BREASTFEEDING

PEDIATRIC DEPARTMENT UNIVERSITAS ISLAM BANDUNG

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

Protection against infection

1. Mother infected 2. White cells in mothers body make antibodies to protect mother

4. Antibodies to mothers infection secreted in milk to protect baby

3. Some white cells go to breast and make antibodies there

Why breastmilk is a perfect food ? (continue)

Component Iron Breastmilk 0,5 (absorp >>) Cow milk 0,5 (absorp <<)

Zinc 4 4 Vitamin enough not enough Protectif factors Imunoglobulin, leucocyte, lact. Bacillus bifidus, Lactoferrin, lysosim, antibody

Anatomy of breast (1)

Anatomy of the breast (2)

Prolactin

Secreted during and after feed to produce next feed

Sensory impulses from nipples
Prolactin in blood

Baby suckling More prolactin secreted at night Suppresses ovulation

Prolactin, enhancing and hindering factors

More suckling makes more milk

Other effects of prolactin : - supress the activity of the ovaries delays the return of fertility and menstruation

Engorgement

DIFFERENCES BETWEEN FULL AND ENGORGED BREASTS

Full Breasts Hot Heavy

Milk flowing No fever hours

Engorged Breasts Painful Oedematous Tight, especially nipple Shiny May look red Milk NOT flowing May be fever for 24

Oxytocin reflex

Works before or during feed to make milk flow

Oxytocin in blood

Sensory impulses from nipples

Baby suckling
Makes uterus contract

Oxytocin, enhancing and hindering factors

To help a mothers milk ejection : Be kind and supportive. Help her not to worry Reassure her that she can breastfed.

Other effects of oxytocin : make the uterus contract which helps to deliver placenta.

SIGNS & SENSATIONS OF ACTIVE OXYTOCIN REFLEX A mother may notice: A squeezing or tingling sensation in her breasts just before she feeds her baby, or during a feed. Milk flowing from her breasts when she thinks of her baby, or hears him crying. Milk dripping from her other breast, when her baby is suckling. Pain from uterine contractions, sometimes with a rush of blood, during feeds in the first week.

HOW TO STIMULATE THE OXYTOCIN REFLEX Help the mother psychologically: Build her confidence Try to reduce any sources of pain or anxiety Help her to have good thoughts and feelings about the baby Help the mother practically: Sit quietly and privately or with a supportive friend Hold her baby with skin-to-skin contact if possible Take a warm soothing drin warm her breasts Stimulate her nipples Massage or stroke the breasts lightly Ask a helper to rub her back

A helper rubbing a mother's back to stimulate the oxytocin reflex

COLOSTRUM
PROPERTY
-

IMPORTANCE
- protects against infection and allergy - Protect against infection - Clears meconium helps to prevent jaundice - Help intestine to mature prevents allergy, intolerance - Reduces severity of infection, prevents eye disease

Antibody rich
Many white cells Purgative Growth factors Vitamin A rich

Variation of composition of breastmilk

Colostrum - produce in the first few days after delivery - thick and yellowish or clear colour Fore milk - produce early in a feed, large amounts - looks bluer than hindmilk, plenty of protein, lactose and other nutrients Hind milk - looks whiter, contains more fat.

Differences between colostrum and mature milk

Foremilk Hindmilk

Fat

Protein

Lactose

Colostrum

Mature milk

GOOD ATTACHMENT
a. The baby's chin touches the breast.

b. His mouth is wide open.

c. His lower lip is turned outwards. d. You can see more of the areola above his mouth and less below.

RESULTS OF POOR ATTACHMENT

Pain and damage to nipples Breastmilk not removed effectively Apparent poor milk supply

Sore nipples Engorgement Baby unsatisfied wants to feed a lot Baby frustated, refused to suckle

Breasts make less milk

Baby fails to gain weight

CAUSES OF POOR ATTACHMENT

Use of feeding bottle - before breastfeeding established - for later suplements Inexperienced mother - first baby - previous bottle feeder Functional difficulty - small or weak baby - breast poorly protactile - engorgement - late start Lack of skilled support - less traditional help and community support - doctors, midwives, nurses, not trained to help

How the baby suckle

Signs that a baby is suckling in a good position

The babys whole body is facing his mother & close to her, the babys head and body should be in a straight line If her baby is newborn, she should support his buttom, and not just his head and shoulders The babys face is close up the breast, with his nose opposite the nipple The babys chin is touching the breast The babys mouth is wide open The babys lower lip is curled outwards There is more areola showing above the babys upper lip and less areola showing below the lip You can see the baby taking slow, deep sucks The baby is relaxed and happy and is satisfied at the end of the feed The mother doesnt feel nipple pain You may be able to hear the baby swallowing

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

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

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.
Adapted from AAFP Journal September 2001

Most mothers are scared of

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 Ushaped to guide the baby's mouth to your breast

Adapted from AAFP Journal September 2001

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

Is breastmilk enough ?
1.

2.

Subjective sign Objective sign - Urinary > 6 times / day - Growth chart : - Dancis curve for neonates Birth Weight should be regained by two weeks of life - Normal growth

HOW TO EXPRESS BREASTMILK BY HAND

Wash her hands thoroughly. Sit or stand comfortably, and hold the container near her breast. Put her thumb on her breast ABOVE the nipple and areola, and her first finger on the breast BELOW the nipple and areola, opposite the thumb. She supports the breast with her other fingers. Press her thumb and first finger slightly inwards towards the chest wall. She should avoid pressing too far, because that can block the milk ducts.
.

Press her breast behind the nipple and areola between her finger and thumb. She must press on the lactiferous sinuses beneath the areola. Sometimes in a lactating breast it is possible to feel the sinuses. They are like pods, or peanuts. If she can feel them, she can press on them.

Press and release, press and release. This should not hurt - if it hurts, the technique is wrong.

At first no milk may come, but after pressing a few times, milk starts to drip out. It may flow in streams if the oxytocin reflex is active.

Press the areola in the same way from the SIDES, to make sure that milk is expressed from all segments of the breast.

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 24 hours

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

RECOMMENDATION

Start breastfeeding within hour of birth Breastfeed exclusively from 0-6 months of age Give complementary foods to all children from 6 months of age Continue breastfeeding up to 2 years of age beyond

BREASTFEED OBSERVATION FORM

GENERAL
Sign that breastfeeding is going well Mother: Mother looks healthy Mother relaxed and comfortable Signs of bonding between mother & baby Baby: Baby looks healthy Baby calm and relaxed Baby reaches or roots for breast if hungry Sign of possible difficulty Mother: Mother looks ill or depressed Mother looks tense and uncomfortable No mother/baby eye contact Baby: Baby looks sleepy or ill Baby is restless or crying Baby does not reach or root Breasts look red, swollen, or sore Breast or nipple painful Breast held with fingers on areola

BREASTS
Breasts look healthy No pain or discomfort Breast well supported with fingers away from nipple Babys head and body in line Baby held close to mothers body Babys whole body supported Baby approaches breast, nose to nipple More areola seen above babys top lip Babys mouth open wide Lower lip turned outwards Babys chin touches breast Slow, deep sucks with pauses Cheeks round when suckling Baby releases breast when finished Mother notices signs of oxytocin reflex

BABYS POSITION
Babys neck and head twisted to feed Baby not held close Baby supported by head and neck only Baby approaches breast, lower lip/chin to nipple More areola seen below bottom lip Babys mouth not open wide Lips pointing forward or turned in Babys chin not touching breast Rapid shallow sucks Cheeks pulled in when suckling Mother takes baby off the breast No signs of oxytocin reflex noticed

BABYS ATTACHMENT

SUCKLING

HOW TO HELP A MOTHER TO POSITION HER BABY Greet the mother and ask how breastfeeding is going

Assess a breastfeed Explain what might help, and ask if she would like you to show her Make sure that she is comfortable and relaxed Explain how to hold her baby, and show her if necessary

Show her how to support her breast

Explain or show her how to help the baby to attach Look for signs of good attachment. If the attachment is not good, try again Notice how she responds and ask her how her baby's suckling feels

The mother sit in a comfortable and relaxed position A low seat is usually best, if possible one that supports the mother's back

If the seat is rather high, find a stool for her to put her feet onto. However, be areful not to make her knees so high that her baby is too high for her breast
If she is sitting on the floor, make sure that her back is supported If she supports her baby on her knee, help her to hold the baby high enough so that she does not lean forward to put him onto her breast

How to hold her baby

Babys head and body in line Baby held close to mothers body. The baby's whole body should almost face his mother's body Baby supported. Babys whole body supported with the mothers arm along the babys back. For older babies, support of the upper part of the body is usually enough Baby approaches breast, nose to nipple

How to support her breast

If she has small and high breasts, she may not need to support them. She should place her fingers flat on her chest wall under her breast, so that her first finger forms a support at the base of the breast. She can use her thumb to press the top of her breast slightly. This can improve the shape of the breast so that it is easier for her baby to attach well. She should not hold her breast too near to the nipple. Holding the breast too near the nipple makes it difficult for a baby to attach and suckle effectively. Such as: - holding the breast with the fingers and thumb close to the areola - pinching up the nipple or areola between your thumb and fingers, and trying to push the nipple into a babys mouth

- holding the breast in the scissor hold index finger above and
middle finger below the nipple