Breastfeeding and Human Milk Properties

1
Breastfeeding and Human Milk Properties
AAP Policy Statement Breastfeeding and the Use
of Human Milk. Pediatrics 2005115496-506. WHO
Breast Feeding http//www.who.int/topics/breastfee
ding/en/
2
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3
Learning Objectives

• Describe why breast feeding is the best source
  of nourishment for infants and young children
• Describe the quantity and quality of components
  in breast milk
• Describe the beneficial impact on infants
  health, maternal condition, and socio-environment
  
• Describe the few contraindications and common
  challenges of breast feeding, which could be
  faced in clinical practice by parents and
  clinicians

4
Content

• Breast feeding - definition, goal rates
• Human milk
• Composition
• Functional components
• Benefits
• Relative contradictions
• Support system

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Definition Goal

• Exclusive breast feeding is defined as the
  consumption of human milk with no supplementation
  of any type except for vitamins and medications
• Breast feeding is the best nutrition and health
  protection for the first 6 months of life
• Breast feeding with complementary foods for at
  least 12 months is the ideal feeding pattern for
  infants
• Exclusive breast feeding rate target in the US
• 75 at initiation
• 50 at 6 months
• 25 at 12 months

Agostoni C, et al. J Pediatr Gastroenterol Nutr
20084699-110.http//www.healthypeople.gov/docum
ent/HTML/Volume2/16MICH.htm
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Breast Feeding Rates

• From 1970 through 1990 breast feeding dropped
• More mothers stepped into the workplace
• Easier access to commercial infant formula
• Misunderstandings of breast feeding
• Since 2000
• Recognition of the benefits of breast feeding by
  the public and by health professionals made
  breast feeding initiation rates increase
  gradually

7
Global Breast Feeding Rates

• At 4 months
• 66 in Norway
• 41 in Japan
• 28 in Vietnam
• At 6 months 33 in the US
• Breast feeding rate in Taiwan is unsatisfactory
  In 2004
• Immediately postpartum, 50 of mothers breast
  fed
• At 1 month, 29-33 exclusively breast fed
• At 6 months,13 exclusively breast fed 20
  supplemented breast feeding with formula feeding

WHO Global Data Bank on Breastfeeding and
Complementary Feeding http//apps.who.int/research
/iycf/bfcf/
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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 (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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Physiology of lactation

• Lactation and milk production goes into 3 stages
• Lactogenesis  I 
• Lactogenesis II
• Lactogenesis III
• Lactogenesis ( I II ) ? milk supply is
  hormonally driven endocrine control system.
• Lactogenesis III ? switch to the autocrine (or
  local) control system.

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Physiology of lactation
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Physiology of lactation

• The mother will start making colostrum about
  halfway through pregnancy (Lactogenesis I), but
  high levels of progesterone inhibit milk
  secretion.
• At birth, the delivery of the placenta results in
  a sudden drop in progesterone/estrogen levels.

progesterone/estrogen Prolactine
Lactogenesis II
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Physiology of lactation

• After Lactogenesis II, there is a switch to the
  autocrine (or local) control system (Lactogenesis
  III )
• Milk removal is the primary control mechanism for
  supply.
• Under normal circumstances, the breasts will
  continue to make milk indefinitely as long as
  milk removal continues.

Maintenance stage of milk production
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Neonatal feeding reflexes- 1) Rooting reflex
touching the check or circumaural area leads to
turning the head to the side of the stimulus
leading to opening the mouth seeking for the
nipple.2) Suckling reflex tactile stimuli of
the nipple or aereolar tissue filling the mouth
leading to milking action by tongue against hard
palate.
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3) Swallowing reflex follows suckling or allows
interruption to breathing to prevent choking
during swallowing.
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Facts about babies and newborns.

• They are considered as immunocompromised due to
  there immature immunity.
• Thy need a high amount of energy for growth and
  development.
• There renal solute load is low.
• There different organs and systems are still not
  100 mature.
• Breast Milk is tailored to help coping with these
  different immaturity aspects

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Composition of breast milk-

• Colostrum
• Small amount during days 3 up to 5.
• Thin yellowish fluid, provide passive immunity to
  the baby.
• High in protein, immunoglobulins and minerals.
• Low in lactose and fat.
• Bright lemon yellow alkaline
  viscous fluid secreted during first 5-7 days
  compared to mature milk it is
• 1) More rich in protein (2.3gm/dl) but less CHO
  or fat.

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2) Very rich in immunoglobulin especially
IgA.3) rich in cholesterol , Na , K , Cl , Zinc
, Copper , leucocytes ( macrophages , lymphocytes
)Antibacterial ( lactofissin , lactofirrin
)more rich in Vit.A than mature milk.
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4) Laxative effect by enhancing GIT motility
leading to prevention of meconium blood formation
which is the most common cause intestinal
destruction.
5) reducing enterohepatic circulation and prevent
hyperbilirubinaemia.
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Milk composition

• Transitional milk
• produced during days 4 to10
• High in fat, lactose
• Lower in protein and minerals

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Milk composition

• Mature milk available by 2 weeks post-partum.
• Milk yield 750 ml/d
• Provides 67 kcal/100 ml
• 60-80 whey protein.
• 7 Lactose ? provides 40 of caloric need.
• 4 fat ? Provides 50 of the caloric need
• Growth promoting factors
• Low in vitamin D

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Breast feeding

• Nowadays there is a world wide efforts to rise
  the awareness of the importance of breast feeding
  for the benefit of the baby, and better health
  for all humans.
• WHO strongly recommends exclusive breastfeeding
  for the first six months of life.

Exclusive Breast Feeding Breast milk ONLY, and no
other foods or liquids. Not even water !!
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Breast feeding

• WHO recommendations regarding breast feeding
• Breastfeeding should begin within the first hour
  of life.
• It should be Exclusive breast feeding for the 1st
  6 months.
• Breastfeeding should be "on demand", as often as
  the child wants day and night.
• Bottles or pacifiers should be avoided.
• Other foods should complement breastfeeding for
  up to two years of life.

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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
30
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
32
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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Breast Milk vs. Cow Milk
Composition (approx.) Breast Milk Cow Milk
Water () 87 87
Calories (Kcal/100ml) 67 67
Protein (g/100ml) 0.9 1.5 3.3
Fat (g/100ml) 3 3.5 3.7
Lactose (g/100ml) 6.8 4.8
Casein () 40 82
Whey () 60 18
Calcium (mg/L) 240 - 280 1000 -1200
Phosphorus (mg/L) 100 - 140 960
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Breast Milk Contains

• Macronutrients
• Protein
• Fat
• Carbohydrate
• Micronutrients
• Minerals
• Vitamins
• Enzymes, hormones, growth factors, immune
  globulins, trace elements and cells

35
Protein

• 75 of the nitrogen-containing compounds in
  breast milk
• Aqueous whey
• Micellar casein
• Ratio varies considerably during lactation
• Non-protein nitrogen substances include urea,
  nucleotides, peptides, free amino acids, and DNA
• Colostrum
• Protein 2.5 gm/dl
• Rich in cells
• Provides numerous immune factors - secretory IgA
  and lactoferrin
• Relatively low fat

36
Protein
Human Milk Bovine Milk
Major protein Alpha-lactalbumin Beta-lactoglobulin
Whey components Secretory IgA, lactoferrin, lysozyme Trace quantities only
Lonnerdal B. Am J Clin Nutr. 2003
Jun77(6)1537S. Markus CR. Am J Clin Nutr. 2002
Jun75(6)1051-6.
37
Fat

• About 50 of kcal
• More than 98 as triglycerides
• Oleic acid (181), palmitic acid (160) are the
  most abundant fatty acids
• Human milk palmitic acid esterified to center
  or 2-position of the triglyceride
• Vegetable oil palmitic acid esterified mainly
  at external or 1- 3-positions
• Human milk has significant beneficial effects on
  intestinal absorption of fat and calcium in
  healthy term infants

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Long-Chain Polyunsaturated Fatty Acids (LC-PUFA)

• Fatty acids with chain length of 18 carbons or
  more and at least 2 double bonds
• They have a positive impact on cognitive function
  and visual development
• Arachidonic acid 204?6 and docosahexaenoic
  acid 226?3 are higher in plasma and
  erythrocytes in breast fed infants than in
  formula-fed infants
• Maternal supply of egg yolk lipid, fish oil or
  vegetable oil can increase human milk content of
  LC-PUFA

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Enzymes

• Human milk lipases
• Lipoprotein lipase
• Essential for formation of milk lipid in mammary
  gland
• Bile salt-stimulated lipase
• Stable at low pH
• Not affected by intestinal proteolytic enzymes
• Heat labile, inactivated by pasteurization
• Effective for optional vitamin A absorption
• Beneficial for newborn, premature infants

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Carbohydrates

• Lactose is the major carbohydrate
• Hydrolyzed to glucose and galactose
• Oligosaccharides
• About 10 of total milk carbohydrates
• Lactose-N-tetraose and monofucosylated
  derivatives
• Some have structures that mimic specific
  bacterial antigen ligands - prevent bacteria and
  toxins attachment to the host mucosa
• Production of beneficial short-chain fatty acids
  is increased by intestinal flora

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Minerals and Vitamins

• Human milk calcium
• Combined with phosphorus bound to casein
• High bioavailability
• 0.2 g casein/100 g milk
• 280 mg/L (41mg/100Kcal)
• 3 forms of calcium
• Free or ionized
• Combined with inorganic anions (eg, phosphate,
  citrate)
• Bound to casein

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Iron

• Infants born with abundant iron stores
• Meet the infants requirement until 4 to 6 months
• Low birth weight, preterm infants need
  supplementation
• Iron absorption from a variety of foods is about
  1
• Iron absorption from human milk is greater than
  50
• At 6 months, breast fed infants need 1 mg iron
  supplementation/kg/day

Dee DL, et al. Pediatrics 2008122S98-S104. Ameri
can Academy of Pediatrics. Pediatric Nutrition
Handbook. 6th ed. Elk Grove Village, IL American
Academy of Pediatrics 2009.
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Vitamins K and D

• Vitamin K
• Transmitted poorly across the placenta and is in
  low concentrations in human milk
• A single intramuscular dose of vitamin K at birth
  to prevent hemorrhagic disease
• Vitamin D
• Vitamin D deficiency may harm bone growth and
  tooth enamel formation
• Adequate sun exposure may help vitamin D
  formation
• In 2008, the American Academy of Pediatrics (AAP)
  recommended that all infants have a minimum
  intake of 400 IU of vitamin D per day, beginning
  during the first few days of life

www.pediatrics.org/cgi/doi/10.1542/peds.2008-1862.
44
Selected Bioactive Factors in Human Milk
Secretory IgA Specific antigen-targeted anti-infective action
Lactoferrin Immunomodulation, iron chelation, antimicrobial action, anti-adhesive, trophic for intestinal growth
Nucleotides Enhances immune response, promotes growth of mucosa
Oligosaccharides Reduce bacterial attachment, nourish beneficial bacteria in GI tract
Lysozyme, macrophages, lymphocytes Lysis of microorganisms, immunomodulation
45
Selected Bioactive Factors in Human Milk
Vitamin A, E, C Carotenoids Antioxidants
Growth factors Epidermal growth factor Transforming growth factor Nerve growth factor Repair of intestinal epithelium Promotes epithelial cell growth Suppresses lymphocyte function Promotes epithelial cell growth Promotes nerve growth
Enzymes Platelet activating factor (PAF)- acetylhydrolase Glutathione peroxidase Blocks action of PAF Prevents lipid oxidation
Free amino acids Glutamine Intestinal cell fuel, promotes immune responses
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Breast Feeding Benefits for Infants

• Preventing infectious diseases
• Bacterial meningitis, bacteremia, diarrhea,
  respiratory tract infection, necrotizing
  enterocolitis, otitis media, urinary tract
  infection, and late-onset sepsis in preterm
  infants
• Reduced chronic diseases/conditions
• Sudden infant death syndrome, diabetes, lymphoma,
  leukemia, Hodgkins disease, obesity,
  hypercholesterolemia, atopy, asthma
• Neurobehavioral aspects
• Cognitive development

Pediatrics 2005115496-506. (http//aappolicy.aap
publications.org/cgi/content/full/pediatrics115/2
/496).
47
Breast Feeding Benefits for Mothers

• Short-Term
• Decreased postpartum bleeding
• Uterine involution
• Decreased menstrual blood loss
• Increased child spacing
• Postpartum weight loss
• Long-Term
• Reduced risk of breast and ovarian cancer
• Decreased risks of hip fractures in menopause

Pediatrics 2005115496-506. (http//aappolicy.aap
publications.org/cgi/content/full/pediatrics115/2
/496).
48
Breast Feeding Benefits for Communities

• Decreased annual health care costs
• Decreased public health program costs
• Decreased absenteeism
• Decreased loss of family income
• More time for siblings and family matters
• Decreased environmental burdens

Pediatrics 2005115496-506. (http//aappolicy.aap
publications.org/cgi/content/full/pediatrics115/2
/496).
49
Breast Feeding Do NOT recommend when

• Infants
• The baby is diagnosed with galactosemia, or other
  inborn errors of metabolism
• Mothers
• Infected with the human immunodeficiency virus
  (HIV)
• Those with human T-cell lymphotropic virus
• Herpetic lesions localized to the breast
• Untreated active pulmonary tuberculosis
• Is taking prescribed cancer chemotherapy agents,
  such as antimetabolites
• Is using or dependent upon an illicit drug
• Is taking antiretroviral medications
• Is undergoing radiation therapies

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Breast Feeding Conditions that are NOT
Contraindications

• Mothers who are infected with hepatitis B or
  hepatitis C virus
• Mothers who are seropositive carriers of
  cytomegalovirus (CMV)
• Mothers who are febrile unless cause is a
  contraindication previously outlined
• Mothers who have been exposed to low-level
  environmental chemical agents
• Tobacco smoking
• Breastfeeding mothers who use alcoholic
  beverages

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Counseling and FAQ

• Is there any contraindications for breast feeding
  ?
• Drugs.
• CMV, HSV ( if lesions on breast ).
• HBV ( can breast fed the baby if he took the
  vaccine ).
• Acute maternal illness ( TB, Sepsis ).
• Breast cancer.
• Substance abuse.
• HIV
• Mother can pass infection to her infant during
  pregnancy, delivery and through breastfeeding.
• Antiretroviral (ARV) drug interventions to either
  the mother or HIV-exposed infant reduces the risk
  of transmission of HIV through breastfeeding.

52
Counseling and FAQ

• A mother has mastitis, Does she continue
  breastfeeding or not ?!
• Breast feeding is NOT contraindicated in
  mastitis.
• What about breast abscess ?!
• The mother can nurse form the contralateral
  breast.

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Drugs

• Absolute
• Antineoplastic.
• Radiopharmaceuticals.
• Atropine.
• Lithium.
• Chloramphenicol.
• Alcohol.
• Relative
• Neuroleptics.
• Sedatives.
• Metronidazole.
• Tetracycline
• Sulfonamides.
• Steroids.

54
Challenges to Breast Feeding

• Jaundice / hyperbilirubinemia
• Interrupt breast feeding temporarily during
  severe hyperbilirubinemia
• Growth
• WHO growth charts establish the breast fed infant
  as the normative model
• Iron deficiency
• Introduce iron-rich complementary foods at 6
  months of age
• Supplement infants who have hematologic disorders
  or inadequate stores at birth to gt6 months of age

Pediatrics 2005115496-506. (http//aappolicy.aap
publications.org/cgi/content/full/pediatrics115/2
/496). American Academy of Pediatrics,
Subcommittee on Hyperbilirubinemia. Pediatrics
2004114297316.
55
Obstacles to Breast Feeding

• Insufficient prenatal education about breast
  feeding
• Inappropriate hospital policies and practices
• Lack postpartum home health visits and routine
  follow-up care
• Maternal employment
• Lack of family and broad societal support
• Commercial promotion and media portrayal of
  bottle feeding as normative
• Lack of guidance and encouragement from health
  care professionals

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Breast Milk Storage

• Many mothers manage and store breast milk
• Directions for safe handling and
  storagewww.cdc.gov/breastfeeding/recommendations
  /handling_breastmilk.htm
• Preparing expressed breast milk for feeding
• Expressed milk held at room temperature should be
  fed within 6-8 hours of collection
• Avoid thawing or heating milk in a microwave
  oven
• Do not re-freeze breast milk once it has been
  thawed

57
Support Systems

• A successful practice of breast feeding requires
  education and support
• Breastfeeding Helpline The DHHS Office on
  Womens Health http//www.4woman.gov/Breastfeeding
  /index.cfm?pageask
• Breastfeeding for Parents La Leche League
  Internationalhttp//www.lalecheleague.org/nb.html
  
• One-on-One Consultation  The International
  Lactation Consultant Associationhttp//www.ilca.o
  rg/
• Local communities hotline

58
10 Steps to Successful Breast Feeding

• 1. Have a written breast feeding policy that is
  routinely communicated to all health care staff
• 2. Train all health care staff in skills
  necessary to implement this policy
• 3. Inform all pregnant women about the benefits
  and management of breast feeding
• 4. Help mothers initiate breast feeding within
  half an hour of birth
• 5. Show mothers how to breast feed and how to
  maintain lactation even if they should be
  separated from their infants

http//www.unicef.org/programme/breastfeeding/baby
.htm
59
10 Steps to Successful Breast Feeding

• 6. Give newborn infants no other foods or drinks
  besides breast milk, unless medically indicated
• 7. Practice rooming-in, that is, allow
  mothers and infants to remain together 24 hours a
  day
• 8. Encourage breast feeding on demand
• 9. Do not give artificial teats or pacifiers
  (also called dummies or soothers) to breast
  feeding infants
• 10. Foster the establishment of breast feeding
  support groups and refer mothers to them upon
  discharge from the hospital or clinic

http//www.unicef.org/programme/breastfeeding/baby
.htm
60
Representative Values for Constituents of Human
Milk
Constituent (per liter) Early Milk Mature Milk
Energy (kcal) 650-700
Carbohydrate
Lactose (g) 20-30 67
Glucose (g) 0.2-1.0 0.2-0.3
Oligosaccharides (g) 22-24 12-14
Total nitrogen (g) 3.0 1.9
Nonprotein nitrogen (g) 0.5 0.45
Protein nitrogen (g) 2.5 1.45
61
Constituent (per liter) Early Milk Mature Milk
Total protein (g) 16 9
Casein (g) 3.8 5.7
ß-casein (g) 2.6 4.4
?-casein (g) 1.2 1.3
a-lactalbumin (g) 3.62 3.26
Lactoferrin (g) 3.53 1.94
Serum albumin (g) 0.39 0.41
sIgA (g) 2.0 1.0
IgM (g) 0.12 0.2
IgG (g) 0.34 0.05
Total lipids () 2 3.5
Triglyceride ( total lipids) 97-98 97-98
Cholesterol ( total lipids) 0.7-1.3 0.4-0.5
Phospholipids ( total lipids) 1.1 0.6-0.8
62
Constituent (per liter) Early Milk Mature Milk
Fatty acids (weight ) 88 88
Total saturated 43-44 44-45
C120 5
C140 6
C160 20
C180 8
Monounsaturated 40
C181?-9 32 31
Polyunsaturated 13 14-15
Total?-3 1.5 1.5
C183?-3 0.7 0.9
C225?-3 0.2 0.1
C226?-3 0.5 0.2
Total?-6 11.6 13.06
C182?-6 8.9 11.3
C204?-6 0.7 0.5
C224?-6 0.2 0.1
63
Constituent (per liter) Early Milk Mature Milk
Water-soluble vitamins
Ascorbic acid (mg) 100
Thiamin (µg) 20 200
Riboflavin (µg) 400-600
Niacin (mg) 0.5 1.8-6.0
Vitamin B6 (mg) 0.09-0.31
Folate (µg) 80-140
Vitamin B12 (µg) 0.5-1.0
Pantothenic acid (mg) 2.0-2.5
Biotin (µg) 5-9
Fat-soluble vitamins
Retinol (mg) 2 0.3-0.6
Carotenoids (mg) 2 0.2-0.6
Vitamin K (µg) 2-5 2-3
Vitamin D (µg) 0.33
Vitamin E (mg) 8-12 3-8
64
Constituent (per liter) Early Milk Mature Milk
Minerals
Major minerals
Calcium (mg) 250 200-250
Magnesium (mg) 30-35 30-35
Phosphorus (mg) 120-160 120-140
Sodium (mg) 300-400 120-250
Potassium (mg) 600-700 400-550
Chloride (mg) 600-800 400-450
Trace minerals
Iron (mg) 0.5-1.0 0.3-0.9
Zinc (mg) 8-12 1-3
Copper (mg) 0.5-0.8 0.2-0.4
Manganese (µg) 5-6 3
Selenium (µg) 40 7-33
Iodine (µg) 150
Fluoride (µg) 4-15
65
Conclusions

• Strong evidence continues to demonstrate that
  human milk is the optimal source of nutrition
  for the human infant
• Breast feeding not only decreases the risk of
  infectious diseases of infants, but also provides
  benefits for maternal health and for the
  environment
• Support for breast feeding from clinicians plays
  an important role
• It is predictable that substantial improvements
  in breast feeding ratio could result in valuable
  health gains to women and their infants

66
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