BREASTFEEDING Breastfeeding immediately after birth and receiving the protection

of colustrum
What do you need to know to advise this mother? - Colostrum also provides lactose
“Aren’t baby formulas nearly the same as mother’s milk?” à NO which prevents hypoglycemia
- specific to the human species, a dynamic and complex biological and facilitates the passage of
fluid meconium, which in turn aids in
- over 200 active constituents immunoprotective agents, enzymes, the excretion of bilirubin
hormones, vitamins, growth factors, essential nutrients - Even if a mother decides not to
- it changes in composition during a feed, from feed to feed during breastfeed, it is desirable to
the day and over time as the growing infant’s needs change encourage her to provide
colostrum to assure that her
Breast milk changes in appearance over time infant receives the transitional protection only available in this
maternal substance
- Colostrum is often considered the “first immunization”

PATTERN OF MILK SUPPLY

- Day 1 – some milk (5 ml) may be expressed
- Day 2-4 – Lactogenesis, milk production increases
- Day 5 – milk present; fullness and leaking felt
- Day 6 onward – breast feels empty after feeding

SELECTED BENEFICIAL PROPERTIES OF HUMAN MILK

ANTIBACTERIAL PROPERTIES
Secretory IgA Specific antigen-targeted anti-infective action
Lactoferrin Immunomodulation, iron chelation,
antimicrobial action, antiadhesive, trophic for
intestinal growth
COLUSTRUM κ-Casein Antiadhesive, bacterial flora
Oligosaccharides Prevention of bacterial attachment
- A thick, yellowish fluid present in the breast during pregnancy and
Cytokines Anti-inflammatory, epithelial barrier function
for about the first 2 to 4 days after birth
GROWTH FACTORS
- Though small in quantity (40-50 cc during the first 24 hours),
Epidermal GF Luminal surveillance, repair of intestine
provides an ideal nutrient and immunological substance to help
Transforming GF Promotes epithelial cell growth (TGF-β)
assure the newborn’s successful transition from the protected
Suppresses lymphocyte function (TGF-β)
sterile intra-uterine environment to the non-sterile extra-uterine
Nerve GF Promotes neural growth
environment.
ENZYMES
- Protein content is 70% to 80% whey, 20 Platelet- Blocks action of platelet-activating factor
activating factor-
Comparison of Colustrum (Day 1) and Mature Human Milk*
acetylhydrolase
Constituent (per Liter) Colustrum Mature Milk
Glutathione Prevents lipid oxidation
Energy (kcal) 670 750
peroxidase
Lactose (g) 20.0 35
Nucleotides Enhance antibody responses, bacterial flora
Protein (g) 32.0 9.0
Fat (g) 12.0 38.0
*Data adapted from Lawrence and Lawrence (2005), pp 110 and tables
4-5 and 4-7, pp113 IMPORTANCE OF BREASTFEEDING AND RISKS OF NOT
BREASTFEEDING
- Colostrum contains much more protein and much less fat and - Increase incidence of otitis media and diarrhea
lactose compared to mature milk and is particularly rich in beta - Respiratory infection, atopic dermatitis, asthma, NEC, SIDS
carotene, a precursor of vitamin A, which gives colostrum its - Higher risk of dental caries
yellow color - Chronic conditions type I diabetes, obesity, Crohn’s and celiac
o Vitamin A is important for protection against infection and disease, ulcerative colitis, lymphoma and leukemia.
for early retinal development. - Conditions for which Human Milk may have a PROTECTIVE
o It also contains white cells which also help prevent EFFECT
infection in the newborn • Diarrhea • Chron’s disease
- Protein content - immunoglobulins, (IgA, IgM, IgG) • Otitis media • Childhood cancer
- Decreases transitional and mature milk - significant quantity of • UTI • Lymphoma
immunological protection continues to be transmitted to the infant • NEC • Leukemia
throughout the duration of breastfeeding • Septicemia • Recurrent Otitis media
- As noted in Table 1-2, during the first twenty-four hours after • Infant botulism • Allergy
delivery, colostrum includes an estimated 80 mg of IgG, 120 mg • Insulin-dependent DM • Hospitalizations
- of IgM and 11,000 mg of sIgA, and can provide the breastfed • Celiac disease • Infant mortality
infant with a powerful passive immunization against bacterial and - exclusive breastfeeding for 6 months lowered risk of allergic
viral infections disease (atopic dermatitis, rhinitis, reactive airway disease, food
allergies)
Immunoglobulins in Human Milk - sIgA binds foreign food macromolecules and prevents their
Days Post Partum IgG IgM IgA absorption during the first several months
1 80 140 11,000 - Psychosocial Development
3 50 20 2,000 o Oxytoxin
7 25 10 1,000 § every feeding, maternal oxytocin levels rise
8-50 10 10 1,000 § let-down reflex; maternal effect
*Data adapted from Remington JS and Klein JO (2001) Infectious § “emotional bonding”
Diseases of the Fetus and Newborn, Fifth Edition. Philadelphia, WB § low risk of maternally perpetrated child abuse
Saunders Co. - Breastfeeding and IQ score
o associated with a small but consistent increase in I.Q.
scores and improved school performance

PMMMZJAJPMLP 1
 o specific nutrients found only in human milk, close
supportive relationship (mother infant relationship),
lowered risk of a variety of illnesses which temporarily
interfere with learning capacity
o it is likely that all of these are important to an infant’s
o cognitive development
- Other Risks of using Breastmilk Substitutes
o Besides the loss of specific benefits associated with
breastfeeding and already described, additional risks to
infant health are associated with the use of human milk
substitutes (e.g. cow milk, goat milk, formula)
§ manufacturing errors
§ mixing mistakes
§ contamination during preparation
§ overfeeding
o Contamination in formula (later stages in manufacturing)
à not sterile
§ presence of Enterobacter sakazakii, Salmonella
FOR MOTHERS
- decreases postpartum blood loss results in more rapid uterine
involution
- enhances bonding, attachment and maternal parenting behaviors
- reduced vulnerability to stress
- mothers who do not breastfeed are likely to lose their prenatally
acquired weight more slowly than mothers who do breastfeed
- increased risk of type 2 diabetes, ovarian and breast cancers
- the explanation for these risk relationships is not yet clear
- child spacing
o Nonlactating ovulate by 6 weeks postpartum,
o exclusively or predominantly breastfeed do not ovulate
until at least 6 months after delivery
- reduces the likelihood of pregnancy to less than 2%
- exclusive breastfeeding 0.5%.
- decrease the risk of serious postpartum depression
- maternally caused child abuse and neglect
FOR FAMILIES
- breastmilk substitutes is more costly to families
- no need to use costly energy sources to heat substitutes and
clean containers
- greater expenditure in money and in family time for medical care
for a sick child
- higher incidence of illness in the non-breastfed infant increases
parental absence from work and lost income
FOR COMMUNITIES
- community-wide importance
- increases the risk of childhood obesity, both types I and II
diabetes as well as hypertension and subsequent cardiovascular
disease
- waste and pollution discarding the by-products of formula feeding
- economy - saving community funds
CURRENT RECOMMENDATIONS FOR BREASTFEEDING
- Infants should be exclusively* breastfed for six months** and
continue breastfeeding, with the introduction of appropriate
complementary foods, through the second year of life and
beyond***
o A PUBLIC HEALTH ISSUE AND NOT ONLY A
LIFESTYLE CHOICE
o WHO, UNICEF, CDC, AAFP, AAP, ACOG and other
similar professional organizations around the world
recommend
- *Exclusive breastfeeding = only human milk
o Exceptions include drops or syrups of vitamins, minerals,
or medicines or rehydration solution
o definition allows for an infant to be breastfed by his or her
mother or a wet nurse or fed expressed milk
- ***NO recommendation regarding the age of completion of
breastfeeding is provided in this statement.
o normal and acceptable for mothers to breastfeed their
children until two years and beyond for the many
nutritional, immunologic and developmental benefits
- This recommendation should be the goal for all health providers
who care for mothers, infants and their families
- Our professional task is to help mothers and families make an
informed decision and then provide appropriate evidence-based
care that will help them achieve their decision
THE BREASTFEEDING DECISION
If breastfeeding is so great, why doesn’t everybody do it?
- lack information.
- emotional decision
- embarrassed by the idea of breastfeeding or may lack the
confidence
- cultural factors
- friends and family members may not be supportive
- in many cases, simply providing information will help a woman
make her decision
CONCERNS, CONTROVERSIES AND CONTRAINDICATIONS
Aren’t there some situations when a mother shouldn’t
breastfeed?
- Contraindications
o Galactosemia
o Maple Syrup Urine disease
o Phenylketonuria (PKU)
HIV AND BREASTFEEDING
- CDC (USA) - Breastfeeding is contraindicated HIV and HTLV
infection
- WHO for such “if replacement feeding is acceptable, feasible,
affordable, sustainable and safe (AFASS)” replacement feeding
should be advised
TUBERCULOSIS AND BREASTFEEDING
- active maternal tuberculosis
o the mother and infant should be separated only until the
mother is considered noninfectious (2 weeks of treatment)
o infant should
§ be placed on preventive therapy immediately
§ receive expressed breast milk while separated
o Medications used to treat tuberculosis, including INH, are
compatible with breastfeeding
HEPATITIS AND BREASTFEEDING
- Breastfeeding is acceptable with all three major types (A, B, C)
- In the case of Hepatitis B, the infant can begin breastfeeding
before receiving HBIG and the first dose of the Hepatitis B
vaccine series which can be given up to 7 days after birth,
preferably within 12 hours
VARICELLA ZOSTER INFECTION
- infant should not have direct contact to active lesions
- Infant should receive immune globulin
HERPES SIMPLEX INFECTION
- contraindicated with active herpetic lesions of the breast
MEDICATIONS
- Chemotherapy, radio isotopes – contraindicated
- LactMed app - provides information on the potential effects of
specific drugs and supplements on lactation and breastfeeding
ALCOHOL
- Limit maternal alcohol intake to <0.5 g/kg/day (for a woman of
average weight, this is the equivalent of 2 cans of beer, 2 glasses
of wine, or 2 oz of liquor)
- Occasional and limited use of alcohol is not a
contraindication to breastfeeding
o mothers are individually counseled regarding alcohol
intake
- Alcohol passes quickly into the mother’s bloodstream and into her
milk equilibrating with maternal blood level
- General advice - to avoid breastfeeding for at least 2 hours after
one or two alcoholic drinks
o No need to express and discard milk that has
accumulated during the waiting time
o Alcohol present in the milk will have been reabsorbed into
the plasma and metabolized by the mother’s liver
PMMMZJAJPMLP 2
CAFFEINE Good Attachment Poor Attachment
- excreted into breast milk. Lips widely flanged out Lower lip curled in
- one cup insignificant level Nose touching breast Nose not touching breast
- not well metabolized by the young infant and may accumulate in
infants of mothers who consume large amounts of caffeinated
beverages (such as several cups of coffee or cola drinks daily)
o use of caffeine-free beverages

SMOKING
- For general health reasons, women are encouraged to cut down
or quit smoking during pregnancy and lactation
- For those who cant stop,
o cigarette smoking is not a contraindication to What is the difference between breastfeeding and bottlefeeding?
breastfeeding
o should be counseled to smoke only after nursing (but not
around the baby) to provide the least amount of nicotine to
the baby via the milk
- Effects:
o diminishes the milk supply
o infant growth rate (decreased)
o Sudden Infant Death Syndrome (SIDS)

ATTACHMENT / LATCH
- The way the baby grasps the nipple/areola area and pulls it into
his mouth for feeding
- MOST important factor for preventing early problems that
lead to premature weaning
COMMON BREASTFEEDING PROBLEM
POSITION AND ATTACHMENT DURING BREASTFEEDING
NIPPLE PAIN
- Poor/Improper position and improper attachment
- Ankyloglossia (short lingual frenulum or “tongue-tie”)
- What can be done to alleviate nipples due to physical trauma?
o Breast exam - before and after feeding
o Observe while breastfeeding
o Check baby’s mouth for ankyloglossia - tongue movement
o Ensure feeding frequency to avoid engorgement
o Change of position of the baby
o nipple creams and ointments or the application of
expressed breastmilk - questionable value
- Inverted Nipple
- infant’s tongue presses the o a family trait, present from birth, and
nipple/areola against the hard palate caused by failure of the mammary
and then lowers the posterior area of pit to elevate during fetal
the tongue and soft palate, creating a development
vacuum o Treatment: Retraction – may use
- lower intra oral pressure à milk 20ml syringe to retract the nipple
flowing into the baby’s mouth from 1. Women with inverted nipples can breastfeed but they may
lactiferous ducts beneath the areola need more help postpartum
stimulating swallowing and further 2. She should request assistance with breastfeeding as
suckling actions in a rhythmical pattern soon as possible after her baby is born
- assisting a mother to learn how to help her baby attach or latch-on 3. After delivery a breast pump might be useful to help evert
effectively is very important to preventing problems and achieving the nipples.
breastfeeding success § If a pump is not available, a 20 ml syringe with the
- (Note: Always observe breastfeeding before intervening. Mothers adaptor end cut off and plunger inserted
and babies may be doing fine and need only encouragement.) backwards is used to help draw out a nipple
4. Avoid bottle and pacifier use so the baby does not
become accustomed to the longer artificial nipple which
feels and flows differently
Step 1: Elicit the rooting reflex by touching the 5. When all else fails, an ultra-thin silicone nipple shield can
baby’s upper lip with mother’s nipple be tried temporarily.
o Note that nipple preparation during pregnancy in no longer
recommended

Step 2: Bring baby into the breast so that baby

gets a large mouthful of nipple and areola

Steps to proper latching on

BREAST ENGORGEMENT
- ineffective milk removal - most common cause
- “milk comes in” at 3 to 5 days postpartum
- the rapid increase in milk volume can cause vascular
congestion/edema

PMMMZJAJPMLP 3
- Physical Examination MOTHER’S POSITION
o breasts swollen with shiny Baby’s body needs to be
appearance - In line with ear, shoulder and hip in a straight line
o (+) tender, diffuse redness o neck is neither twisted nor bent forward or far back
o maternal fever - Close to mother’s body
- IVF during labor lead to excessive - Supported at the head, shoulders and if newborn, the whole body
interstitial fluids and also - Facing the breast
contribute to postpartum engorgement and areolar edema.
- Management
BREASTFEEDING IN A SITTING POSITION
o frequent breastfeeding / proper attachment
- Mother’s position is important
o hot compress before feeding
o comfortable and relaxed position
- Sit with back and feet supported
MASTITIS - Bring the baby level with the breast using rolled up towel or
- Occurs in 2-3% of lactating mother clothes, cushion or pillow
- Localized warmth, tenderness, edema and o Help the mother to hold her baby straight, close facing
erythema on the second week and supported
- Management - Inform her on the FOUR key points on the correct positioning
o continued breastfeeding or breast of the baby are:
milk removal will avoid 1. Baby’s head and body in a line
engorgement 2. Mother should hold the baby close to her
o antibiotic and analgesic 3. If the baby is newborn, support the whole body and not just
- Inadequate treatment of mastitis may lead to a breast abscess, a the head and shoulder
complication usually requiring surgical intervention. 4. Baby’s face should face the breast, with the baby’s nose
opposite the nipple
JAUNDICE
- Inadequate Milk Intake BREASTFEEDING IN A LYING POSITION
- Breastfeeding jaundice – related to insufficient fluid intake during - Mother to lie on her side (to be relaxed)
the first week of life - Rolled pillow under her head & between her knees
- Dehydration and hypernatremia - Her back needs support
- Breastmilk jaundice – high indirect hyperbilirubinemia, healthy, - Can support baby’s back with lower or upper arm
thriving newborn - Can support breast (if necessary)
o declines 2nd or 3rd week of life - A common reason for difficulty attaching when lying down, is that
the BABY IS TOO HIGH (too near the shoulder) and the baby’s
head has to bend forwards to reach the breast
BREASTFEEDING POSITIONS
ASSESSING A FEED
MOTHER’S POSITION
WHY
1. Sitting on the floor or ground
2. Sitting on a chair - To identify and praise what mother and baby are doing well
3. Lying down - See current difficulties with BF
4. Standing up - Highlight practices that may result in problems later if not changed

- Comfortable with back supported HOW

- Feet and breast should be supported
CRADLE POSITION
- The baby’s lower arm is tucked around the
mother’s side
- Not between the baby’s chest and the mother
- Take care that the baby’s head is not too far into
the crook of the mother’s arm
- Watching what a mother & baby are doing
- Listening what mother tells you.
- “WATCH THE BABY FEEDING”
o It can help you to put the mother at ease if you explain
that you would like to watch the baby feeding, rather than
saying you are watching what the mother is doing.

SIDE LYING
- after a cesarean section
- Take care that the baby’s nose is on a
level between mother’s nipple
- the baby does not need to bend his
neck to reach the breasT

UNDER-ARM POSITION
- Useful for twins
- Gives the mother a good view of the attachment
- Take care that the baby is not bending his neck
forcing the chin down to the chest

CROSS ARM POSITION

- Useful for small or ill baby.
- Mother has good control of baby’s head and body
- Take care that the baby’s head is not held too tightly
preventing movement

PMMMZJAJPMLP 4
CASE 1
- General:
o Mother looks healthy overall
o Sitting comfortably
o Looking in a loving way at her baby
o Baby looks healthy calm relaxed
o Her breast looks healthy
o She is not supporting her breast.
o Her breast maybe pushed out of line by her bra or a top
that does not open wide
- Baby’s position:
o Baby’s head and body are in a line
o Baby is not held close
o Baby is not well supported
o Baby’s chin does not touch the breast.
- Baby’s attachment:
o Mother has a large areola. However, it looks like the baby
does not have a large mouthful of breast
o The baby’s mouth is open but not wide enough
o Baby’s lower lip is turned out
o Baby’s chin does not touch the breast
What POSITIVE SIGNS would you point out to the mother?
- Her baby looks thriving and happy breastfeeding
- She is looking lovingly at her baby
- Baby’s body is held in a line and facing mother
What SUGGESTIONS would you offer the mother?
- To reposition and attach her baby again for a more effective
suckling
- It may help if she takes off her top and bra so that the breast is
less constrained
- She can easily support her breast with one hand, use the other
arm to hold the baby close so that the baby can take a large
mouthful of breast
CASE 2
- General:
o In this picture, you cannot see much of the mother or her
position
o She is using two fingers to support her breast in a
‘scissors hold’
§ It is difficult to keep fingers in this position for long
and they may slip nearer the nipple, which could
prevent the baby taking a big mouthful of the
breast
o The baby looks healthy
o However, the baby looks tense (Note: hand in a tight fist)
- Baby’s position:
o Baby’s head and body are not in a line. The baby’s head
is far back.
o Baby is not held close
o Baby is not well supported
o Baby is facing mother
- Baby’s attachment:
o You cannot see the areola well in this picture
o The baby’s mouth is not open wide
o The baby’s lower lip is not turned out.
o The baby’s chin does touch the breast.
o We cannot see signs of suckling in a picture
What POSITIVE SIGNS would you point out to the mother?
- Her baby looks healthy
- She is looking lovingly at her baby
- Baby’s body is held facing mother
What SUGGESTIONS would you offer the mother?
- To reposition and attach her baby again for a more effective
suckling
- If she held the baby closer and higher with his or her body
supported (maybe with a rolled towel or pillow), the baby could
reach the breast without straining and holding his/her head back
- Holding her breast cupped in her hand might make it easier to
help the baby to take a large mouthful of the breast
CASE 3
- General:
o In this picture, you cannot see much of the mother or her
position.
o She is using two fingers to support her breast, however
they do not look like they are actually supporting her
breast. It looks like the breast is hanging down to reach
the baby rather than the baby is being brought up to the
level of the breast.
o This baby looks like there are some health concerns, so
he or she may find it difficult to suckle for long at one time.
- Baby’s position:
o Baby’s head and body are in a line, the baby’s neck is not
twisted
o Baby is not held close
o Baby is supported, however he or she needs to be
supported at the level of the breast and turned towards
the mother
o Baby is not facing mother
PMMMZJAJPMLP 5
- Baby’s attachment:
o You cannot see the areola well in this picture
o The baby’s mouth is not open wide
o The baby’s lower lip is turned out
o The baby’s chin does not touch the breast.
o We cannot see signs of suckling in a picture.

What POSITIVE SIGNS would you point out to the mother?

- Her baby is being breastfed, which shows her care and love for
her baby

What SUGGESTIONS would you offer the mother?

- The mother may need to find a more comfortable position for
herself so she is not bending over the baby. Reposition and attach
her baby again for more effective suckling
- If she held the baby closer, with the baby’s whole body turned
towards the breast, and higher with his or her body supported
(maybe with a rolled towel or pillow), the baby could reach the
breast easily and this might make it easier for the baby to take a
large mouthful of the breast

These pictures showed a number of signs that could be improved.

However, remember that many mothers and babies breastfeed with no
difficulties. Notice the signs that breastfeeding is going well, not just the
signs of possible difficulty. Later you will observe real mothers and
babies.

WATER
- Major constituent of human milk
- Even in hot climates, human milk, which is 87% water, provides
sufficient water for the exclusively breastfed infant to remain
adequately hydrated
- Only if the infant is unable to nurse effectively as needed or has
an unusual health problem (e.g. diabetes insipidus) would
additional fluids be required

VITAMINS AND MINERAL

VITAMIN D, IRON, VITAMIN K
- Iron and vitamin D, are low in human milk, and deficiency can
occur
- AAP recommends supplementation of breastfed infants
- All infants should begin supplementation of vitamin with 400IU/day
in the first few days of life and continue until the infant is weaned
to at least 1L/day or 1quart/day of vitamin D-fortified formula
whole milk
- Some mothers, may consume larger quantities of vitamin (up to
6400IU/day) to improve the vitamin D content in their milk
transferred to their infants
- Iron supplementation should begin at 4 months of age with
1mg/kg/day of oral iron or until the infant consumes adequate or al
iron from foods or iron-fortified formula
- To improve iron intake during weaning is to introduce meat as the
first complementary food
- Although meats provide a highly bioavailable source of iron and
zinc, this may not be a desirable solution for all families, especially
those who do not eat meat (vegetarian diet)
- Oral iron and zinc (given as part of a multivitamin)
supplementation
- Poorly transported prenatally via the placenta to the fetus and is
also limited in human milk
- Newborns whether breastfed or not are at risk for hemorrhagic
disease
- All newborns receive Vit K (IM route) 0.5 to 1.0 mg

PMMMZJAJPMLP 6