Breastfeeding

Question 1

For how long after birth should an infant be breastfed?

Answer 1

Exclusively for 6 months, then occasionally for up to at least 1 year along with introduction of other foods

Question 2

Introducing gluten

Answer 2

Breast milk reduces the risk of developing Celiac’s disease, specifically when an infant is exposed to gluten while mostly breastfeeding.

Gluten-containing foods should be introduced while the infant is receiving only breast milk and not infant formula or other bovine milk products

Question 3

Cow milk β-lactoglobulin

Answer 3

It is proposed that exposure to cow milk β-lactoglobulin may trigger cross-reactivity leading to type 1 diabetes in newborns.

For this reason, avoiding cow’s milk in the first 3 months of life reduces rates of type 1 diabetes.

Question 4

Breastfeeding in phenylketonuria

Answer 4

Baby can still breastfeed, but breastfeeding should be alternated with special PKU-safe formula meals

Question 5

Infectious contraindications to breastfeeding

Answer 5

• HIV
• Active tuberculosis
• HTLV type I and type II
• Brucellosis
• Active Herpes simplex lesion on the breast

Question 6

Varicella and breastfeeding

Answer 6

Moms who develop varicella 5 days prior to delivery through 2 days post-delivery should be separated from their infant until they recover

However, their bresat milk, if expressed/pumped, is safe for the infant, as viral particles are not contained within.

Question 7

CMV and breastfeeding

Answer 7

Seropositive CMV is not a contraindication to breastfeeding

Only preterm infants with very-low birth weight (<1500 g) are at risk of acquiring CMV, but even in these individuals the benefits likely outweigh the risks.

Question 8

Diet for breastfeeding

Answer 8

Well balanced diet high in omega-3 fatty acids (specifically DHA)

Fish is an excellent source, but larger predatory fish should be avoided.

Good fish: herring, canned light tuna, salmon

Bad fish (high mercury content): pike, marlin, mackerel, tile fish, swordfish

Question 9

Main classes of drugs that are contraindications to breastfeeding

Answer 9

• Amphetamines
• Chemotherapeutics (including methotrexate)
• Ergotamines
• Statins

Question 10

Breastfeeding of infants with G6PD deficiency

Answer 10

Mom should avoid all of the foods and drugs that trigger G6PD deficiency’s hemolytic process. This includes:

• Fava beans
• Nitrofurantoin
• Primaquine
• Phenazopyridine

Question 11

Pacifier use

Answer 11

Extended early pacifier use is linked to less successful breastfeeding.

So, pacifiers should be used only in certain situations. For example: pain relief, as a calming agent when necessary, as part of a functional program for enhancing oral motor function.

However, mothers of healthy term infants should be instructed to use pacifiers at infant nap or sleep time after breastfeeding at 3-4 weeks of age, as this is associated with a decreased rate of SIDS.

Generally speaking, they are best used sparingly after breastfeeding is already established.

Question 12

Supplements to breastfeeding

Answer 12

• Intramuscular vitamin K at birth
• Vitamin D orally every day
• Fluoride starting AFTER 6 months UP TO 3 years ONLY in places where water fluoride is <0.3 ppm
• Complementary food rich in iron and zinc starting at 6 months

Question 13

It is okay to start using cow’s milk as part of an infant’s diet after. . .

Answer 13

. . . 1 year of age

Question 14

Cortisol and breastfeeding

Answer 14

Cortisol decreases milk production

Thus, stress decreases milk production!

Question 15

Feedback inhibitor of lactation

Answer 15

Feedback inhibitor of lactation (FIL) is a protein in breast milk that is important in the supply and demand process of milk production; if the breasts are emptied regularly, there is less FIL present in the breast and more milk will be produced.

Question 16

Galactopoiesis

Answer 16

Stage of milk generation following the colostrum phase. In this stage, milk production is predominantly dependent upon frequent breastfeeding: The more you breastfeed, the more milk will be produced.

This is primarily due to feedback inhibition by mechanical distension of lobules and by FIL.

Question 17

Laxative effect of colostrum

Answer 17

Colostrum stimulates the neonate’s bowel for passage of meconium, making the way for infant stools.

Question 18

“Transition milk”

Answer 18

The phase in between colostrum and mature milk

Its content is lower in proteins and immunoglobulins, but higher in calories, fat, and lactose levels compared to colostrum

Question 19

Foremilk and hindmilk

Answer 19

• Foremilk is provided when the breast is full and has a lower fat content.
• Hindmilk is provided when the breast is nearly empty and has a higher fat content, which increases infant satiety and is needed for healthy weight gain.
• The baby should empty the breast before switching to the other breast to ensure that the baby is getting the hindmilk with the higher fat content along with the foremilk.

Question 20

Absolute infantile contraindication to breastfeeding

Answer 20

Galactosemia

And kind of PKU – PKU babies cannot exclusively breastfeed, but they can and should breastfeed some of the time

Question 22

Breastfeeding infants with allergies

Answer 22

If mom consumes an allergen, a small amount of the allergen will find its way into the breastmilk.

So, mom has to avoid all of baby’s allergens while breastfeeding.

Question 23

Predictors of early breastfeeding termination

Answer 23

• Use of supplements in the hospital
• Delay of first breastfeeding beyond the first hour of life
• Not breastfeeding on cue
• Not sleeping near the baby
• Use of pacifiers

Question 24

Signs of successful latch

Answer 24

• Audible swallowing noises without clicking noises from the infant’s mouth
• Infant nose aligned to nipple with head tilted backwards
• Full rounded cheeks, no dimpling cheeks
• Rhythmic jaw movements

Question 25

___ is almost always the most effective way to express colostrum

Answer 25

Hand expression is almost always the most effective way to express colostrum

Pumps are not useful, as the quantities are so small that they tend to get lost in the pump’s tubing and machinery.

Question 26

Crying as a sign of hunger in infants

Answer 26

Crying is a relatively late sign of hunger in infants, and parents should not wait for crying to feed infants.

Infants will indicate hunger by spontaneously rooting and sucking various objects and by vocalizing.

Question 27

The point of inflection for baby weight should be. . .

Answer 27

. . . 5 days postpartum

Here they should stop losing weight (from excess fluid and hepatic glucose and fat stores) and start gaining weight.

If they continue to lose weight past 1 week, something is wrong.

Question 28

Symptoms of thrush of the nipple

Answer 28

• Nipple itching and/or burning even when not breastfeeding
• Nipples that appear pink or red, puffy, flaky, or dry
• Shooting pain from the breast during or after breastfeeding
• Intense nipple or breast pain not improved with better latch and positioning

Question 29

When treating a mother for thrush of the nipple or a breastfeeding infant for oral thrush. . .

Answer 29

. . . you should always treat the other too

Mom may have an asymptomatic candidiasis of the nipple, or the infant may have an asymptomatic oral thrush.

Question 30

Aspirin while breastfeeding

Answer 30

Should be used with caution or avoided in breastfeeding, for two reasons:

1. There have been some reports of mothers on high dose-aspirin communicating it to their infant via breastfeeding and inducing mucocutaneous bleeding.
2. It is associated with Reye’s syndrome – a rare but serious condition that causes confusion, swelling in the brain, and liver damage.

Question 31

Reye’s syndrome

Answer 31

A rare but potentially life-threatening condition in children < 19 years that generally develops after treating a viral illness (e.g., influenza, varicella) with salicylates like aspirin.

The viral infection alters the metabolism of salicylates and leads to accumulation of metabolites in the liver, which causes hepatic mitochondrial injury that prevents hepatic ATP production. The result is hepatic failure (hyperammonemia, metabolic acidosis, and hepatic steatosis) that manifests with acute hepatic encephalopathy.

Treat with withholding of aspirin/salicylates, supportive measures, and mannitol (to decrease intracranial pressure caused by cerebral edema).

Question 32

The ACA and lactational support

Answer 32

The ACA requires that employers offer 1) sufficient time for mom to express breast milk when necessary, and 2) a location separate from the bathroom for them to do so, for at least one year after delivery.

Question 33

Ductal ectasia

Answer 33

• Subareolar periductal chronic inflammatory condition defined by dilated mammary ducts which are eventually clogged
• Most common in perimenopausal women
• Presents with unilateral greenish nipple discharge, nipple inversion, and firm, stable, painful breast mass. May progress to abscess.
• Dx with ultrasound. Biopsy if any suspicious or inconclusive US.
• Therapy: None necessary, usually resolves on its own. Abx if infected.

Question 34

Witch’s milk

Answer 34

Bilaterally enlarged breasts in a neonate, irrespective of the biological sex, is a common physiological condition caused by circulating maternal estrogen stimulating glandular proliferation, and is known as neonatal gynecomastia.

In ∼ 5% of newborns, milky discharge (galactorrhea) is also present. Both neonatal gynecomastia and galactorrhea will usually resolve spontaneously within two weeks (but up to one year) of life and do not require treatment.