Breastfeeding

1
Breastfeeding

• Effective Practices, Benefits to Mothers and
  Infants and The Role of the Family Physician

Folake Falaki, MD PGY2 Emory Family
Medicine. June 25, 2009
2
Outline

• Introduction
• Anatomy and Physiology of Lactation
• Composition and Storage of Human Breast Milk
• Achieving Optimal Breastfeeding
• Breastfeeding Techniques and Positions
• Benefits of Breastfeeding to Infants and Mothers
• Barriers to Effective Breastfeeding
• Contraindication to Breastfeeding
• Reason for supplementation
• Role of the Family Physician
• Conclusion

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Breast fed infants, are Healthy Infants.
4
Introduction

• Breastfeeding is the optimal source of nutrition.
  The Human Milk is specie specific and it provides
  all the essential nutrients necessary for the
  growth and development of the newborn infant.
• The AAP, AAFP and WHO recommend exclusive
  breastfeeding for the first six months of life ,
  and continuous breastfeeding for at least 12
  months of life.
• The Target of USDHHS Healthy People 2010
  initiative is to achieve breastfeeding at birth
  of 75, 50 at 6 month and 25 at 12 months of
  life.
• 2008 data published by the CDC shows that 77 of
  mothers in the US initiate breastfeeding at
  birth. Only about 30 of women continue with
  breastfeeding of the infant to 6 months of age.

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Anatomy and Physiology of Lactation
Structure of the Human Breast
Source Lactation Education Program Nutrition
Policy and Education
6
Structure of the Human Breast

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

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Structure of the Human Breast (Contd)

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

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Suckling Hormonal Reflex Arc
Source Lactation Education Program Nutrition
Policy and Education
9
Suckling Hormonal Reflex Arc (Contd)

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

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Types and Composition of Human Breast Milk

• Types of Breast Milk
• Colostrum or Early Milk
• Transitional Milk
• Mature Milk
• Colostrum or Early Milk is produced in the late
  stage of pregnancy till 4 days after delivery
  and is rich in antibodies.
• Transitional Milk produced from day 4 10 is
  lower in protein in comparison to Colostrum.
• Mature milk is produced from approximately ten
  days after delivery up until the termination of
  the breastfeeding.

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Types and Composition of Human Breast Milk
(Contd)

• Fat - The main lipids found in human milk are
  the triglycerides phospholipids and essential
  fatty acids.
• Protein Whey lactoferrin, lysozymes,
  immunoglobulin , A- lactalbumin, Casein
  lower concentration in human milk.
• Carbohydrate Include lactose and
  oligosaccharides.
• Leukocytes - Include neutrophils, marcrophages ,
  lymphocytes.
• Non protein nitrogen urea, uric acid
• Other constituents steroid hormones, peptides,
  insulins, growth factors, minerals, vitamins,
  lipase.

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Storage of Breast Milk

• Human milk can be stored at room temperature for
  6-8 hours.
• Expressed milk can be stored in an insulated
  cooler bag with icepacks for 24hours.
• Breast milk can be stored in the refrigerator for
  about 5 days at about 40 F.
• It can also be kept in a freezer compartment of
  a fridge for up to two weeks at 0 - 5F
• It can be stored in a deep freezer for about
  3-12 months
• Breast milk should be stored in BPA (Bisphenol A)
  free containers.

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Achieving Optimal Breastfeeding

• Activities, attitudes and procedures during the
  delivery and post partum period have an impact on
  breastfeeding .
• There is well documented evidence that skin to
  skin contact between infant and mother helps to
  maintain the body temperatures, reduce risk of
  hypoglycemia, enhance oxytocin release and
  beneficial nutrition with intake of colostrum
• Skin to skin contact should occur for about 1-2
  hours after delivery. Procedures after delivery
  like weighing, administration of vitamin K, eye
  prophylaxis and other procedures should be
  delayed

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Achieving Optimal Breastfeeding
(Contd)

• Breastfeeding should be started and fully
  established before discharge from the hospital
• Physicians and health care professionals should
  observe at least one feeding and ensure this is
  done properly and breast milk is produced
• Lactation specialist should also work with
  parents that are having difficulty with breast
  feeding.
• Early follow up after leaving the hospital is
  required.

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Signs of Effective Breastfeeding

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

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Good Breastfeeding Techniques

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

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Good Breastfeeding Techniques
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Breastfeeding Positions

• Cradle Hold
• This is the most common position used by mothers.
• Infants head is supported in the elbow, the back
  and buttock is supported by the arm and lifted to
  the breast.

Adapted from AAFP Journal September 2001
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Breastfeeding Positions

• Football Hold Position
• The infants is placed under the arm, like
  holding a football
• Babys body is supported with the forearm and the
  head is supported with the hand.
• Many mothers are not comfortable with this
  position
• Good position after operative procedures

Adapted from AAFP Journal September 2001
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Breastfeeding Positions

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

Adapted from AAFP Journal September 2001
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Breastfeeding Positions

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

Adapted from AAFP Journal September 2001
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Breastfeeding Positions

• Australian Hold Position
• This is also called the saddle hold
• Usually used for older infants
• Not commonly used by mothers.
• Best used in older infants with runny nose, ear
  infection.

Adapted from AAFP Journal September 2001
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Benefits of Breastfeeding to Infants

• Helps in Gastrointestinal development and
  function
• Helps in development of the immune system
• Helps in cognitive development of the infant
• Infants who are breastfed have reduced risk of
  infection compared to formula fed infants.

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Benefits of Breastfeeding to Infants

• Breastfed infants have reduced risk of obesity
  later in life compared to formula fed infants.
• Reduced risk of sudden infant death syndrome,
  Hodgkin's lymphoma, Leukemia and Type 1
  Diabetes.
• Lower risk of infections e.g. otitis media,
  Lower respiratory tract infection, Diarrheal
  diseases, Allergies , eczema, Meningitis and
  inflammatory bowel diseases.

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Benefits of Breastfeeding to Mothers

• Enhance early maternal infant bond.
• Aids involution of the uterus.
• Long term breastfeeding helps in loss of the
  excess weight acquired during pregnancy.
• Prolonged Breastfeeding prolongs anovulation.
• Documented long term effect of breastfeeding
  include reduced risk of breast, ovarian and
  endometrial cancers.

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Supplements that increase lactation

• Herbal dietary supplement
• - Fennel fruit
• - Aniseed fruit
• - Coriander fruit
• - Fenugreek seed
• - Blessed thistle herb
• Not FDA approved.

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Socio-economic Benefits of Breastfeeding

• Income savings average of 1000 - 1200 per
  infant per year.
• Reduced risk of infections and diseases hence
  reduced hospital visits and attendant medical
  cost.
• Mothers are more economically productive since
  they will spend less time caring for a sick
  child.

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Barriers To Effective Breastfeeding

• Lack of confidence in mother
• Belief that breast milk is not sufficient
• Lack of adequate support system
• History of previous breast surgery
• Breast engorgement, cracked and sore nipples
• Retractile nipples

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Barriers To Effective Breastfeeding

• Embarrassment by mother
• Jealousy by Partner and siblings
• Chronic illness in mother psychosis, Cancer.

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Contraindication to Breastfeeding

• HIV , HLTV 1 11 infections.
• Active Tuberculosis.
• Herpes lesions on mothers breast.
• Infant with Inborn error of metabolism
  galactosemia, phenylketonuria.
• Mothers on certain medications anticancer
  therapy, radioactive isotope etc.

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Reason for Supplementation

• Birth weight lt 1500 g or GA lt 32 weeks
• Severe hypoglycemia
• Acute water loss
• Hyperbilirubinemia related to poor intake
• Delayed bowel movement or dark stools at day 5
• Delayed milk production
• Weight loss gt8 of birth weight.

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Role of the Family Physician

• Provide education about breastfeeding at first
  prenatal visit
• Physical exam should include breast exam
• Ensure rooming-in after delivery
• Ensure breastfeeding is started and established
  before discharge after delivery.
• Observe at least a session of breastfeeding to
  ensure it is done correctly

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Role of the Family Physician

• Office should be breastfeeding friendly
• Staff should be well trained and willing to
  answer questions mothers might have
• Prenatal package should have literatures and
  patient hand out that outlines benefit of
  breastfeeding
• Prenatal records should have a checklist that
  ensure all question are addressed.

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Conclusion

• Breastfeeding is the best source of nutrition for
  a healthy term infant.
• AAP, AAFP and WHO recommends exclusive
  breastfeeding for the first six month of life and
  for at least twelve month of life.
• Human milk is human specific and contains
  nutrients that are essential for the proper
  growth and development of the newborn.
• Breast milk is beneficial to both infant and
  mother.

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Conclusion

• Proper positioning on the breast helps ensure
  adequate latching on and subsequently adequate
  breastfeeding.
• Breast milk can be stored away, and utilized
  later when needed.
• There are absolute contraindications to
  breastfeeding, these include HIV, 1 and 11 , HTLV
  1 and 11, active TB and active herpes simplex
  lesions on the breast.
• The family physician has a significant role in
  promoting breastfeeding.

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References

• Riordan J, Auerbach KG. Breastfeeding
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  Jones and Bartlett, 1999
• American Academy of Pediatrics
  Journals Periodicals Pediatrics in Review
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• Gartner LM, Morton J, Lawrence RA. et
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• United States Department of Health and
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• McDowell MA, Wang C-Y,
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  2001
• Lawrence RA and Lawrence RM.
  Breastfeeding, A Guide for the Medical
  Profession, 6th Ed. Elsevier Mosby, Philadelphia
  PA. 2005

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References

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