NUT 565

Nutrition through the life cycle –0-6 months-Breastfeeding

Lecture 3

Dr Reginald Annan
Raannan.cos@knust.edu.gh// 020 1237169
Jan 2014
 Learning objectives
• At the end of the lecture the students should be able to:
• Describe the key nutrition concepts for lactation
• Describe the issues around lactation
• Explain lactation physiology, including the hormones involved and their
function
• Explain how breastmilk is produced
• Outline the benefits of breastfeeding to the child and mother
• Explain the recommendations for breastfeeding in HIV infected mothers

2
Key nutrition concepts
• Human milk is the best food for newborn infants for the first year of
life or longer.
• Maternal diet does not significantly alter:
 the protein, carbohydrate, fat, and major mineral composition of
breast milk,
but alters the fatty acid profile and the amounts of some vitamins and
trace minerals.
What happens when maternal diet is inadequate
• When maternal diet is inadequate:
• the quality of milk is preserved over the quantity for the majority of
nutrients.
• Health care policies and procedures and the knowledge and attitudes
of health care providers affect community breastfeeding rates.
Introduction – the issues
• The benefits of breastfeeding are well established.

• The health care system, the workplace, and the community can either
hinder or facilitate the initiation and continuation of breastfeeding

• Support is needed for women to breastfeed and for women who have
challenges and medical problems
 Lactation physiology
• The functional units of the mammary gland are the
alveoli
• Each alveolus is composed of a cluster of cells
(secretory cells) with a duct in the centre whose job is to
secrete milk
• The ducts are arranged like branches of a tree. These
branchlike collecting ducts lead to the nipple.
• Myoepithelial cells surround the secretory cells, contract
under the influence of oxytocin
• Oxytocin is a hormone produced during letdown that
causes milk to be ejected into the ducts.
 Mammary gland

7
Lactation - Anatomy and Physiology
Latch On and sucking

Oxytocin Release

Releases Milk

Infant Empties Breast

Production Increases

Milk Production Occurs

Interference with this cycle decreases the milk supply.

Source: Juidth Brown et al., (2011), Nutrition through the life cycle 4 th Edition Wadsworth USA.
 Hormones contributing to breast development and lactation
Hormone Role in lactation Stage of lactation
Estrogen Ductal growth Mammary gland differentiation with
menstruation

Progesterone Alveolar development After onset of menses and during

pregnancy

Human growth hormone Development of terminal end Mammary gland development

buds

Human placental lactogen Alveolar development Pregnancy

Prolactin Alveolar development and Pregnancy and breastfeeding (from the

milk secretion third trimester of pregnancy to weaning)

Oxytocin Letdown: ejection of milk From the onset of milk secretion to

from myopithelial cells weaning
 Lactogenesis
• Lactogenesis I. First stage of milk production, first few days post partum:
milk begins to form, and the lactose and protein content of milk increase.
• Lactogenesis II. Starts 2–5 days post-partum, increased blood flow to the
mammary gland. Considered the onset of copious milk secretion.
Significant changes milk composition and the quantity of milk that can be
produced occur over the first 10 days of the baby’s life.
• Lactogenesis III. Stage of BM production begins about 10 days after
birth and is the stage in which the milk composition becomes stable.

Milk secretion
• Factors such as nutritional
status, supplementation,
medications, and disease
may affect breastfeeding or
milk composition.
Some components like lactose
are made in the secretory cells
and secreted into ducts
Milk fat comes from
triglycerides from the
mother’s blood and from
new fatty acids produced
in the breast
The milk-fat globules are
then secreted into the ducts

Fats are made soluble in

The secretory cell in the
breast uses five pathways
for milk secretion
milk by addition of a
protein carrier to form
milk-fat globules
Immunoglobulin A and other plasma
Water, sodium, potassium,
and chloride are able to
proteins are captured from the mother’s
pass through alveolar cell blood and taken into the alveolar cells
membranes in either and secreted into the milk ducts
direction
Breastfeeding
Infant Health Benefits
COLOSTRUM
• Small amount for the immature
digestive system
• ‘paints’ the digestive tract
• Low fat for easy digestion
• Contains mothers antibodies which
boost infants’ immune system
• Acts as a laxative to ease passage of
meconium

Source: Juidth Brown et al., (2011), Nutrition through the life cycle 4 th Edition Wadsworth USA.
Source: Juidth Brown et al., (2011), Nutrition through the life cycle 4 th Edition Wadsworth USA.
Source: Juidth Brown et al., (2011), Nutrition through the life cycle 4 th Edition Wadsworth USA.
Source: Juidth Brown et al., (2011), Nutrition through the life cycle 4 th Edition Wadsworth USA.
Source: Juidth Brown et al., (2011), Nutrition through the life cycle 4 th Edition Wadsworth USA.
Water
• Breast milk is isotonic with plasma. This biological de- sign of milk
means that babies do not need water or other fluids to maintain
hydration, even in hot climates.
• As a major component of human milk, water allows suspension of the
milk sugars, proteins, immunoglobulin A, sodium, potassium, citrate,
magnesium, calcium, chloride, and water-soluble vitamins
Milk carbohydrates
• Lactose is the dominant carbohydrate
in human milk.
• Other carbohydrates—including
monosaccharides (such as glucose),
polysaccharides, oligosaccharides,
and protein-bound carbohydrates—
are also present.
• Lactose enhances calcium absorption.
As the second largest
carbohydrate component,
oligosaccharides contribute
calories at low osmolality,
stimulate the growth of bifidus
bacteria in the gut, and inhibit
the growth of E. coli and other
potentially harmful bacteria.
Energy

• Human milk provides approximately 0.65 kcal/mL, although the

energy content varies with its fat (and, to a lesser degree, protein and
carbohydrate) composition.
• Breastfed infants consume fewer calories than those fed artificial milk.
Lipids
• Lipids are the second largest component of breast milk by
concentration (3–5% in mature milk).
• Lipids provide half of the energy of human milk.
• Human milk fat is low at the beginning of a feeding in foremilk, and
higher at the end in the hindmilk that follows.
Effect of Maternal Diet on Fat Composition
• The fatty acid profile of human milk varies with the diet of the mother.
• When diets rich in polyunsaturated fats are consumed, more
polyunsaturated fatty acids are present in the milk.
• When a mother is losing weight, the fatty acid profile of her fat stores
is reflected in the milk.
• When very low-fat diets with adequate calories from carbohydrate and
protein are fed, more medium-chain fatty acids are synthesized in the
breast.
Docosahexaenioic acid
• Milk DHA levels are increased by maternal supplementation.
• Recent interest in lipids in human milk stems from studies showing
developmental advantages provided by (DHA).
• DHA is essential for retinal development and accumulates during the
last months of pregnancy.
• The advantages of human milk seem particularly important to
premature infants born before 37 weeks, perhaps because the
concentrations of DHA are higher in the milk of mothers delivering
preterm infants as compared to full-term infants
Trans fatty acids
• Trans fatty acids stemming from the mother’s diet are present in
human milk.
• Trans fat concentrations are similar in American and Canadian
women, but lower in the milk of women from European and African
countries.
• Removal of trans fatty acids from many food products in Canada led
to lower levels of trans fat in human milk.
Cholesterol
• Cholesterol, an essential component of all cell membranes, is needed
for growth and replication of cells.
• Cholesterol concentration ranges from 10–20 mg/d and varies
depending on the time of day.
• Breastfed infants have higher intakes of cholesterol and higher levels
of serum cholesterol than infants fed HMS.
• Early consumption of cholesterol through breast milk appears to be
related to lower blood cholesterol levels later in life.
 Proteins
• The protein content of mature human milk is relatively low (0.8–
1.0%) compared to other mammalian milks, such as cow’s milk
• The concentration of proteins synthesized in the breast are more
affected by the age of the infant than maternal intake and maternal
serum proteins.
• Proteins synthesized by the breast are more variable because hormones
that regulate gene expression and guide protein synthesis change with
time
• Proteins and their digestive products, such as peptides, exhibit a
variety of antiviral and antimicrobial effects
Fat-soluble vitamins
• Vitamin A Colostrum has approximately twice the con- centration of
vitamin A as mature milk does.
• Some of the vitamin A in human milk is in the form of beta-carotene.
• Its presence is responsible for the characteristic yellow color of
colostrum. In mature milk, vitamin A is present at 75 μg/dl or 280
IU/dl.
• Vitamin D
• Vitamin D is present in both lipid and aqueous (water) compartments
of human milk.
• Most vitamin D is in the form of 25-OH2 vitamin D and vitamin D3.
• Vitamin D levels of human milk vary with maternal diet and exposure
to sunshine
• Vitamin K
• Vitamin K is present in human milk at levels of 2.3 μg/dL.
• Approximately 5% of breastfed infants are at risk for vitamin K
deficiency based on vitamin K- dependent clotting factors.
• There are cases of vitamin K deficiency among exclusively breastfed
infants who did not receive vitamin K at birth
Water-soluble vitamins
• Water-soluble vitamins in human milk are generally responsive to the
content of the maternal diet or supplements (vitamin C, riboflavin,
niacin, B6, and biotin)
• Clinical problems relating to water-soluble vitamins are rare in infants
nursed by mothers with inadequate diets.
• Vitamin B6 is considered most likely to be deficient in human milk;
levels of B6 in human milk directly reflect maternal intake
• Vitamin B12
• Vitamin B12 and folic acid are bound to whey proteins in human milk
• Therefore, their content in milk is less influenced by maternal intake
of these vitamins than are the other water-soluble vitamins.
• Factors that influence protein secretion (hormones and the age of the
infant, or time since delivery) are more likely to alter the human milk
levels of B12 and folate than is dietary intake
Minerals in milk
• The minerals in human milk contribute substantially to the osmolality
of human milk.
• Monovalent ion secretion is managed closely by the alveolar cells, in
balance with lactose, to maintain the isosmotic composition of human
milk
• Mineral content in milk is related to the growth rate of the
offspring.
• The mineral content of human milk is much lower than the
concentration in cow’s milk and the milk of other animals whose
offspring grow faster
Bioavailability
• An important feature of several of the minerals (magnesium, calcium,
iron, zinc) in human milk is the packaging that makes them highly
available (bioavailable) to the infant.
• This also reduces the burden to the mother because less of the mineral
is needed in the milk.
• For example, zinc is 49% available from human milk, but only 10%
available from cow’s milk and cow’s milk
• Exclusively breastfed infants have little risk of anemia, despite the
seemingly low concentration of iron in human milk.
Zinc

• The importance of zinc to human growth is well established.

• Human milk zinc is bound to protein and is highly available, in comparison to
cow’s milk and cow’s milk
• Both the zinc intake (per kg) and the zinc requirements of infants decline after
the first few months.
• Normally, zinc homeostasis and human milk zinc levels are maintained even in
the face of low maternal zinc intake.
• Rare cases of zinc deficiency, which appears as intractable diaper rash, have
been noted in exclusively breastfed infants, however.
Exclusive Breastfeeding
Definition
 Giving an infant only breast milk, with the exception of
drops or syrups consisting of vitamins, mineral
supplements, or drugs

• No food or drink other than breast milk, not even

water
Daily stool and urine output guidance
Day 0 1 wet nappy and meconium at least once a day

Day 1 2 wet nappies and meconium at least once a day

Day 2 & 3 3 or 4 wet nappies and changing stools at least once a day

Day 4+ 5 or 6 heavy wet nappies and yellow stools at least once daily

A baby who is passing meconium at 3 or 4 days old may not be getting enough milk.

A baby who does not have yellow stools by day 5 may not be getting enough milk.

A baby who is not doing as many wet nappies each day as expected may not be getting
enough milk.
Breastfeeding benefits to the infant

• Nutritional
• Immunologic Fewer acute illness

• Lower infant mortality in Cognitive benefits

developing countries
• Reduction in chronic Analgesic effects
diseases
Socio-demographic benefits
• Prevention of childhood
overweight/obesity
Source: Juidth Brown et al., (2011), Nutrition through the life cycle 4 th Edition Wadsworth USA.
Source: Juidth Brown et al., (2011), Nutrition through the life cycle 4 th Edition Wadsworth USA.
Good attachment
What can you see?

Poor attachment
6/3

Breastfeeding Counselling: a training course,

WHO/CHD/93.4, UNICEF/NUT/93.2
 What can you see?
6/4

Breastfeeding Counselling: a training course,

WHO/CHD/93.4, UNICEF/NUT/93.2
Good attachment Poor attachment

Source: Juidth Brown et al., (2011), Nutrition through the life cycle 4 th Edition Wadsworth USA.
 Close
In line

Facing
Supported
Breastfeeding Positions
7/1

Breastfeeding Counselling: a training course,

WHO/CHD/93.4, UNICEF/NUT/93.2
 Breastfeeding Barriers

• Breast Pathology
• Flat/inverted nipples, breast reduction surgery that severed milk ducts, previous
breast abscess, extremely sore nipples (cracked, bleeding, blisters, abrasions)
• Hormonal pathology
• Failure of lactogenesis, hypothyroidism
• Overall health
• Smoking, anemia, poor nutrition, depression
• Psychosocial
• Restrictive feeding schedules, mother without support system, not rooming in with
baby, bottle supplementing when not medically required
• Other
• Previous breastfed infant who failed to gain weight well, perinatal complication
(hemorrhage, htn, infection
Infant Feeding:
HIV-Negative Mothers
UN Recommendations
• Exclusive breastfeeding for 6 months
• Breastfeeding continued for 2 years or beyond
• Introduction of nutritionally adequate and safe complementary foods
after 6 months
• Information to mothers about the risk of
HIV-infection late in pregnancy or during breastfeeding
Breastfeeding - The Results
• Baby gains weight
• No more than 7% weight loss
• Back to birth weight in 2 weeks
• 1oz per day weight gain for the first three months
• Mother is comfortable and satisfied
• If baby is still loosing weight on the 4th day of life:
• Get feeding evaluation
• Remember to:
• 1. feed the baby
• 2. maintain the milk supply
• 3. continue breastfeeding
Breastfeeding Complications
• Infants at risk for poor
weight gain
• Premature (less than 38
weeks)
• Difficulty latching on
• Ineffective or un sustained
sucking
• Oral anatomic
abnormalities (cleft
lip/palate, short frenulum,
receding chin)
• Multiples
Jaundice
Cystic fibrosis
Infection
Cardiac disorders
Neurologic problems – downs, hypo or
hypertonia
Sleepy, non demanding, passive
temperament
Separation from mother early after delivery
Infants less than 5 lbs
 Chin Support 10/6

Kay Hoover and Barbara Wilson-Clay, from The Breastfeeding Atlas

UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
 11/1

Hand
Expression

©UNICEF 910164F

UNICEF/WHO Breastfeeding Promotion and Support i

n a Baby-Friendly Hospital – 20 hour Course 2006
 Cup Feeding

n a Baby-Friendly Hospital – 20 hour Course 2006

UNICEF/WHO Breastfeeding Promotion and Support i
11/2

Promoting breastfeeding in health facilities:

A short course for administrators and policy makers WHO/NUT/96.3, Wellstart International
 11/3

Supplementer

Dr Ruskhana Haider, Dhaka, Bangladesh

UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
 12/1

Size and Shape

There are many different

Breastfeeding Counselling: a training course,

shapes and sizes of breast

WHO/CHD/93.4, UNICEF/NUT/93.2
and nipple.
Babies can breastfeed
from almost all of them.

UNICEF/WHO Breastfeeding Promotion and Support i

n a Baby-Friendly Hospital – 20 hour Course 2006
 Full Breast
12/2

UNICEF C-107-19
UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
 12/3

Engorged Breast

© UNICEF C-10-25
UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
 12/4
Mastitis

©UNICEF C107-39
UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
 12/5
Sore Nipple

©UNICEF C107-31
UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
 12/6

Sore
Nipple

©UNICEF C107-32
UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
 12/7

Syringe method for inverted nipples

Breastfeeding Counselling: a training course,

WHO/CHD/93.4, UNICEF/NUT/93.2
UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
 12/8

Candida on the nipple

©UNICEF C107-34
UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
 12/9
Candida on the nipple

©UNICEF C107- 33
UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
Tongue-tie 12/10

©UNICEF C107-35
UNICEF/WHO Breastfeeding Promotion and Support i
n a Baby-Friendly Hospital – 20 hour Course 2006
Infant Feeding: HIV-Positive Mothers
WHO Recommendations

• Avoid all breastfeeding if replacement feeding is :

• Acceptable
• Feasible
• Affordable
• Sustainable &
• Safe
• Otherwise, exclusive breastfeeding during the first months of life
Breast-milk Feeding Options:
Exclusive Breastfeeding
Advantages Disadvantages
• Easily digestible
• Nutritious and • Risk of passing
complete HIV to baby
• Always available • Requires feeding on
• No special preparation demand
needed • Mother requires
• Protects from additional calories to
diarrhoea, pneumonia, support breastfeeding
and other
infections/diseases
• Promotes bonding
Guidelines for the Community
 Ensure all HIV-infected mothers receive feeding counselling
 Identify the range of feeding options that are acceptable, feasible,
affordable, sustainable, and safe
 Educate the public about MTCT
 Train infant-feeding counsellors
 Train peer counsellors
 Support the mother’s choice
Breast-milk Feeding Options:
Exclusive Breastfeeding with Early Cessation
Disadvantages
Advantage
•• Breast-milk substitute
Terminates infant’s exposure to HIV
is necessary
• Mother's breasts may become engorged
• Mother at risk of becoming pregnant if sexually active
Expressed Heat-treated Breast Milk
Steps for breast milk preparation
• Wash all containers with soap and water

• Heat enough expressed milk for one feed

• Heat to boiling and cool

• Use within one hour

Replacement Feeding Options:
Commercial Infant Formula
•Advantages
Disadvantages
•• Infant
No riskisof
more likely to HIV
transmitting get sick
• Need reliable formula supply
•• Formula
Made especially for infants
is expensive
• Requires
Includes most
cleannutrients
water an infant needs
•• Must
Othersbecan
made
feedfresh each time
infant
• Infant needs to drink from a
cup
• Not breastfeeding may raise questions about mother’s HIV status
Replacement Feeding Options:
Home-Prepared Modified Animal Milk
Advantages
• No risk of transmitting HIV
• Less expensive than commercial
formula
• Can be used when commercial infant
formula runs out
• Others can feed infant
Disadvantages
• Infant more likely to get sick
• Must be made fresh each time
• Difficult to digest
• Multivitamin supplements needed
• Must add boiled water and sugar
• Mother must stop breastfeeding
• Does not contain antibodies
• Infant needs to drink from a cup
• Not breastfeeding may raise
questions about mother’s HIV
status
Infant-Feeding Counselling
and Support
Infant-feeding counselling, • Provide women with safer
education, and support should feeding skills
• Be provided before and after birth • Include demonstrations or
• Be based on national protocol
opportunities to practice
• Be based on a woman’s circumstances
• Encourage partner or family
• Include information on infant-feeding options
and advantages and disadvantages involvement
• • Provide disclosure support
Infant-Feeding Counselling
and Support
• Counselling Visits
• At least one during the antenatal period
• Immediately after birth
• Within 7 days of birth to monitor post-partum and infant-feeding
progress
• Monthly follow-up sessions
• Additional sessions may be required during high-risk time periods
Infant-Feeding Counselling
and Support

• Infant-Feeding Counselling Steps

• STEP 1: Explain risks of MTCT

• STEP 2: Explain advantages and disadvantages of different feeding

options, starting with mother’s initial preference

• STEP 3: Explore mother’s home and family situation

• STEP 4: Help mother choose an appropriate option

Infant-Feeding Counselling
and Support
• Infant-Feeding Counselling Steps (continued)
• STEP 5: Demonstrate how to practice chosen feeding option

• Replacement feeding
• Exclusive breastfeeding
• Other breast milk options

• STEP 6: Provide follow-up counselling and support

 Thank You

For any concerns, please contact

elearning@knust.edu.gh
elearningknust@gmail.com
0322 191132
Jan 2014