Breastfeeding

Effective Practices, Benefits to Mothers and Infants and The Role of the Family Physician

Folake Falaki, MD
PGY2 Emory Family Medicine. June 25, 2009

Outline

Introduction Anatomy and Physiology of Lactation Composition and Storage of Human Breast Milk Achieving Optimal Breastfeeding Breastfeeding Techniques and Positions Benefits of Breastfeeding to Infants and Mothers Barriers to Effective Breastfeeding Contraindication to Breastfeeding Reason for supplementation Role of the Family Physician Conclusion

Breast fed infants, are Healthy Infants.

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 of age.

Anatomy and Physiology of Lactation

Structure of the Human Breast

Source: Lactation Education Program Nutrition Policy and Education

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.

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.

Suckling Hormonal Reflex Arc

Source: Lactation Education Program Nutrition Policy and Education

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.

Types and Composition of Human Breast Milk

Types of Breast Milk: Colostrum or Early Milk Transitional Milk Mature Milk

Colostrum or Early Milk is produced in the late stage of pregnancy till 4 days after delivery; and is rich in antibodies.
Transitional Milk produced from day 4 10 is lower in protein in comparison to Colostrum. Mature milk is produced from approximately ten days after delivery up until the termination of the breastfeeding.

Types and Composition of Human Breast Milk (Contd)

Fat - The main lipids found in human milk are the triglycerides phospholipids and essential fatty acids. Protein Whey ; lactoferrin, lysozymes, immunoglobulin , lactalbumin, Casein; lower concentration in human milk. Carbohydrate Include lactose and oligosaccharides. Leukocytes - Include neutrophils, marcrophages , lymphocytes. Non protein nitrogen urea, uric acid Other constituents : steroid hormones, peptides, insulins, growth factors, minerals, vitamins, lipase. A-

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 24hours.
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.

Achieving Optimal Breastfeeding

Activities, attitudes and procedures during the delivery and post partum period have an impact on breastfeeding . There is well documented evidence that skin to skin contact between infant and mother helps to maintain the body temperatures, reduce risk of hypoglycemia, enhance oxytocin release and beneficial nutrition with intake of colostrum Skin to skin contact should occur for about 1-2 hours after delivery. Procedures after delivery like weighing, administration of vitamin K, eye prophylaxis and other procedures should be delayed

Achieving Optimal Breastfeeding (Contd)

Breastfeeding should be started and fully established before discharge from the hospital Physicians and health care professionals should observe at least one feeding and ensure this is done properly and breast milk is produced

Lactation specialist should also work with parents that are having difficulty with breast feeding.
Early follow up after leaving the hospital is required.

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.

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.

Good Breastfeeding Techniques

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. Most mothers are scared of crushing the baby.
Adapted from AAFP Journal September 2001

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

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

Benefits of Breastfeeding to Infants

Helps in Gastrointestinal development and function Helps in development of the immune system Helps in cognitive development of the infant Infants who are breastfed have reduced risk of infection compared to formula fed infants.

Benefits of Breastfeeding to Infants

Breastfed infants have reduced risk of obesity later in life compared to formula fed infants. Reduced risk of sudden infant death syndrome, Hodgkin's lymphoma, Leukemia and Type 1 Diabetes. Lower risk of infections e.g. otitis media, Lower respiratory tract infection, Diarrheal diseases, Allergies , eczema, Meningitis and inflammatory bowel diseases.

Benefits of Breastfeeding to Mothers

Enhance early maternal infant bond. Aids involution of the uterus. Long term breastfeeding helps in loss of the excess weight acquired during pregnancy. Prolonged Breastfeeding prolongs anovulation. Documented long term effect of breastfeeding include reduced risk of breast, ovarian and endometrial cancers.

Supplements that increase lactation

Herbal dietary supplement - Fennel fruit - Aniseed fruit - Coriander fruit - Fenugreek seed - Blessed thistle herb
-

Not FDA approved.

Socio-economic Benefits of Breastfeeding

Income savings average of $1000 - $1200 per infant per year. Reduced risk of infections and diseases hence reduced hospital visits and attendant medical cost.

Mothers are more economically productive since they will spend less time caring for a sick child.

Barriers To Effective Breastfeeding

Lack of confidence in mother Belief that breast milk is not sufficient Lack of adequate support system History of previous breast surgery Breast engorgement, cracked and sore nipples

Retractile nipples

Barriers To Effective Breastfeeding

Embarrassment by mother Jealousy by Partner and siblings Chronic illness in mother; psychosis, Cancer.

Contraindication to Breastfeeding

HIV , HLTV 1 & 11 infections. Active Tuberculosis. Herpes lesions on mothers breast. Infant with Inborn error of metabolism; galactosemia, phenylketonuria. Mothers on certain medications ; anticancer therapy, radioactive isotope etc.

Reason for Supplementation

Birth weight < 1500 g or GA < 32 weeks

Severe hypoglycemia
Acute water loss

Hyperbilirubinemia related to poor intake

Delayed bowel movement or dark stools at day 5

Delayed milk production

Weight loss >8% of birth weight.

Role of the Family Physician

Provide education about breastfeeding at first prenatal visit Physical exam should include breast exam Ensure rooming-in after delivery Ensure breastfeeding is started and established before discharge after delivery. Observe at least a session of breastfeeding to ensure it is done correctly

Role of the Family Physician

Office should be breastfeeding friendly Staff should be well trained and willing to answer questions mothers might have

Prenatal package should have literatures and patient hand out that outlines benefit of breastfeeding
Prenatal records should have a checklist that ensure all question are addressed.

Conclusion

Breastfeeding is the best source of nutrition for a healthy term infant. AAP, AAFP and WHO recommends exclusive breastfeeding for the first six month of life and for at least twelve month of life. Human milk is human specific and contains nutrients that are essential for the proper growth and development of the newborn. Breast milk is beneficial to both infant and mother.

Conclusion

Proper positioning on the breast helps ensure adequate latching on and subsequently adequate breastfeeding. Breast milk can be stored away, and utilized later when needed. There are absolute contraindications to breastfeeding, these include HIV, 1 and 11 , HTLV 1 and 11, active TB and active herpes simplex lesions on the breast. The family physician has a significant role in promoting breastfeeding.

References
Riordan J, Auerbach KG. Breastfeeding and Human Lactation. 2nd edition, Sudbury, Mass: Jones and Bartlett, 1999 American Academy of Pediatrics Journals & Periodicals Pediatrics in Review www.aappublications.org Gartner LM, Morton J, Lawrence RA. et al Breastfeeding and the Use of Human Milk, Pediatrics 2005 Feb;115 (2): 496 506 United States Department of Health and Human Services. Healthy People 2010: Volume II. Objectives for Improving Health. Retrieved March 2009 from http://www.healthypeople.gov/Document/tableofcontents.htm#volume1 McDowell MA, Wang C-Y, Kennedy-Stephenson J. Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Surveys 1999-2006. NCHS Data Briefs, No 5, Hyattsville, MD: National Center for Health Statistics. 2008. Wright AL. The rise of breastfeeding in the United States. Pediatric Clinics of North America 2001; pp1-12. Gerard JT. Introduction to the Human Body: The Essentials of Anatomy and Physiology 5th ed. John Wiley & Sons, Inc.: New York, 2001 Neville MC. Anatomy and physiology of lactation. Pediatrics Clinics of North America 2001 Lawrence RA and Lawrence RM. Breastfeeding, A Guide for the Medical Profession, 6th Ed. Elsevier Mosby, Philadelphia PA. 2005

References
Nancy G, Powers, Wendelin S. Breastfeeding Update 2: Clinical Lactation Management. Pediatrics In Review: May 1997; pp147-15 Ali Z, Lowry M. Early maternal-child contact: effects on later behaviour. Dev Med Child Neurol. Vol. 23 June 1981; pp337-345 Sinusas K, Gagliardi A. Initial Management of Breastfeeding American Family Physician, Journal of the AAFP; September 15, 2001 Moreland J, Coombs J. Promoting and supporting Breastfeeding. American Family Physician, Journal of the AAFP; April 1, 2000 Agency for Healthcare Research and Quality Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries; April 2007; #153; Retrieved March 15 2009 from http://www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf
Protecting, promoting and supporting breastfeeding: the special role of maternity services. A Joint WHO/UNICEF statement. Int J Gynecol Obstet 1990; 31(suppl 1):171-83. Moreland J, Coombs J Promoting and Supporting Breast Feeding American Family Physician 2000; 61:2093-100, 2103-4