Case 14- breast feeding Flashcards
Factors that influence maternal choice in neonatal feeding
- Cultural- may think formula is as good as breastfeeding
- White
- Young age
- Left education early
- Support within families and community
- Socio-economic status- lower class
- Employed full time
- Concern on milk supply
- Low confidence on ability to breastfeed- especially if they find it difficult and feel they cant do it in public. Support from partner greatly increases chance of breast feeding. Healthcare professionals can have a negative effect if their information is inconsistent
Maternal support during breast feeding
- Midwife
- Infant feeding specialist
- Breast feeding support groups
- Ongoing support essential for both well neonates but particularly for the neonate in the neonatal unit (e.g. preterm)
- Support with expressing & storing breast milk (EBM) if neonate unable / too unwell to feed
- Mother’s health & hygiene– give advice & information giving show sensitivity & maintain privacy / dignity plus consider culture
How much breast milk does the infant need
- Calorific requirements increase initially after birth and increase slowly in the first 2 weeks, it reaches 150 mls/kg (100-120 kcal/kg/day)
- Small/preterm neonates have higher requirements to achieve ideal growth.
- Nutrients needed- Protein, Carbohydrate, Lipids, Vitamins, Electrolytes, Trace elements, Iron
How to measure growth and nutrition in baby
- Weight- mass of lean tissue, fat, intra and extracellular fluid components
- Length- reflects lean tissue mass
- Head circumference- correlates with overall growth and developmental achievements
Specific energy requirements for the infant
- Requirements kcal/kg/day
- Basal metabolic rate 40
- Physical activity 4+
- Specific dynamic action of food (10%)
- Thermoregulation variable
- Growth 70
- (To match in-utero growth of 15g/kg/day)
The risks of total parental nutrition are
- Line associated sepsis
- Line related complications (ie thrombosis)
- Hyperammonaemia
- Hypercholoraemic acidosis
- Cholestatic jaundice
- Trace element deficiency
How to feed preterm babies
At 32 gestational the preterm can start feeding on bottle/breast. At 35 weeks the infant should be nippling all feeds. Before 32 weeks they have no gag reflex or rooting reflex. At 33/34 weeks the baby can coordinate suck/swallow/breath.
Formula milk
90% water. Lactose is the only carbohydrate. Whey/Casein ratio is 60:40. The whey components are beta-lactoglobulin and alpha-lactalbumin. There is an adequate amount of vitamins and the mineral contents are similar to break milk.
Stillbirth
Death of a baby before or during birth after 24 weeks of gestation in the UK (WHO definition is >28 weeks)
Perinatal mortality
Stillbirths plus early neonatal deaths, under 7 days
Neonatal death
Death of a baby within 28 days
Postneonatal death
Death of a baby after 28 days and within 1 year of age
Infant mortality
Deaths of those under 1 year, doesnt cover stillbirths
Infant mortality rate in the uk
2.7 deaths per 1000 live births.
Perinatal mortality rate in the UK
5.13 per 1000, includes 3.5 stillbirths and 1.6 neonatal deaths.
Factors for an increased risk of infant mortality
- Births outside marriage
- Maternal age under 20
- Deprivation
- Low birthweight- associated with poor long term health outcomes
- Low socioeconomic status
- Ethnic minority background
Risk factors for still birth
- Fetal growth restriction is biggest risk factor
- Babies born to women >40yrs
- Obesity doubles it, BMI ≥30
- Smoking
- Chronic diseases- i.e. diabetes, renal disease, hypertension, haemoglobinopathy, rhesus disease. Gestational diabetes does not increase risk just pre-existing
- Infection- varicella, measles
- Substance abuse- cocaine
- Pre-eclampsia & antenatal haemorrhage
- Multiple pregnancy- monochorionic
- Malpresentation
- Nulliparous
- Congenital abnormality
- SGA
- Deprivation
- Ethnicity
- Region of residence
Risk factors for neonatal death
• Congenital abnormality
• Obstetric complications
• Babies born to women <25yrs & >40
• Obesity doubles it, BMI ≥30
• Infection
• Preterm birth is the biggest risk factor
The commonest causes of neonatal death is immaturity related conditions (respiratory and cardiovascular disorders), congenital abnormalities.
Malnutrition
A condition where the body does not get the right amount of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function.
Criteria for Calorific undernutrition
- BMI <18.5kg/m^2
- Unintentional weight loss >10% of total body weight within the last 3-6 months
- BMI <20kg/m^2 and unintentional weight loss >5% of total body weight within the last 3-6 months.
How do you detect undernutrition in children
BMI is not used
• Underweight- low weight for age, may be stunted, wasted or both
• Stunting- low height for age, the result of chronic or recurrent undernutrition i.e. poor socioeconomic conditions
• Wasting- low weight for height. Usually indicates recent and severe weight loss i.e. due to diarrhoea from an infectious disease.
The effect people with malnutrition have on hospitals
Have more hospital visits, Have more GP visits, Have on average a 3 day longer hospital stay.
Problems with children with malnutrition
- Have an increased risk of infection/mortality
- Cognitive defects
- Poor motor development
- Poor school performance
- High incidence of non-communicable disease
Types of malnutrition
- Deficiencies- calories, specific nutrients.
* Excesses- calories, specific nutrients (usually due to iatrogenic replacements i.e. IV fluid)
3 reasons for a calory deficiency
1) Reduced intake
2) Decreased absorption
3) Increased requirements
Reasons for reduced calorie intake- Eldery
More likely to be institutionalised, more chronic disease, loose appetite
Reduced calorific intake- infectious disease
Diarrhoea (leads to reduced food intake, reduced nutrient absorption and increased metabolic requirements), Parasites (Helminthiasis)
Reduced calorific intake- chronic disease
Nausea i.e. from gastric reflux, dysphagia i.e. oesophageal cancer, poor dentition/poorly fitting dentures
Reduced calorific intake- mental health
Dementia (swallowing impairment as it advances, lack of volition to eat), Depression (lack of volition to eat), Mania (patients don’t feel the need to eat), Schizophrenia (can become paronoid about food contents), Anorexia nervosa
Reduced calorific intake- medication
Chemotherapy (nausea is a side effect), NSAIDS (causes reflux and gastritis which can lead to nausea), Opiates (increases early satiety)
Reduced calorific intake- Maternal factors
Children under the age are dependent on their mothers nutrition during pregnancy as well as breastfeeding.
Malnutrition- increased requirements
- Cancer- cancerous cells have a higher turnover so increased energy demands
- Congenital heart disease
- Cystic fibrosis
- Cerebral palsy
Risk factors for deficiency in nutrients
- Lack of sun exposure- don’t get enough vitamin D. Can be housebound, wearing covered clothes, BAME
- Pregnancy- increased risk of calcium, folate, iron, and vitamin C&D deficiency
- Alcohol excess- less likely to have a varied diet, reduces absorption of thiamine (need supplements)
- Vegetarianism/Veganism- can get deficiencies in iron, folate, vitamin B12
Common micronutrient deficiencies in children
- Iron- needed for motor and cognitive development, causes anaemia (supplements)
- Iodine- needed in pregnancy and infancy for growth and cognitive development
- Vitamin A deficiency- supports healthy vision and immune system function. Breast milk is a source of vitamin A. Prevents childhood infections i.e. measles and blindness
- Zinc- promotes immune function
The two types of protein energy malnutrition
- Kwashiorkor- adequate calories, deficiency in proteins. Associated with oedema and hepatomegaly, often precipitated by infections.
- Marasmus- inadequate calories, deficiency in protein. Associated with severe wasting, often precipitated by infection.
Risk factors for developing protein energy malnutrition
- Poverty
- Low birth weight
- Too early or too late weaning of breast feeding
- Recurrent infections
- Existing co-morbidities
Overweight and Obesity criteria
Overweight = BMI ≥25kg/m2 Obesity = BMI ≥30kg/m2
Double burden of malnutrition
In low/middle income countries that still deal with calorific/nutrient deficiency whilst experiencing a rise in calorific excess
Obesogenic environment
The environment promotes weight gain. • More fat, sugar and salt in food • Bigger portions • Jobs require less movement • Unhealthy food being cheaper •Can be influenced by food processing and marketing, education and transport
The 4 stage model of the human sexual response
1) Excitement
2) Plateau- changes that occur in excitement intensify
3) Orgasm - the uterus and walls of the vagina contract
4) Resolution- physiological changes return to normal
Master and Johnsons theory.
The 4 stage model of human sexual response- Excitement
Various erotic stimuli prepare the genitalia for sexual intercourse, can be tactile or psychological stimulation. Areas of the body that possess receptors for sexually arousing tactile stimulation (erogenous zones) are the genitalia, lips, tongue, nipples and ear lobes. There is an increase in heart rate, respiratory rate, blood pressure and vasocongestion of the skin. The penis becomes erect, the testis becomes drawn up and the scrotum is tense. There is swelling of the labia and enlargement of the clitoris. The uterus elevates and grows in size, and the vaginal walls begin to secrete fluid to aid lubrication.
Circular model of sexual response
Better reflects females, invented by Basson. Notes that some women don’t have spontaneous sexual desire and may be in response to a stimuli. Non sexual stimuli can produce sexual desire and arousal and incorporates intimacy, love and other emotional relationship factors. The circular model begins with the individual in a state of sexual neutrality, who then may seek or respond to sexual stimuli, therefore experiencing sexual arousal and desire. Not a rejection of the 4 stage model.
Sexual dysfunction
A subjective dissatisfaction with the level or nature of sexual activity. Estimated to be 40% of women, can cause stress and anxiety
The 3 types of sexual dysfunction
- Sexual interest/desire disorders, where there is reduced or absent sexual interest, responsiveness, erotic thoughts or sexual pleasure
- Female orgasmic disorders, where there is absence, infrequency, reduction or delay of orgasm
- Sexual pain disorders, where there is difficulty in vaginal penetration, pain during penetration, fear or anxiety about pain in anticipation of penetration or tightening of the pelvic floor muscles during attempted penetration
Causes of Sexual dysfunction in women
- Psychological- anxiety, depression, past trauma, relationship issues
- Atherosclerosis- may effect the ability for the clitoris to become erect
- Neurological- disorders of the CNS and PNS
- Menopause- oestrogen insufficiency causes urogenital atrophy and reduced vaginal secretions
- Thyroid disease
- Diabetes
- Pregnancy- multiple hormones and physical changes
- Post-partum period
- Muscular- Hypo and hypertonicity of the pelvic floor or vaginal canal
- Chronic pain
- Medication i.e. SSRI
Management of sexual dysfunction
- Diet, physical activity, smoking and alcohol
- CBT
- Pelvic floor exercises especially after childbirth
- Vaginal dillators used in vaginismus
- Vaginal lubricant
- Oestrogen preparation- to improve lubrication and libido in post menopausal women
Causes of Dyspareunia
Pain during intercourse
• Psychology- past trauma during intercourse
• Skin reaction to the external genitalia, possibly due to latex
• Superficial pain- infections (thrush or STI’s), vaginismis (involuntary contraction of pelvic floor), lack of lubrication (post menopausal women)
• Deep pain- vaginitis or inflammation of the cervix. Fibroids in the uterus, pelvic inflammatory disease, endometris, adhesions from previous pelvic surgery
• IBS
Structure of the penis
The Penis is made of 3 long cylindrical bodies, the corpus spongiosum surrounds the urethra and two corpora cavernosa. The corpora cavernosa are wrapped in a fibrous coat of the tunica albuginea. Blood is drained from the penis by small emissary veins which drain into the deep dorsal vein to return blood to the systemic circulation.
Innervation of the penis
Parasympathetic and Sympathetic fibres merge to form the cavernous nerve and are responsible for an erection. Sensory information is carried by the dorsal nerve.
The stimulation which produces an erection
- Parasympathetic stimulation and sympathetic inhibition produces vasodilation of penile arteries and an erection.
- The Parasympathetic nerves in the cavanosal space release AcH to muscarinic receptors on endothelial cells.
- Activates the enzyme nitric oxide synthase, which converts the amino acid Arginine into Citrulline and Nitric oxide.
- The Nitric oxide diffuses into the nearby smooth muscle cells which activates Guanylate cyclase.
- This converts GTP to cGMP, causing the release of Ca+2 from smooth muscle cells
- The fall in intracellular Ca+2 causes smooth muscle cells to relax in the corpora cavernosa
- The spaces then expand and fill with blood, which passively compresses the veins trapping the blood within the corpora.
- The erectile tissue becomes angorged and the penis lengthens and stiffens
Stopping an erection
cGMP is converted to GMP using the enzyme PDE-5. GMP restores intracellular Ca+2
What happens on ejaculation
During ejaculation a sphincter at the base of the bladder contracts to prevent retrograde flow of sperm into the bladder and to prevent urine from mixing with sperm. Semen is expelled due to a series of rapid muscular contraction, average sperm volume is 3ml (between 2-6ml) of which 10% is sperm. Orgasm and ejaculation are different, an orgasm is an altered physiological state.
Types of erectile dysfunction
- Premature ejaculation
- Delayed ejaculation
- Retrograde ejaculation
- Anejaculation
- Aspermia
- Priapism - a persistent erection lasting >4 hours with risk of causing ischaemic injury
Erectile dysfunction
Persistent inability to initiate or sustain a penile erection. Age is the largest risk factor
Psychological causes of erectile dysfunction
- Most erectile dysfunction is not psychogenic, however psychogenic erectile dysfunction is more common in younger males
- Can be due to relationship issues, poor sexual experiences or underlying psychological problems.
- Males are still able to get waking erections, indicating that the physiological processes are intact.
Vascular causes of erectile dysfunction
- The most common cause of erectile dysfunction is the presence of atherosclerosis affecting the penile arteries. Build up of atheromatous plaques harden the arteries supplying the penis, making it harder for them to dilate.
- Lifestyle modifications may improve erections
- Hypertension causes wear and tear to endothelial cells, causing a decrease in their ability to produce nitric oxide.
- The hyperglycaemic state seen in diabetes mellitus causes deposition of hyaline in arteriole walls, making it harder for them to dilate. They build up in capillaries, increasing the diffusion distance of oxygen to enter tissues. This eventually causes hypoxia and death of smooth muscle cells and parasympathetic fibres (no ACH released).
Neurological causes of erectile dysfunction
- Diffuse neurological injury - e.g. multiple sclerosis
- Central nerve injury - e.g. stroke
- Peripheral nerve injury - e.g. pelvic fractures, nerve damage during prostate surgery
Endocrine causes of erectile dysfunction
- Low testosterone (primary or secondary hypogonadism) – reduces levels nitric oxide synthase
- Hyperprolactinaemia (anterior pituitary tumour) – excessive prolactin impacts sexual function
Other causes of erectile dysfunction
- Iatrogenic - antidepressants, antihypertensives
* Recreational drugs - cannabis, opioids, alcohol
