1.

03a
August 1, 2016
BREASTFEEDING (PART 1)
Dr. Nellie Gundao
Department of Pediatrics

TOPIC OUTLINE regulation of promotion, distribution, selling, advertising,

Topics in bold face are part of the 1st lecture on breastfeeding. product public relations, and information services,
artificial milk formulas and other covered products (Milk
I. Breastfeeding Code Philippines).
II. Breast Structure  Exclusive breastfeeding for infants from 0 to 6 months of age
III. Physiology of Lactation  Appropriate complementary feeding should start from age 6
IV. Breastmilk months with continued breastfeeding up to 2 years and
a. Colostrum beyond.
b. Human Milk
V. Advantages of Breastfeeding Risks of not Breastfeeding (Formula Feeding)
VI. Techniques of Breastfeeding  Formula feeding interferes with milk supply.
a. Antenatal Preparation  It delays lactogenesis.
b. Postnatal Preparation  It increases the risk of breast engorgement.
VII. Possible Reasons for not Breastfeeding or  It undermines maternal confidence.
Stopping Breastfeeding  It shortens the duration of breastfeeding.
VIII. Composition of Breastmilk  It alters infant intestinal flora.
a. Protein  It affects bioactive factor interactions within the infant’s
b. Fats intestine.
c. Carbohydrates  It is associated with increased risk for acute and chronic
d. Minerals illness
e. Vitamins
IX. Breastmilk vs. Cow’s Milk Elements in Normal Breastfeeding Process
X. Types and Methods of Milk Feeding 1. Breast that produces and releases milk
XI. Forms of Cow’s Milk 2. Baby who is able to remove the milk from the breast
a. Certified with effective sucking
b. Pasteurized  A woman should have undergone pregnancy to be able to
c. Homogenized breastfeed.
d. Evaporated  The maneuver in which the baby is attached, and the type of
e. Condensed breast will determine how successful these elements come
f. Dried together.
g. Skimmed Dried
h. Fermented BREAST STRUCTURE
i. Acid
j. Filled
k. Recombined
l. Reconstituted
m. Infant Formulas
n. Special Formula
XII. Milk Not Recommended For Infants
XIII. Feeding During the Second 6 Months of Life
XIV. Preparation of the Prospective Mother for
Breastfeeding
XV. Establishing and Maintaining the Milk Supply Structure of the mammary gland. A. Alveolus and myoepithelial cell.
XVI. Weaning from Breastfeeding B. Ductule. C. Duct. D. Lactiferous duct. E. Lactiferous sinus. F.
XVII. Contraindication to Breastfeeding Ampulla. G. Nipple pore. H. Alveolar margin
XVIII. Choosing the Right Milk for your Baby  The size of the breast does not determine how much milk it
a. Infant Formula can make.
b. Follow-on Formula  Much of the breast is made up of fatty and connective tissue
c. Specialty Formula rather than milk-producing glands.
BREASTFEEDING  Each breast has 15-20 lobes of milk-producing glandular
 Breastfeeding should be initiated soon (within 1 hour) after tissue.
birth unless medical conditions preclude them  Ducts: special channels that run from the lobes
 EO 51: The Milk Code o Expand to form sinuses directly behind the areola
o A law that ensures safe and adequate nutrition for infants o Reservoirs for the collection of milk
through the promotion of breastfeeding and the
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o It is from here that milk flows out through tiny openings
or pores in the nipple.
 Skin covering of the nipple
o many nerves which when stimulated by the sucking of
the baby initiates the release of hormones necessary for
milk production and secretion
o these nerves also send impulses to the brain to
stimulate the involution of the uterus to its normal size
after childbirth
 Nipple area: large number of oil glands and sweat glands
o Glands of Montgomery: produces oil and a characteristic
odor which helps the baby recognize his/her mother
o the secretions keep the skin of the nipple soft and
pliable
o also protect it from the baby’s saliva and the friction of
his/her sucking
o secretions tend to kill germs on the nipple and
breastmilk itself has antiseptic qualities
PHYSIOLOGY OF LACTATION
 Breast milk production is mainly dependent on how well the
breasts are emptied completely and regularly.
 Breast galactagogue is the vigorous sucking of the breast
by the infant.
 Breastmilk secretion is facilitated by the early onset of
breastfeeding
o Preferably within 12 hours after delivery or at the
latest, 24 hours post-partum.
o Full breast milk supply occurs on the third to the
fourth day after delivery, however it has been shown
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Breastfeeding (Part 1)
in local and foreign literature that breastmilk
production can be stimulated earlier by the vigorous
sucking of the infant.
 When the baby is put to the breast, the tactile stimulation at
the nipple during sucking stimulates the afferent nerve
endings, sending impulses which are carried to the
hypothalamus.
 The hypothalamus in turn activates the pituitary gland
causing the release of the hormones prolactin and oxytocin.
The reflexes governing breast milk recreations are:
o Prolactin reflex
 Prolactin is secreted from the anterior lobe of the
pituitary
 Its secretion is proportional to the stimulation of
the nipple and areola
o Let-down or milk ejection reflex
 Oxytocin is secreted from the posterior lobe of the
pituitary.
 It causes contraction of the myoepithelial cells in
the mammary gland propelling milk along the duct
and the milk drips from the nipple pores
Mechanism of Sucking
 When a baby sucks, he draws the nipple into the back of his
mouth by suction so that the lactiferous sinuses are between
his upper and lower jaws.
 It is the “chewing” action of the jaws on the sinuses which
expresses milk into the baby’s mouth.
 The tongue, which protrudes out over the lower jaw, acts as
a supporting pad for the nipple and areola.
 The further back in the baby’s mouth the nipple lies, the less
it will be rubbed by his tongue as he sucks.
 SIGNS OF A GOOD ATTACHMENT:
o Chin touching the breast
o Mouth wide open
o Lower lip turned outwards
 Breastfeeding (Part 1)

 SIGNS THAT THE BABY IS SUCKING EFFECTIVELY:

o Slow, deep sucks with short pauses ADVANTAGES OF BREASTFEEDING
o The baby is heard/seen swallowing 1. Breast milk contains the necessary nutrients in the proper
o His/her cheeks are full quality and quantity.
o He/she looks contented  The digestibility and high rate of utilization of
breast milk cannot be attained by other baby foods
BREASTMILK 2. Rates of growth of breast-fed infants on developing
 The more fat there is in the milk, the yellower the milk. countries are better during the first 3-4 months of life than
 Milk usually has a light blue hue, but if the mother is on a those artificially fed.
high fat diet, it is yellowish. 3. Breast feeding prevents hypersensitivity or allergy.
 It is postulated that breast milk with its high
Colostrum content of IgA prevents the absorption of antigen
 The secretion of the human breast during the first 2-4 days into the blood stream and thus protects against
postpartum. atropic disease
 Deep yellow fluid containing more protein, more vitamins, 4. Anti-infective properties of breast milk are universally
more salt, more immune bodies but less fat and sugar than proven and accepted.
the mature milk.  Acute disorders
 Amount of secretion: 10-40ml is secreted per day.  Otitis media and recurrent
 The higher the protein content reflects the high  Urinary tract infection
concentration of immunoglobulins present, which accounts  Diarrhea
for about 95% of the protein in colostrum.  Septicemia
 Macrophages: prominent mononuclear cells found in  Necrotizing enterocolitis
colostrums, mobile and capable of phagocytosis  Infant botulism
 transition from colostrum to milk  Chronic disorders
o Decreased number of cells/mm3and concentration of  Insulin-dependent diabetes mellitus
IgA present.  Celiac Crohn’s disease
o Over the first four weeks, the composition slowly  Lymphoma leukemia
changes from “transitional” to “mature” milk  Allergies
o Gradual increase in fat and lactose content  Obesity and overweight
o Decreased protein concentration 5. The mother’s desire to feed her infant is aroused if there is a
o Decreased Na, K & Cl close physical contact with him.
6. In the absence of any contraception, the interval between
Human Milk subsequent pregnancies is longer when a mother
 Mature milk: achieved by the end of the first month of breastfeeds her infant than when she does not.
lactation 7. Breast milk seems to have a protective effect against
 Level of protein, fat and lactose are very similar despite wide necrotizing enterocolitis.
variations on maternal diet 8. It is safe.
 Composition Baby Mother
o Fat 5% Reduced
o Protein 1.1% Allergies Breast/Ovarian CA
o Lactose 7% Asthma Osteoporosis
 Total nitrogen content: 1.2%, now known to include a Diabetes Diabetes
significant portion of non-protein nitrogen Obesity Less worktime missed
 Fatty acids that are present in breast milk generally reflect Celiac disease
maternal diet SIAS
 Total milk quantity produced IBS
o In the 1st month: 600 ml Childhood leukemia
o In the 6th month: 800 ml Ear infections
o Estimate of total milk quantities produced by well- Enhanced
nourished mothers show a steady increase from the 1st Mother-baby bonding More sleep
to 6th months Emotional security Financial savings
 Human milk = fore milk + hind milk Increased IQ scores Increased mothering skills
Financial security for and confidence
Fore Milk vs. Hind Milk family
Fore Milk Hind Milk According to Nelson’s:
First milk expressed Last milk obtained at the 1. Breast milk is the natural food for full term infants.
during a nursing period end of a feed 2. It is always available
Clear, thin and bluish Thick and cream-white 3. It is fresh and free of contaminating bacteria
Low fat, high water Higher fat content 4. Breastfeeding is associated with fewer feeding difficulties
content incident to allergy and/or intolerance to bovine milk
5. Human milk contains bacterial and viral antibodies
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6. It also contains substances that inhibit growth of many 2. Mother acquired syphilis shortly before delivery
common viruses 3. Mother intends to put the baby for adoption
7. Antibodies in human milk are thought to provide local
gastrointestinal immunity Breastfeeding is TEMPORARILY withheld when:
8. Macrophages in human milk may synthesize complement, 1. Mother is taking anticoagulants, antibiotics like
lysozyme, and lactoferrin penicillin to avoid antigenic stimulation, steroids or
9. It contains bile salt-stimulated lipase other potentially toxic substances like mercury or
10. Milk from the mother whose diet is sufficient and properly benzene products.
balanced will supply all the necessary nutrients 2. Mother suffers from pseudo-retracted nipple. This can
11. Human milk has low iron, vitamin K and fluoride be corrected with good prenatal care and by manually
pulling the affected nipple/s before delivery
TECHNIQUES OF BREASTFEEDING
Antenatal Preparation  Congenital anomalies such as harelip and cleft palate may
1. Wearing a fitted maternity brassiere make breastfeeding difficult if not impossible. In such cases,
2. The daily bath is sufficient cleansing for the nipple breast milk may be obtained under sterile conditions and
3. Rubbing the nipple and areola with a little anhydrous lanolin given to the baby.
will make the nipple more supple  When the newborn has unconjugated bilirubinemia
4. Expressing colostrums form each breast should be done breastfeeding does not have to be stopped for 203 days.
from the 7th month  If the baby is suspected to be allergic to breast milk, which is
5. Practice Hoffman’s technique for flat or pseudo-inverted highly unlikely, this must be proven thoroughly. The mother
nipple must also be checked for allergens. Her diet and hygiene
Postnatal Preparation must be thoroughly investigated before discontinuing
1. Breastfeeding may be started about 30 minutes after a breastfeeding.
normal delivery to a well baby and 3-4 hours after caesarean
delivery. COMPOSITIONS OF HUMAN MILK
2. Short feeding times are recommended at first and gradually Protein
increased so that the nipple become used to being suckled  In infants, milk protein is digested into:
3. Frequent feeds as well as short feeds are ideal. The breast o Casein: a Ca-phosphorus-containing precipitate (↑ in
should be given alternately Cow’s milk)
4. The mother should be seated comfortably and relaxed o Whey proteins: proteins that remain in solution(↑ in
preferably on an armchair Human milk)
5. If the mother does not prefer to sit up, she may give her  Casein of human milk is distinct from all other
breast while in the recumbent position mammalianspecies in its amino acid content
6. It is important to teach the mother how to break the suction o Very ↓ methionine :cystine ratio
of the baby when she feels that it is time to stop the feeding o Cystathionate
 Necessary in conversion of methionine to cysteine
POSSIBLE REASONS FOR NOT BREASTFEEDING OR  Not present in premature infant
STOPPING BREASTFEEDING  Cystine is then an essential amino acid for
1. Lack of motivation and preparation prematureinfants
2. Aesthetic reasons  Breast milk contains ↓ levels of phenylalanine &
3. Status seeking tyrosine(aromatic amino acid) than other mammalian milks
4. Effective promotion of infant foods  Curd of breast-fed human infant: softer, smaller, and sweeter
5. Fear of failure and fear of losing the form of their breasts smelling than that of the formula fed infant
(creates anxiety)
6. Fear that breast feeding would drain their health both Fats
physically and emotionally  Both human and bovine milk contain neutral fat of
Note: Mothers who have no desire to breastfeed must be respected. triglycerides like:
Mothers who cannot breastfeed despite their desires and efforts o Palmitin
should not be made to feel inadequate or even remiss on their o Stearin
obligations. o Olein
 Fatty acids found in human milk:
Factors that interfere with successful lactation o Butyric Acid
1. Lack of motivation o Caproic Acid
2. Anxiety, fear and uncertainty o Capric Acid
3. Separate maternity and nursery wards o Caprylic Acid
4. Pre-lacteal feeds
5. Cultural milleu LINOLEIC ACID
 A dienoic fat
Breastfeeding is withheld when:
 Found to be necessary in infant nutrition to avoid failure of
1. Mother has chronic disease such as open TB, cardiac
growth and production of thick, scaly skin
disease, thyrotoxicosis, advanced nephritis and mental
seizure
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BILE-SALT STIMULATED LIPASE Vitamin D

 Found in breast milk  Occurrence of rickets among breast-fed infants is unusual
 Capable of rapid digestion of human milk fat  At present, cow’s milk & formulas are all Vit. D fortified
 Account for the efficient digestion and absorption  Water soluble vitamin D sulfate
o Has been isolated in human milk
Carbohydrates o May explain adequacy of breast milk in preventing
rickets
 Lactose: main carbohydrate o Previously, only fat soluble VitD has been measured
 Formulas have added lactose or other carbohydrate to o Adequate dose: 1.00 mg/dL
approximate human milk sugar content
 At present, it is safe to prescribe VitD to breast-fed infants
 Bifidus Factor: one group of nitrogen-containing complex who will not be exposed to sunlight (400 IU vitamin/day)
carbohydrates found in human milk
Vitamin K
Minerals
 Both breast-fed & bottle-fed infants should be routinely
 The fully nursing normal infant requires no extra water even given VitK as prophylaxis against hemorrhagic disease of the
in tropical heat or with febrile illness newborn
 The breast-fed infant with severe diarrheal disease may  Prescribed dose: 1mg vitamin K-1 I.M. or P.O.
become hypotonically dehydrated, unlike the bottle-fed  This is because adequate levels of vitamin depend on gut
infant in whom hypertonicity and acidosis in similar flora which are not present at birth
circumstances is common
 Too much solutes present in cow’s milk might damage the
Human Milk Versus Cow’s Milk
kidneys
 Comparison of Human Milk and Cow’s Milk
HUMAN MILK COW’S MILK
MINERALS (mg/100 ml)
PROTEIN
HUMAN MILK COW’S MILK 60:40 20:80
Whey Protein to
Calcium 33 125 Casein Ratio
Sodium 15 96  Lactalbumin (40%)  B-lactoglobulin
Chlorine 43 103  Lactoferrin (25%)  (mostly)
Whey Protein  Secretory IgA  a-lactoglobulin
Composition  Lysozyme (0.08%)  (small amount)
 Ca/P ratio (2:1)  Albumin (0.08)  lactoferrin (trace
o This ratio is sought by makers of infant formulas  IgA, IgG, IgM  amount)
because of incidence of hypocalcemia in infants fed with (0.15%)
cow’s milk formula with lower ratios Phenylalanine ↓ ↑
 In case of deficiencies: and tyrosine
o maternal stores are depleted first FATS
o fish/meat insufficiency: mother is at risk for B12 Fat Emulsion Finer Coarser
deficiency Fatty Acid ↓ (1.3%) ↑ (9%)
Content  Predominantly long-  Predominantly
Iron Deficiency chain unsaturated & saturated fatty
 rare in term breast-fed infants polyunsaturated acids
 despite this, practice of giving iron supplements in breast- fatty acids
fed infant is still common  Better source of
linoleic acid (usually
o due to frequency of iron deficiency in formula-fed
supplies 4-5% of
o due to low iron content of human milk calories)
 once solids are started (at 4-6 months) Readily  2x more
o extra sources of iron may be needed Absorbed Olein
o this is due to the interference with absorption of milk
⨉ ✔
iron once solids are added to the diet
Loss of Fat in Modern proprietary formulas use vegetable
 ideally: a full-term infant with a well-fed mother needs no Stool
iron supplementation to maintain iron status oil & medium-chain triglycerides in place of
 premature infants cow’s milk fat in an attempt to decrease loss
o born with insufficient iron stores CARBOHYDRATES
o should be followed closely for iron deficiency Lactose ↑ (7%) ↓(4.8%)
o need for iron supplementation is likely to occur early Bifidus Factor ⨉ ✔
LACTOFERRIN – component of breastmilk thatbinds to ironand MINERALS % VITAMINS
increases its absorption; prevents iron from fueling the growth of Mineral & ↓ ↑
infection or triggering a highly damaging free radical cascade. Electrolyte Lower electrolyte concentrations ensure that
Concentration sufficient free water is available to the infant
Vitamins Ca:P ratio 2:1
 Vitamin content depends on maternal intake Iron Content Better absorbed Poorly absorbed

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Has more niacin and Has more thiamine

Vitamins Vitamin C and riboflavin
Both contain large amounts of Vitamin A and
minimal amounts of Vitamin D

 QUALITIES THAT HUMAN & BOVINE MILK SHARE

pH 6.8 – 7.4 (ave. of 7)
water content 87 – 87.5%
specific gravity 1.026 – 1.036 (ave. of 1.031)
 SOME IMPORTANT NOTES
o Although current recommendations are to avoid intake
of bovine milk, particularly low fat or skimmed milk,
before at least 1 yr of age, surveys suggest that a sizable
percentage of infants older than 6 mo of age are fed
homogenized bovine milk rather than infant formula
and almost half of these are fed low fat or skimmed
milk.
o However, infants fed bovine milk, on average, ingest
roughly three times the recommended intake of protein
and about 50% more sodium than the upper limit of the
“safe range” of intake of this mineral but only about two
thirds of the recommended intake of iron and only half
of the recommended intake of linoleic acid.
o Ingestion of bovine milk also increases intestinal blood
loss and, hence, further contributes to development of
iron-deficiency anemia.
o On the other hand, infants who were breast-fed or fed
formulas with a high linoleic acid content earlier in life
may have sufficient body stores to limit the
consequences of a low intake later

TYPES AND METHODS OF MILK FEEDING

Complementary Feeding
 When artificial feeding immediately follows breast-feeding
to make a single feeding

Supplementary Feeding
 When artificial milk feeding alternates or replaces breast
feeding
o Milk feeding may be given an infant in two ways:
scheduled and “on demand”.
o On demand feeding
o Baby is allowed to set his own pattern of feeding
o Manifested by his crying or restlessness
o Feedings may be given at intervals of 2-4 hours at times,
and 4-5 hours at other times within 24 hours. Thus, the
infant establishes his own feeding schedule of 6-8
feedings per 24 hours.

REFERENCES
Kliegman, R., & Nelson, W. E. (2016). Nelson textbook
of pediatrics. Philadelphia: W.B. Saunders Co.

Milk Code Executive Order 51. Retrieved from

http://www.milkcodephilippines.org/

Transes by 2A 2017 and 2A 2018

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