed through breast milk

Can cause the infant to be sick, vomit.
Increases exposure to organochloride pesticides, PCBs and
hexachlorobenzene.
Benefits of breastfeeding still outweigh risks in infants of
smoking mothers. However, smoking mothers should delay feedings
as long as possible after smoking.

Caffeine:

Can cause fussiness and difficulty sleeping.

Alcohol:

Passes through the milk and levels in milk are directly related to
amount consumed by mother.
Discarding pumped milk wont help. Milk will still contain alcohol
as long as mothers blood contains alcohol.
Data on the short and long term effects of alcohol in breast milk
are limited.
La Leche League and AAP allow occasional alcohol use in limited
amounts may be okay.

Few Rx Drugs are actually contraindicated while

breastfeeding. Those that are contraindicated
include:
Antineoplastic drugs
Radioactive isotopes
Drugs of abuse
Drugs that suppress lactation.
Other drugs may be looked at individually by the
mother and her physician and risk assessed and
other less risky drugs used where warranted.
One good source: Medications and Mothers Milk
by Hale

Well-balanced, healthful, including

variety.
In general, breast milk will be adequate
to allow for growth even if moms diet is
not.
However, for the health of the mother,
diet should be optimized. Also, some
nutrients may be deficient if mothers
diet is deficient.
Limit caffeinated beverages: 2 8-oz
servings/day.

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No strong evidence suggests that allergen

elimination diets during pregnancy and
breastfeeding will reduce rates of allergies in
offspring, whether the infant is at high or
low risk for allergic disease.

Calorie restriction and early attempts at

weight loss may decrease milk production
if diet contains less than 1500 calories
per day.
Routine supplementation isnt needed.
Needs to be individualized.
Large amounts of fluid are not needed for
adequate milk production.
Vegans may need to plan carefully to get
adequate:

No good evidence to suggest need to

eliminate gassy foods or spicy foods from
the diet.
Several studies have shown a reduction in
colicky behavior when a low allergen diet
was followed by the mother.
If the mother suspects a reaction, it
might be helpful to keep a food diary.
It can take anywhere from 5-7 days to 2
weeks to remove the substance from
mothers milk once the substance has
been removed from mothers diet.

Breastfeeding twins, triplets & quadruplets

is possible
Main obstacle is the time & fatigue of
mother
Frequent nursing increases milk supply
Parents of multiples need support in:
Organization
Feeding
Individualization
Stress management

protein, calcium, vitamin D, vitamin B12,

iron and zinc.

Donor human milk is breast milk donated

by a lactating woman to an unrelated
infant.
Provides an alternative to formula feeds
for babies when mothers milk is
unavailable.

The Human Milk Banking Association of North

America (HMBANA) provides guidelines for
dispensing banked human milk only by
prescription of various medical conditions.
There are ~12 milk banks in the US at this
time.
Human milk banking began in the ~1900s as
the process of milk pasteurization became
available and the use of wet nurses became
less acceptable.
The first milk bank was founded in Germany in
1919.

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Healthy, non-smoking women

Breastfeeding an infant under 1 year of
age
Surplus of donor milk.
Willing to have blood tests to rule out HIV
1,2, Hepatitis C, Hepatitis B, TB, syphilis,
CMV, Human T-cell Lymphotrophic Virus.
Free from risky behaviors.
Not regularly using medication except for:
progestin-only birth control
thyroxin
Insulin
prenatal vitamins
Iron
calcium.

Reduces:
Immune Properties:

20% less IgA

No IgM
66% less lactoferrin
Decrease in TLC and antibodies.
Decrease in growth factors.

Vitamins:
50%
25%
10%
20%

less B12.
less Thiamine
less biotin
less vitamin C.

Lysozyme stable.

Milk is:
Pooled from 3-5 donors to ensure a
more homogeneous nutrient content.

Frozen donor milk is:

Slow-thawed, cultured, pooled, and

dispensed into 3-4 ounce bottles,
Pasteurized at 62.5 degrees C for 30
minutes in a shaking water bath.

Quick cooled,
Frozen at -20 degrees C.
Pasteurized milk is:
Cultured for pathogens.

The effects of exclusive donor

milk feeding on LOS and NEC.
Are other methods of
pasteurization possible that
would better preserve the
beneficial properties of human
milk?
The effects of donor milk feeding
on length of stay, diseases of
prematurity.

Rose W.
Age 6 months.
Term infant.
BW: 7# 8 oz.
Current weight: 13 pounds. Length: 25.5
Rose has been feeding well, but nurses
frequently: 8-10 times a day. Roses mother
reports that she has plentiful milk. In addition to
nursing, she has been pumping after feeding to
empty her breasts and stores up to 20 oz a day.
Rose has lost weight compared to her 4 month
pediatricians visit.
Assess and make recommendations.

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