Chapter 6 Flashcards
Alveoli
Milk producing components of the breast
Apoptosis
Death of cells that occurs as a normal and controlled part of an organisms growth or development
Areola
Circular, dark pigmented area that surrounds the nipple
Cooper’s ligaments
Connected tissue in the breast that helps maintain structural integrity. Name for Ashley Cooper who was first to describe them in 1840
Feedback inhibition of lactation
Small active way protein that is synthesize by the lactocites and accumulates in the Aveolar lumen
Galactopoiesis
Maintenance of milk production
Involution
Removal of milk producing cells after weaning by apoptosis
Lactocytes
Specialized epithelial cells that line the interior of the aveolus
Lactogenesis
Process of cellular changes in Glanger tissue in the breast whereby memory epithelia cells are converted from a nonsecretory state (milk producing) to a secretory state (milk producing)
Lactogenesis I
Differentiation of alveolar epithelial cells into lactocytes that secrete colostrum
Lactogenesis II
Onset of copious milk production that begins 32 to 96 hours after birth
Montgomery glands
Sebaceous glands in the areola surrounding the nipple that make oily secretions to keep the areola and the nipple lubricated and protected
Myoepithelial cells
Sells that encase the aveloi and contract in response to oxytocin to eject milk into ductles
Parenchyma
Functional tissue of an organ is distinguished from the connective and supporting tissue
Poland syndrome
Unilateral hyperplasia of the breast combined with hyperplasia of the thorax and pectoral muscles
Prolactin receptor sites
Sites in the lattice sites that allow prolactin to be absorbed from the blood and enter into the alveoli to stimulate milk production
Sheehan syndrome
A pituitary infarct caused by severe postpartum hemorrhage
Tail of Spence
Mammory glandular tissue the projects into the axillary region
Breast development facts
Only organ that is not fully developed at birth
Capable of a full lactation from about 16 weeks of pregnancy onward
Under endocrine or hormonal control before delivery of the placenta. Changes to autocrine or local control during lactogenesis II
Breast development during embryonic and neonatal stages
Weeks 3 to 4 a primitive milk streak forms and runs bilaterally from the Axilla to the groin
Weeks 4 to 5 milk stream becomes a memory milk ridge or Galactic band. Pairedbreast develop from this line of glandular tissue
Week 7 to 8 thickening an inward growth into the chest wall continues
Weeks 12 to 16 specialize cells differentiate into smooth muscle of nipples and areola
Weeks 15 to 25 shallow epithelia depressions or mammary pits begin to form which represent future secretary of the alveoli
After 32 weeks a lumen or canal forms in each part of the branching system
Near-term 15 to 25 memory ducks form the fetal memory gland
Neonate galactorrhea also called witches milk begins which is the secretion of colostral like fluid from neonatal memory tissue coming from maternal hormones
Breast development continues through puberty
Breast growth keep pace with general physical growth
Growth of the breast parenchyma or functional parts of the breast produces ducts, lobes, alveoli, and surrounding fat pads
Onset of menses at age 10 to 12 continues breast development. Primary and secondary ducts grow and divide. Terminal endbuds form which later become alveoli. Proliferation and active growth of ductal tissue takes place during each menstrual cycle and continues to about age 35 years
Complete development of memory function occurs only in pregnancy. Breast size increases, skin appears thinner, and veins become more prominent. Areola diameter increases, Montgomery glands enlarge, and nipple pigment darkened.
Breast anatomy - exterior breast
Exterior breast is located in the superficial fascia between the second rib and the six intercostal space
Mammary glandular tissue the projection to the axillary region is called tale of Spence. It connects to the duct system. Potential area can be affected by mastitis
Skin surface contains the nipple, Ariola, and Montgomery glance. Size is not related to functional capacity. Fat composition of the breast gives it its size and shape
Nipple areolar complex
Target for the newborn to latch and feed.
Conical elevation located slightly below the center of the areola
Average diameter of a nipple is 1.6 cm, the average length is 0.7 cm.
Smooth muscle fibers function to close off milk.
Nipple is densely innervated with sensory nerve endings.
Longitudinal inner muscles and outer circular and radio muscles make nipple erect when contracted
Nipple becomes smaller, firmer, and more prominent to help the infant latch.
Areola is a circular, dark pigmented area that surrounds the nipple
The average diameter is 6.4 cm.
Constructed a smooth muscle and collagenous, elastic, connected tissue fibers in a radio and circular arrangement.
Increased in melanin deposits during pregnancy causes darkening to occur which is usually a company by enlargement
Montgomery tubercles are located around the areola. They contain ductal openings of sebaceous and lactiferous glands and sweat glands. They secrete a substance that lubricates and protects the nipples. Secretions produce a scent to help the infant locate the nipple.
Parenchyma
Functional parts of the breast.
Alveoli are the milk producing units in the breast
Lactocyte which are specialized epithelial cells line the interior of the alveol, absorb nutrients, immunoglobulin, and hormones from the bloodstream to compose milk
Prolactin receptor sites in the lactocytes allow prolactin to be absorbed from the blood and enter the alveoli to stimulate milk production
Myoepithelial cells encase the alveoli and contract in response to oxytocin to eject milk into ductules
Lobes are clusters of lobules that are filled with alveoli.
Breast contains 15 to 25 lobes the carry milk through the ductles from the alveoli to the nipple
Ducts branch very close to the nipple. Widen temporarily in response to milk ejection and then narrow when the duct is drained.
Milk not removed flows backward up the collecting ducks
Lactiferous ducts lead to openings in the nipple. Each nipple has 4 to 18 openings, there is an average of nine openings
Stroma supporting tissue of the breast include connective tissue, fat tissue, blood vessels, nerves, and lymphatics
Cooper’s ligaments run vertically through the breast and attach the deep layer of subcutaneous tissue to the dermis layer of the skin
Diagrams on page 86 and 87
Examine these figures and memorize
Breast is highly vascular
Internal mammary artery supply 60% of the blood to the breast. The lateral thoracic artery supplies 30% of the blood in the breast.
Blood vessels within the breast enlarge with an increase in progesterone
Surges of estrogen stimulate duct growth
Searches of progesterone cause glandular tissue to expand
Lymphatic system
Collects Excess fluid from tissue spaces, bacteria, and cast off sale parts. Drains mainly to the axillary lymph nodes.
Breast innervation - fourth intercostal nerve
Derives mainly from branches of the fourth intercostal nerve which is the primary nerve that affects lactation due to its importance in the endocrine loop that involves oxytocin and prolactin.
Supplies greatest sensation to areola, 4 oclock postion on left breast and at 8 oclock on righ
More superficial as reaches areola, divides into 5 branches,
Trauma to this nerve might result in loss of of senasation, aberrant sensory or autonomic nerve in nipple-areola complex can arrect milk ejection reflex and secretion of prolactin and oxytocin. Breast augmentation or reduction surgery may sever or cause nerve trauma.
Breast size, shape, color and placement on chest wall variation
Weight increases, nonpregnant woman weighs 200 g, pregnancy near term, 400-600 g and will lactation can be 600 to 800 g
Left breast is often larger than right breast
Test self on Table 6-1, breast types - page 90
Polythelia
Presence of extra nipples.
Accessory or supernumerary nipple develops along milk line between Axilla and the groin. Often prominent during pregnancy and lactation. May be associated with renal or other organ system anomalies - should be investigated
Polymastia
Presence of extra breast tissue. Accessory glandular tissue can lactate and undergo malignant changes
Hyperthelia
Nipple without accompanying mammory tissue
Hypertrophy
An abnormally large breast
Hypomastia
And abnormally small breast
Hyperplasia
Over development of the breast, hyperplastic breast
Hypoplasia
Insufficient glandular tissue.
Hyperplasia result in a tubular or tuberous shape because of the lack of glandular tissue. Breast may have large aerolas
Breast are frequently asymmetric and widely spaced.
Condition may present an increase risk for insufficient milk production.
Unilateral hyperplasia of the breast combined with hyperplasia of the thorax and pectoral muscles is known as Poland syndrome
Nipple restricted protractility
Nipple should evert and become protractile when compressed or stimulated. Incidence of poor protactility prima women ranges from 10 to 35%.
Protractility improves during pregnancy.
Effect on latch is minimal when breast baby has a large mouth full of breast tissue.
Nipple inversion
Occurs in about 3% of women and is usually bilateral.
Truly everted nipple remains everted when compressed or stimulated which is also called the pinch test.
Pseudo everted nipple appears everted but everts when compressed or stimulated. Short shanked nipple appears everted but retracts with compressed or stimulated
Bulbous nipple
Large nipple that may be difficult for a baby to grasp and achieve a successful latch
Dimpled nipple
Increases the risk for maceration because the nipple is enveloped by the areola
Bifurcated nipple
A single nipple that is separated by a split into two or more sections
Double or multiple nipples close together
Skin tag
Small benign skin growth that may appear on the breast or nipple. Skin tags are more prevalent during pregnancy
Nipple piercings studs and bars
Nipple piercings generally do not affect milk production.
Can contribute to maternal discomfort, poor latch, altered milk flow during feeding, and increase milk leakage.
Wearing jewelry on nipple during feeding could put infant at risk of aspiration and injuries of the gums, soft palate and tongue.
Nipple jewelry should be removed when breast-feeding
Mamogenesis. Prenatal breast development
Final preparation for Lactation occurs during pregnancy.
First trimester memory epithelial cells proliferate, ductile sprouting and branching begin. Ducts proliferate into the fatty pad and the ductals and buds differentiate into alveoli. Increase in mamory blood flow.
New capillaries around the lobules grow.
Last trimester secretory cells fill with fat droplets and the alveoli are distended with colostrum
Memory cells become more confident to secrete milk proteins at mid pregnancy. Kept in check by high circulating levels of steroids, particularly progesterone
Milk products that are secreted during pregnancy find their way back into plasma by the leaky junction’s which are the spaces between the mammoryalveolar cells
Hormonal influences prenatal breast changes
Lactogenesis is hormonal driven by the endocrine control system.
Human placental lactogen, prolactin, and human chorionic gonadotrophin accelerate growth.
A form of estrogen called 17 beta estradiol required for memory growth and epithelial proliferation during pregnancy.
Glucocorticoids enhance formation of the lobules during pregnancy.
Estrogen increases during pregnancy and stimulates ductal sprouting.
Prolactin is necessary for complete growth of the gland. Secreted by the anterior pituitary gland. Stimulates prolactin receptor sites for initiation of milk secretion on alveolar cells surfaces.
Prolactin levels rise throughout pregnancy.
Prolactin is prevented from exerting influence on milk during pregnancy by high levels of circulating progesterone.
Prolactin inhibiting factor (PIF) is secreted by the hypothalamus to negatively control prolactin. Dopamine is an example of PIF. Does in respose to stress, fatigue or depression.
Progesterone increases during pregnancy. Stimulates lobularaveolar growth while suppressing secretary activity. Sensitizes memory cells to the effects of insulin and growth factors. May be involved in the final preparation of glandular tissue for copious milk production
Lactogenesis I or Secretory Differentiation
Lactogenesis I is the beginning of secretory cellular activity and milk production.
Occurs at about 16 week prenatal.
Stage at which breast is first capable of synthesizing unique milk components.
Thyroid hormones increase responsiveness of mammary cells to prolactin and can improve lactation performance.
Main hormones necessary for secretory differentiation include estrogen progesterone, placental lactogen, and prolactin.
Supportive metabolic hormones include glucocorticoids including cortisol, insulin, thyroid-parathyroid hormone, and growth hormone.
Antepartum secretion, or colostrum, shows a gradually increasing presence of lactose, casein, and alpha-lactaalbumin
Colostrum has an increase in concentrations of two immuno protective proteins, scretory immunoglobulin A and lactoferrin all occur after delivery
Lactogenesis II or Secretory Activation
Lactogenesis II is the onset of copious milk.
Occurs between 30 and 72 hours following delivery of placenta.
Women feel breast fullness around 50 to 72 hours after birth.
Initially under endocrine control now under autocrine or local control.
Maintain by stimulation of the nipple and regular milk removal.
Placenta expulsion precipitate abrupt decline in levels of human placental lactogen, estrogen, and progesterone.
Progesterone is a prolactin inhibitor. Dropping per lap and progesterone is beginning of lactogenesis capital I I.
Changes in milk composition occur including a sharp rise in citrate and alpha-lactoalbumin.
Risk factors for delayed onset of lactation include
Fluid volume overload in labor.
C-section or stressful vaginal birth with long stage to labor.
Maternal health status including type one diabetes mellitus, obesity, history of reduction mammaplasty, hypo plasia, polycystic ovarian syndrome, infertility, and thyroid dysfunction.
Any maternal illness interfering with early milk removal including Sheehan syndrome, a severe postpartum hemorrhage.
Paridy promas are at increased risk.
Retained placental fragments
Steps after placenta delivery - facts about prolactin
Prolactin levels increase sharply after placenta leaves and rise and fall with frequency, intensit and duration of nipple stimulation
Falls to 50% in 1st week postpartum
Found in milk up to 40 weeks postpartum
Circadian rhythm - higher at nigh, surging when baby suckling or pumpping
Frequent feeding in early lactation stimulates development of prolactin receptor sites - SITES MAY CONTROL MILK SUPPLY NOT PROLACTIN LEVELS
Milk comes in sooner if breastfed before possibly due to more receptor cells
Drops to prepreg level in 2 weeks if not breastfeeding
Lactogenesis III or Galactopoiesis
Later than 9 days after bbirth to beginning of involution
Maintenance phase of lactation
Depends on autocrine or local contol
Feedback Inhibition of Lactation (FIL)
Small active whey protein synthesized by lactocytes and accumlates in alveolar lumen
Moderate milk synthesis locally, based on fullness of breast
Rate of milk synthesis slows when milk accumulates in the breast because more FIL is present
Rate of milk synthesis speeds up when milk is removed and less FIL is preset
NOT JUST FIL - also B1-integrin, a-Lactalbumin, transorming growth factor B, insulin like growth factor finding protein 5 and lactoferrin
Prolactin receptor theory - local mechanism involving prolactin receptors in basement membrane of the alveoli - milk accumulates and lactocyte shape distorted and prolactin annot bind - inhibited by alveolar distension which down regulates milk syntesis.
Involution: Apoptosis of Secretor Cells
Involution occurs when milk producing system in breast is no longer being used.
Results in secretory epithelial apoptosis or cell death.
Complete involution happens about 40 days after cessation of breast-feeding.
Depends on the type of weaning if abrupt or gradual.
Anecdotally may take longer for milk production to stop longer breastfeedingg.
Milk production and synthesis
Affected by volume of milk removed from breast at feeding or during expression.
Elegant sample of supply and demand.
Increase sensitivity of prolactin receptors in muliparous women.
Breast hyperplasia, obesity, disease, and metabolism rate can affect milk production. Medication specifically prolactin inhibiting factors (also known as dopamine agonist) such as bromocriptine and ergotamine can inhibit prolactin secretion.
Milk storage
Milk stored in the alveoli and small ducts adjacent to cells that secrete milk.
Storage compresses and flattens the cells.
Storage capacity varies. Storage capacity of a breast increases with breast size.
Cells that line both the alveoli and the small ductiles appear to be capable of secreting milk
Rate of milk synthesis
Degree to which milk is removed signal the amount of milk to be made for next feeding. Degree Of fullness in a breast and rate of short-term synthesis are inversely related. Wide variability in rate of milk synthesis from 17 to 33 ML per hour.
Local control regulates short-term milk synthesis.
Controlled independently in each breath.
Small breasts are capable of secreting as much milk over a 24 hour period as large breasts.
Milk synthesis in the Latus site
Secretory epithelial cell. Synthesis occurs after the uptake of substrate from the blood that are necessary for milk production.
Five pathways involved in milk synthesis
Pathway one: protein secretion with the most important protein synthesized by the memory cell being casein, lactoferrin, alpha lactalbumin, and lysozyme
Pathway II: lactose secretion.
Pathway III: milk fat synthesis.
Pathway IV: monovalent ion secretion into milk includes sodium, potassium, and chloride.
Pathway V: plasma proteins secretion were plasma immunoglobulin-a bind to the mammory alveolar cells and is released into the milk - involved in disease protection.
Milk Ejection Reflex or Letdown
Results from stimulation of sensory neurons and the release of oxytocin.
Stimulation by the infant to sensory neurons in the areola initiates a neuroendocrine arc to the posterior pituitary to release oxytocin into the bloodstream.
Impulses from the cerebral cortex, ears, and eyes can also elicit the release of oxytocin. May feel increased pressure or tingling within the breast or shooting pains or nothing. First few days after birth breast-feeding will be accompanied by uterine cramping. Especially felt by muliparous women.
Oxytocin release may also elicit increase thirst, a warmer flush feeling, increased heat from the breast, or a feeling of sleepiness or calmness.
Signs include milk dripping from the breast and when the baby begins audibly swallowing milk.
Milk ejection reflex serves to increase the intraductal mammory pressure and to maintain it at levels sufficient to overcome resistance to outflow of milk.
Amount of milk transferred by infant is correlated to the number of milk ejection per feeding and independent of amount of time spent at the breast.
Oxytocin role
Causes a contraction of the myoepithelial cells surrounding the alveoli forcing milk into the collecting ducts of the breast.
Has a calming analgesic effect. Lowers maternal blood pressure. Decreases cortisol levels, decreases anxiety, and aggressive behavior.
Permeates the areas of the brain associated with parenting and body behaviors.
Nipple stimulation causes oxytocin released in brief 3 to 4 second pulse burst into the bloodstream every 5 to 15 minutes.
Can also see oxytocin bursts from stimuli including mechanical stimulation from breast pump.
Causes shortening of the ducts without constricting them thus increasing milk pressure. Oxytocin secretion can be inhibited by pain, fatigue, anxiety, or stress.
Alcohol and labor practices using synthetic oxytocin has been found to interfere with the release of endogenous oxytocin.
Key points from chapter 6
Complete development of mammary function occurs only in pregnancy.
Alveoli are the basic components of mature mammory gland.
Within lactocytes absorb nutrients, immunoglobulins, and hormones from the blood to compose milk.
Cluster alveoli form lobules which form lobes. Lobes clustered together and milk flows through ductiles which converge into lactiferous ducts which lead into openings in the nipple.
Prolactin stimulates milk production
oxytocin release triggers milk ejection or let down
17 beta-estradiol is required for mammory growth and epithelial proliferation during pregnancy.
Elevated levels of progesterone during pregnancy prevent prolactin from influencing milk production.
Lactogenesis I I is caused by abrupt drop in progesterone.
Rate of nerve synthesis slows when milk accumulates in the breast because more FIL is present in the milk.
Alpha- lactalbumin
Major whey proteins and human milk. Involved in lactose synthesis
Amino acids
Building blocks of proteins
Carbohydrate
Macro nutrient composed of one or more sugars
Essential nutrients composed of carbon, hydrogen, and oxygen. Lactose known as milk sugar is primary carbohydrate and human milk and contributes to approximately 98% of carbohydrates in human milk.
Lactose is made from glucose in the blood.
Lactose is a disaccharide.
Lactose is synthesized by the enzyme lactase synthase in the Golgi secretary vesicle system of the lactocyte.
Human milk has one of the highest concentrations of lactose among species. Lactose averages about 7% in human milk but only 4 to 5% in milk from cows.
Lactose digestion occurs at the brush border of the intestine by the enzyme lactase.
Casein
Type of protein found both in solution and suspended in micelles in milk
Cholesterol
Member of the group of Lipids known as Darrell’s. Produced by body and present in foods. Including human milk.
Disaccharides
Pairs of single sugars linked together
Enzymes
Proteins that serve as catalyst in biochemical reactions. Facilitate reactions while maintaining their structure and concentration
Fatty acid
Type of liquid made of a hydrocarbon chain with a carboxyl group on one end and a methyl group on the other end. Main component of triglycerides and phospholipids
Growth factors
Proteins responsible for regulation of a variety of cellular processes including cellular growth and differentiation
Hormones
Chemicals secreted by glands within body that serve as messengers, acting on other organs to regulate or maintain conditions within the body
Immunoglobulin
Proteins that function is antibodies. Secretory immunoglobulin A (SigA) is an important immunoglobulin in human milk.
Lactoferrin
A whey protein in human milk they can modify immune system, facilitate iron absorption, and regulate bone growth
Lactoferrin serves as an anti-microbial, a modulator of immune function, and a facilitator of nutrient utilization.
Has a high affinity for iron and is able to suppress E. coli in the intestine.
May modify immune function through a lactoferrin receptor in the intestine.
Facilitates iron absorption, specifically by transporting the iron across the surface of cell membranes and to stimulate intestinal epithelial cell growth and differentiation. Important regulator a bone growth and has protective effects on osteoblasts and inhibitory effects on osteoclasts.
Because of high affinity for iron lactoferrin prevents pathogens from utilizing iron for growth and survival.
Lipids
Organic molecules that are insoluble in water. Include fatty acids, oils, waxes, sterols, phospholipids, and triglycerides.
Composed of hydrogen and carbon atom changes. Variations in the chains determine function of lipid.
Fatty acids are present in greatest concentration.
Fatty acids can be cleared from the glycerol backbone by the enzyme lipase at which point they are known as free fatty acids.
Triglycerides are 98% of total lipids in human milk.
Phospholipids comprise 0.8%.
Cholesterol comprises 0.5%.
Lipids are not fat soluble in water and help transport fat soluble vitamins including A, D, E, and K.
Triglycerides are 98% of total lipids in human milk. Human milk lipids provide the greatest source of calories in human milk. Also provide essential fat soluble vitamins and essential fatty acids.
Lipids are present in milk between 3 and 5% and exist as an emulsion or a dispersion of tiny droplets within the aqueous phase of milk.
Lipids in human milk provide 40 to 50% of the infants caloric requirements and are important components of neural and retinal development
Average fat content of human milk is about 3.8 to 3.9 g per DL
breast-feeding for six months or longer with milk of high fat content is associated with higher developmental scores at one year of age.
Hypothesize that the supply of fat contributes energy affects brain composition or both. Alveolar cells within the mammory gland form milk fat globules.
Fat globules are surrounded by the milk fat globules membrane ( MFGM)
MFGM contains mucopolysaccharides, cholesterol, and enzymes.
Lipids are most variable portion of human milk.
Increase both during a feeding and as the child gets older.
LCPUFA (long chain polyunsaturated fatty acids) are responsible for infant needs and play a role in cognitive development, vision and nerve myelination.
Amount and type of LCPUFA can vary by maternal dietary intake.
Fat content in human milk increases from 2.0 g per DL in colostrum to 4.9 g per DL in mature milk.
Fat content changes during feedings and throughout the day.
Most fat and human milk is in form of triglycerides which must be broken down by enzymes called lipases before infant can absorb them.
LCPUFAs have important effects on memory function photo receptor differentiation activation of rotor spin, enzyme activity, ion channel function, and the levels metabolism of Neuro transmitters.
Clinical studies term and preterm infants comparing breast-feeding formula fed infant show enhance development visual function, improve retina function and improve visual acuity in breast-fed infants due to LCPUFS.
During third trimester neonate accumulates about 40 to 60 mg of poly unsaturated fatty acids per kilogram of body weight per day. LCPUFA intake important during lactation because approximately 30% of human milk fatty acids are derived from the maternal diet.
Nonesterified fatty acids (NEFA) also called free fatty acid produced during storage of human milk have been shown to have potent cytolytic effects or cell destroy effects on normal human blood cells and intestinal parasites as well as gram-positive bacteria and yeast.
In human milk with the most lipoprotein lipase antiviral activity was the highest.
Lipid content is lower in milk first ejected at beginning of feeding. Fat content was eight times higher and cell levels were 12 times higher at the end of a feeding compared to levels before the feeding.
Long chain poly unsaturated fatty asses (LCPUFAS)
Fatty acids including linoleic acid, alpha -linoleic acid,docosahexanoic acid, , and arachidonic acid.
Lysozyme
An ezyme found in body secretions, including human milk, saliva, tears, nasal mucus, and pancreatic juice. Capable of breaking down cell walls bacteria
Represents one to 4% of weight protein nitrogen.
Capable of breaking down outer cell wall of gram-positive bacteria and some gram-negative bacteria.
Secreted into human milk with concentrations between two and 6 mg per DL. Concentration relatively constant over course of lactation.
May work together with the lactoferrin to kill gram-positive and gram-negative bacteria. Lactoferrin binds bacterial Lipo polysaccharide and removes it from the outer cell membrane of the bacteria , lysozyme then penetrates outer bacterial membrane and degrades and kills the bacteria.
Macronutrients
Includes water and energy providing nutrients such as proteins, lipids and carbohydrates
Proteins provide 4 calories per gram.
Carbohydrates provide 4 calories per gram.
Lipids provide 9 cal per gram.
The energy provided by human milk is 60 to 77 kcal per 100 ML (18 to 23 kcal per ounce)
Monosaccharides
Simple sugar
Phospholipids
Similar to triglycerides but in place of one of the fatty acids have a phosphorus containing acid. Present in cell membranes
Proteins
Compounds composed of carbon, hydrogen, oxygen and nitrogen that are arranged in strands of amino acids
Human milk contains more than 400 different proteins that provide calories and bio activity including immune factors, growth factors, hormones and enzymes.
Nutritional value of proteins caloric content, used for growth and development, and immunological components.
Human milk provides all essential amino acids needed for infant growth and development.
Amount of protein in milk decreases from birth over the first 4 to 6 weeks of life.
Whey to casein ratio in early Lactation is about an 80:20 and it’s about 50:50 in late lactation.
Protein concentration of human milk is 14 to 16 g/L during early lactation, 8 to 10 g/L at 3 to 4 months, and 7 to 8 g at six months and later.
Human milk contains antimicrobial and immuno stimulatory proteins including SIGA and others.
Mucins are milk-fat globular membrane proteins that surround the lipid globulus in milk.
Casein is mostly found in micelles in solution in the milk.
Casein proteins bind calcium which gives milk it’s cloudy white color and form soft curds in the stomach.
Casein concentrations are low in human milk compared to other species.
Main subunit of human milk casein is beta-casein.
KApppa-casein may preevend adhesion of pylori to infant’s gastic mucosa.
Colostrum has a high protein concentration consisting primarily of way proteins to the low sentences of Casein during the first days of lactation.
SIGA coats mucosal surfaces and got to block pathogens, prevent inflammation and stimulate infants production of SIGA.
Triglycerides
Main form of liquid in human diet and human body. Three fatty acids are bound to a glycerol molecule backbone, also called triglycerols.
Water
Majority of human milk or 87.5% is made of water.
Human milk provides all water infant needs for first six months of life.
Infants should not be given additional water even in hot dry climates.
SIGA
Levels vary during lactation, high G a secretions reach 4 g per day at which point its concentration is higher in milk than any other bodily fluid. Drops to about 1 g per day at 10 days postpartum. SIGA is able to remain an active form in G.I. tract because it is resistant to degradation from protease is. SIGA antibodies fight against bacterial proteases.
SiGA antibodies neutralize bacterial toxins and prevent binding of intestinal bacterial pathogens to epithelial cells.
Unlike other immunoglobulins including IgG and I GM,
IGA does not activate an inflamed inflammatory pathway and may help prevent inflammation by competing with IgG and I GM antibodies.
Alpha-lactoalbumin
Acts as part of an enzyme called lactose synthese which aids in the synthesis of lactose within the mammry gland.
Provides calories to the infant and is a source of amino acids needed for protein synthesis.
Also shown to inhibit the growth of cancer and non-cancer cell lines.
Other immunoglobulins
Research demonstrates that antibodies transferred from the breast-feeding parent to the infant through the milk.
Provide protection to the infants immune immature system antibodies that are present include immunoglobulins A, G, M, D, and E with SIGA being the most abundant.
Protease is in human milk are enzymes that break down proteins.
Contribute to the high digestibility of milk for the infant.
Particularly important during neonatal period when infant is adjusting to oral feedings. Infants G.I. track has a higher pH than adults therefore proteins are not denatured as easily in the infants stomach.
Protease in human milk aid in the digestion of proteins for the infant.
Human Milk Oligosaccharides (HMOs)
Human milk contains more than 200 oligosaccharides called human milk oligosaccharides (HMO) that are carbohydrates not digested by the infant.
Serve as a prebiotic providing energy to the beneficial bacteria inside the infants intestine.
Beneficial bacteria can use energy from HMOs to help protect infant.
Protects infant from disease causing bacteria that cause diarrhea and respiratory infections.
These beneficial bacteria use HMO‘s for energy they have a growth advantage over other bacteria that are able to use HMO‘s because they lack the enzyme system required for utilization.
Most of ingested HMOs reach small and large intestines because they can resist degradation.
HMOs act as a decoy receptor that prevent the attachment of pathogens to the epithelial cells surface.
When pathogens bind to the HMO rather than the epithelial cells surface the pathogens are excreted in feces.
HMOs act as a decoy receptor and bind to pathogens then excreted.
Pathogens that bind to HMOs include noravirus, rotavirus and E. coli.
HMOs have been shown to protect the infant by acting directly as an antimicrobial, protecting from viruses, bacteria, protozoan, and fungi and by indirectly modifying the cellular response of the infant’s epithelial and immune cells.
Micro nutrients - need for supplementation?
Micro nutrient deficiencies in human milk are not common.
Some vitamins and minerals are dependent on maternal nutritional status and diet.
Due to variability of maternal diet taking a multivitamin during pregnancy and lactation is recommended.
The nutritional needs of infants can be met by human milk for the first six months but after that will need zinc and iron added.
Complementary foods rich in iron and zinc should begin at six months.
Human milk contains an adequate amount of vitamins except for vitamins D and K.
Vitamin D depends on diet and maternal sun exposure.
Recommendations regarding vitamin D supplementation vary.
American Academy of pediatrics recommends breast-fed an infant be given oral supplements of vitamin D.
WHO does not currently recommend routine vitamin D supplementation except for those who are very low birthweight.
Supplementing the breast-feeding parent with high levels of vitamin D supplies infant with adequate vitamin D via the milk.
Vitamin K is low in human milk and plays a role in blood coagulation, cells cycle regulation, cell adhesion, and bone metabolism. The WHO and AAP recommend a single injection of vitamin K at birth for all infants.
Infants for breast-feeding parents who are vegan or who have had gastric bypass surgery may have an increase risk for vitamin B 12 deficiency.
Mechanisms of Milk Secretion - 5 Pathways
- Golgi and secretory vesicle
- Unique lipid secretion pathway
- Eccrine secreion of water and minerals of water and minerals
- Transcytosis
- Paracellular pathway transfer nutrients not through epithelial cells but between
Main Macronutrient
- Carbohydrates (lactose, oligosaccharides)
2. Protein
Protein Secretion in Mammary Cells
Uses a pathway to most excretory or secretory epithelial cells
Genetic information coding protein sequency from DNA to RNA
MRNA links to ribosomes on rough endoplasmic reticulum membranes (rER)
mRNA info translated to protein sequence and goes across rER membrane
Protein continue to form by folding and bud off as vesicles of ER too fuse with golgi apparatus
Protein processing happens in golgi apparatus - bud off as secretoty vessicles then fuse with the apical membrane. Contents are released into the milk space while the membrane component remains part of the cell plasma membrane.
Lactose synthesis occurs primarily in Golgi and secretory vesicles
Two specific proteins called alpha-lactalbumin and galactosyltransferase work together to make lactose synthase enzyme complex.
In mammory cells cytosol, a molecule of glucose combines with a molecule kill of uridine triphosphate to make uridine diphosphoglucose (UDP glucose)
UDP glucose goes to UDP galactose.
This molecule and a molecule of glucose are transported by diffusion across the Golgi membrane to interior of the vesicles where they are linked together by the lactose synthase complex to form lactose.
Related enzymes add additional monosaccharide units to create the milk oligosaccharides.
Milk fat is made by the movement of three fatty acids into the smooth endoplasmic reticulum.
Three fatty acids are linked to a molecule of glycerol to create a triglyceride.
Triglycerides diffuse out of the ER and stay in the cytoplasm as liquid droplets.
Fatty acids for milk fat could come from three sources: fatty acids stored in other adipose tissues of the body, fatty acids absorb directly from the diet, and fatty acids synthesize within the mammory cell from glucose or other substrates.
Eccrine Seretion - used to transport proteins or simple diffusion through apical cell membrate - create an equilibrium between interior and exterior of cell
Eccrine secretion responsible for movement of water into milk.
Electrolytes like sodium potassium chloride and other small molecules and minor milk constituents also enter milk through this pathway.
As a major constituent of milk, water movement that follows lactose and electrolytes largely controls the volume of milk produced.
Transcytosis is internalization of substances in extraellual fluid, bind to basolateral membrane receptors and taken up by endocytotic pathway
Resulting endosomes move directly through the cytoplasm and release the contents into the milk through an exocytosis mechanism.
This pathway is responsible for movement of antibodies such as IGA from their site of secretion from plasma cells outside the alveolar structure.
Milk is separated from blood and from the extra cellular fluid and limp space by the layers of epithelial cells
There is a tight junction normally between memory epithelial cells but the cells become leaky during pregnancy, during weaning and in cases of mastitis.
Colostrum
First milk produced by the breast.
Secretion begins during pregnancy.
High density, thick yellow milk the coats infants got, blocking pathogens and promoting gut closure.
High in SIGA, white cells, growth factors and lactoferrin.
Compared to mature milk colostrum lower in lactose, potassium, and calcium in higher in sodium, chloride, and magnesium.
Transition varies but typically begins 2 to 4 days with complete transmission by 4 to 6 weeks.
Pasteurized donor milk
Recommended for preterm infants when parental milk is not available.
Heat treatment as part of pasteurization reduces bioactive components including SIGA and lysozyme thus reducing some of the health benefits.
Still improves infant health outcomes compared to formula in hospital and later
Infant formula
Standard composition and monitored by US FDA and internationally by Codex ALIMENTARIUS of the united nations food and agricultural organization.
Standards published in 1981 and revised based on new data in 2007 and amended in 2016.
AAP recommends infants not breast-fed or partially breast-fed receive iron fortified formula based on cows milk for first 12 months of life.
Codex Alimentarius standards for infant formula provide minimum concentrations of essential nutrients and in some cases maximum concentrations guidance upper levels (GUL) if scientific evidence for adverse effects of high levels not available.
Energy content equals 60 to 70 KCAL per 100 ML based on intake of 750 ML per day. Protein content range from 1.8 to 3.0 g per 100 kg calories
Proteins source should be product based on milk of cows or other animals.
Minimum protein concentration for soy – protein– based infant formula is 2.25 g per 100 kcal
Lipids in formula
Must be present at a concentration of 4.4 to 6.0 g per 100 kcal
Hydrogenated fats and oils are not allowed.
Total phospholipids should be 300 mg per 100 kcal or less. Lots of details on page 111 can review
Total carbohydrate in infant formula
Should be between nine and 14 g per 100 kcal
Use only lactose or glucose polymers.
Sucrose and fructose are prohibited because unrecognized hereditary fructose intolerance could be life-threatening.
Vitamins and minerals in formula
Minimum and sometimes maximum levels provided in Codex alimentarium.
Generally recognized as safe (GRAS)
Including an infant formula such as thickeners, emulsifiers antioxidants and oxygen displacer’s
Proteins and commercially available formula from nonhuman sources commonly cows milk
Contain 60 to 70 kcal of energy per 100 ML compared to human milk of 50 to 90 kg per 100 ML. Variations to the fat content changing from fore to hindmilk.
Formula is harder for infants to digest in part because of the higher levels of cassein found in cows milk.
Soy based formulas are available when cannot tolerate cows milk protein
Infants with milk protein allergy are likely to also have soy protein allergy so better to use extensively hydrolyzed protein formulas.
Special formulas
Include hypoallergenic formula, lactose free formula, and formulas that meet the need of infants with metabolic errors or special medical conditions.
FDA requires any changes to composition of infant formula be tested in a clinical trial Growth standards for these clinical trials referred to the 1979 National Center for health statistics.
Key points of the bio chemistry of human milk
Human milk and infant formula contain macronutrients and micronutrients to provide nourishment to the human body for growth and maintenance of body tissues.
Human milk contains components that are not found in formula.
Each protein, carbohydrate, and lipid found in human milk provides energy to the human body.
In addition these macronutrients have other functions that support bodily processes, including immune protection and regulation of growth metabolism.
Chapter 8 nutrition during lactation objectives
Anorexia nervosa
Eating disorder characterized by excessive calorie restriction and exercise, abnormal weight loss, and underweight
Bariatric surgery
Performed on obese or morbidly obese individuals to assist in weight loss
Bulimia nervosa
Binge eating followed by excessive exercise, purging and vomiting food, or utilizing laxatives to quickly eliminated from the body to maintain or lose weight
Lactogenic foods
Food and herbs traditionally used in folk medicine to help increase the quantity of human milk produced
Latto – OVO vegetarian
Does not eat meat but does consume dairy products and eggs
OVO vegetarian
Does not eat meat or dairy products but does consume eggs
Pescatarian
Choose Fish as primary source of meat and diet and generally consumes dairy products and eggs
Tandem breastfeedingg
Breastfeeding more than one child at a time typically an infant and toddler
Vegan
Does not consume meat, dairy products, eggs, or animal byproducts.
General nutrition recommendations for lactation
Encourage parents to reach a healthy BMI and seek assessment of nutrient status especially iron, folate, and folic acid.
Precaution should be taken to reduce risk of foodborne illness.
Meals should be planned with an emphasis on non-starchy vegetables and fruit as the primary component.
1/4 of a meal should be protein. 1/4 should be grains or starchy vegetable.
Protein needs during pregnancy and Lactation are nearly identical.
Need 25 additional grams of protein per day.
71 g of protein per day for a parent with a healthy BMI.
Carbohydrate recommendation is 210 g per day or 45 to 65% of daily calorie intake. Refined carbohydrates should be limited.
At a post (fat) tissue place of idol roll in bodies ability to store energy, facilitate hormone production, help protein functions, Norris vital organs, and synthesize and store vitamins
Essential fatty acids are critical to health and must be obtained through the diet.
Omega – three fatty acids help control blood clotting and build cell membranes in the brain.
1.3 g is adequate for omega – 3 fatty acids.
Increased amounts of omega-3 fatty acids are needed during pregnancy and lactation. Fish is an excellent source. Suggest 2 to 3 servings of fish per week. Avoid high levels of mercury including king mackerel, marlin, orange roughy, shark, swordfish, tilefish and bigeye tuna.
Can supplement with DHA- rich omega – 3fatty acid with fish oil.
Water
Best form of hydration for lactating parents.
Consume to quench thirst. 64 ounces recommended.
Increasing fluids does not increase quantity or quality of human milk.
Juice and juice cocktail should be limited to 2 to 3 ounces per day.
Vegetarian and vegan diet
Healthy and nutritionally adequate for lactating parents.
Need a wide variety of proteins sources and not rely on dairy-based foods for proteins. Vegans need B12
Pescatarian diet
Organic pollutants in seafood can remain in the body for 1 to 5 years so it is recommended to limit consumption.
Intake of fish to 2 to 3 servings per week with low mercury levels.
RDA levels that must be higher for lactating parents
Vitamin A, vitamin C, chromium, copper, and iodine needed in quantities nearly double that of a non-lactating parent.
A, B6, B12, C, D, and K, thiamine, riboflavin, choline, selenium, and iodine are all influenced by parental nutritional status and intake.
Deficiency in any of these micro nutrients could result in decreased amounts in human milk which could result in nutritional deficiency in the infant.
Can be easily done through diet alone.
Vitamin A need 1300 mcg like one third small baked sweet potato
Need 120 mg of vitamin C per day equivalent to one kiwi.
Chromium is 45 mg microgram per day broccoli mushrooms oatmeal prunes and others
Copper is one. 3 mg per day. Whole grains, kale, shiitake mushrooms, sesame seeds etc.
Iodine can be met through iodized salt, fish, kelp or other seaweed
Prenatal vitamins are not appropriate for lactating parents. Can take a multivitamin or mineral supplement it does not exceed the recommended daily intake by more than 20%.
In disaster or refugee settings the WHO and UNICEF recommend a daily micro nutrient supplement for pregnant and lactation parents especially with iron and folic acid for positive birth outcomes in underdeveloped in developing nations.
Vitamin D is a common deficiency in most industrialized countries. Very few foods contain vitamin D. Recommended that lactating parents have vitamin D levels checked. If deficient supplement at a dosage of 50,000 IU once per week for eight weeks or 6000 IU once per day for eight weeks. For obese parents 10,000 IU once per day for eight weeks as needed. Followed by a maintenance dose of 3000 to 6000 IU daily.
If Iprevalence of anemia at least greater than 20% in population recommend that all women of childbearing age are supplemented with 60 mg of elemental iron once per week for three months followed by three months of no supplementation then repeat the cycle
Lactating parent BMI
Under weight: BMI less than 18.5.
Healthy weight: BMI 18.5 to 24.99.
Overweight: BMI 25 to 29.99.
Obese: BMI 30 to 39.99.
Morbidly obese: BMI 40 or greater.
Underweight parents are less likely to initiate breast-feeding than parents who have a healthy BMI.
Underweight is also a predictor of lower breast-feeding initiation rates in adolescence. May show a history of disordered eating parents or poor access to food
Overweight and obesity and milk production
Increases the risk of milk production difficulty. Possibly through inhibition of body‘s response to prolactin or sub optimal insulin action.
Starting pregnancy at a BMI greater than 25 in addition to gaining more than recommended amount of weight can delay lactogenesis II.
Obese parents less likely to initiate breast-feeding.
Pre-pregnancy BMI greater than 30 is significantly associated with late onset of lactogenesis II which leads to increase in supplementation with formula until colostrum transitions to mature milk and an increased rate of breast-feeding discontinuation.
If overweight or obese at start of pregnancy have decreased prolactin levels in response to suckling, compared to women who have a normal BMI.
Obesity raises risk of birth via C-section and other complications
Obesity increases the risk of a macrosomic infant weigh more than 8 lbs. 13 oz. Associated with decreased initiation of breast-feeding and increases the risk of birth complications and NICU admissions.
Obese parents have a higher risk of vitamin and mineral deficiencies including vitamins B6 B12 C, D, E iron zinc phosphorus and folic acid.
Energy needs during lactation
Require approximately 500 additional calories per day.
Supplied from a combination of increase food intake and existing fats stores.
Needs are based on exclusive, on demand Breastfeeding.
1 ounce of human milk has 20 cal.
Exclusively breast-fed infants consume from 19 to 30 ounces of human milk per day. Metabolic cost of breast-feeding is 360 to 500 cal to per day depending on infants daily consumption.
Exercise for pregnant and breast-feeding parents
Improves emotional health, reduces stress, improves bone density, and helps with weight management.
No affect on lactic acid in the milk for mild or moderate exercise.
Very strenuous exercise can increase lactic acid concentration in human milk, however no negative side effects have been reported to the infant, milk production, or quality of human milk
Tandem breastfeeding
Feeding an infant and one or more older siblings most likely requires increased macro and micro nutrient needs. However not well-established.
Should consume at least 500 additional calories per day to meet nutrient needs.
Should be counseled to eat foods rich in omega – 3 fatty acids daily because pregnancy and lactation deplete the body of this nutrient.
Supplementation with 500 mg per day of omega-3 fatty acid is also appropriate.
Special populations - adolescents
Initial assessment and interview with parents should cover any special dietary issues.
If have special dietary condition should be referred to a registered dietitian.
Adolescents who are living above the poverty line in their country tend to consume more fruits vegetables and whole grains.
Adolescent girls tend to skip meals particularly breakfast and consume little to no fruits and vegetables.
Teenage parents should be encouraged to breast-feed and eat a healthy balanced diet
Special populations including type one or type two diabetes and gestational diabetes
Type I diabetes is caused by the pancreas not producing insulin - the parent will need to count carbohydrates and take insulin.
Type two diabetes is an inability of cell receptors for glucose to function properly. Can be controlled with diet or a combination of diet and medication.
Gestational diabetes is similar to type two diabetes.
Emerging research says that diabetes is a risk factor for insufficient milk production and may require additional lactation support in monitorig.
Lack of glucose control in pregnancy results in macrosomic infants and reactive hypoglycemia in infants in the immediate postpartum.
Milk of lactating parents with type two diabetes has been shown to have two times greater insulin than those of non-diabetic parents. Higher insulin levels in human milk are associated with lower lean body mass and increase infant body weight in the first month of life.
See altered fetal growth patterns in diabetic parents lead to a higher rate of shoulder dystocia which increases the risk of emergency C-section and decreases or delays the initiation of breast-feeding.
Gestational diabetes is an independent risk factor for delayed lactogenesis II with or without the presence of obesity
Lactating parents with any form of diabetes should be under the supervision of an endocrinologist and dietitian throughout pregnancy and lactation to ensure a good control blood glucose levels.
Losing weight while breast-feeding
Losing weight at a rate of 1 kg per week does not negatively affect lactation.
Not recommended to lose more than that per week.
Exclusive breast-feeding for at least six months increases parental weight loss.
Overall, lactating parents lose weight faster and return to their prepregnancy weight at a faster rate than their non-breast-feeding come counterparts.
Bariatric surgery
Can make it difficult for the body to utilize key nutrients including iron, zinc, magnesium, calcium, and B vitamins.
Fewer nutritional deficiencies are seeing post surgery for both sleeve gastrectomy and lap band.
Pre-existing nutritional deficiencies prior to surgery can be exacerbated post surgery. Should postpone pregnancy for 12 to 18 months after bariatric surgery.
Breast-feeding after bariatric surgery should be encouraged but careful monitoring about the growth and nutritional status of the infant and the lactating parent is imperative skin to skin contact with the infant immediately after birth and frequently in the neonatal period is especially important for lactating parents after bariatric surgery. Frequent feedings should be encouraged to promote the onset of lactogenesis which can be delayed in obese or overweight lactating parents.
Women with significant weight loss after bariatric surgery may have excess skin and pendulous breasts and may need assistance with positioning.
Breast reduction is a common procedure after weight loss from bariatric surgery. This could impact lactating parents ability to produce enough milk.
Malabsorption diseases
Impact nutritional status of lactating parent. Irritable bowel disease including Crohn’s disease and ulcerative colitis.
When disease is active lactating parent will experience significant malabsorption of nutrients including protein, essential fatty acids, calcium, vitamin D, folate, vitamin B 12 and zinc.
Anemia in lactating parent
Does not negatively impact iron levels found in milk. Because body utilizes blood to create milk, anemia and lactating parent can reduce the volume of milk produced while maintaining nutrient values.
Food allergies to dairy products
Can consume nondairy sources of calcium to meet nutritional needs.
Dairy products are quick and reliable sources of calcium.
Can get from bok choy, tofu, salmon, figs, and sardines.
I taking calcium supplements should take two hours before or after any iron containing supplements because calcium and iron compete for the same binding site in the small intestine.
Calcium can decrease the absorption of iron by up to 62%.
Calcium best absorbed in increments of 500 mg or less in the presence of normal vitamin D in the body. If lactating parent is deficient in vitamin taking at 500 mg calcium supplement with vitamin D helps to increase her calcium absorption.
Wheat allergies, gluten allergy, and celiac disease are separate and distinct disease states
Present with an overlap in foods that must be eliminated from the diet to maintain health and proper immune function.
When eliminating wheat or gluten from the diet it is preferable to replace them with whole grains such as brown rice quinoa or oats to ensure an adequate intake of vitamins minerals and fiber.
Lactating parents of multiples have specific and unique nutrient needs and they report increased hunger or thirst.
Should drink at least 64 ounces of water daily.
Should increase caloric intake by 500 to 600 cal per child through a well-balanced diet of 20% protein, 40% carbohydrates and 40% fat.
Not recommended to increase micro nutrient supplementation because this could lead to toxic levels of supplemental nutrients in the body.
Malnutrition
Does not generally lead to poor quality milk.
There can be a decrease in availability of certain nutrients in the milk parents who are deficient in vitamin C, B1, B2, B6, B12, C, D, and K, choline, iodine, and selenium. Malnutrition can be present in both obese and underway parents.
In the short run malnutrition in lactating parent does not appear to negatively impact infant health but long-term starvation or severe deprivation can have a negative affect on the quality and quantity of milk.
There may be a link between malnutrition while breast-feeding and thyroid dysfunction in the offspring that presents in adulthood.
Eating disorders and body dysmorphic disease
History of anorexia Nervosa have a higher risk of disease relapse, postnatal depression postnatal anxiety and breast-feeding failure.
Anorexia nervosa have a higher risk of giving birth to infants with low birth weight. Also higher risk for birth via C-section.
Women with anorexia nervosa tend to have increased anxiety about the quality and quantity of their milk.
Women with bulimia and breast-feeding initiation rates on par with general public and similar rates of sustained exclusive breast-feeding.
Chapter 9 - Nurtrition for the Breastfeeding Child
Celiac disease
Auto immune disease characterized by destruction of the cells lining the small intestine when an individual eats food containing gluten
Complementary foods
Foods added to the diet of an exclusively breast-fed infant, including family foods in traditional tablespoons.
Exclusive breastfeedingg
Infant diet exclusively human milk without the use of artificial infant milk, infant cereal, other fluids or other solid food. Does allow infant to receive oral rehydration solution and medicinal drops and syrups. Also OK to use sweetened pacifiers during medical procedures.
Food allergy
Immune reaction when non-harmful food is consumed and causes a range of symptoms, from uticaria, to gastrointestinal distress and anaphylaxis
Guidelines and recommendations for infant feeding
WHO global strategy for infant and young child feeding it’s the guiding framework for infant nutrition. Published in 2003 based on a symphesis of global scientific evidence to date.
Infant should be exclusively breast-fed for the first six months of life to achieve optimal growth, development, and health.
From the age of six months infants should receive nutritionally adequate and safe complementary foods while breast-feeding continues for up to two years of age or beyond.
Infants should be fed on demand throughout the day and night. Responsive feeding produce the best childhood outcomes across diverse cultures.
And infants to human milk feeding is digested in approximately 90 minutes.
Breast-feeding patterns are usually every 1 to 3 hours throughout the day and night.
No other fluids including cows milk cheers sports drinks should be given to an infant younger than one year.
Water should only be given when solid foods are replacing a full breast-feeding session with a meal.
No other foods should be mixed with human milk and fed to an infant younger than six months.
On modified non-human milk should not be fed infants younger than 12 months due to the increase risk of renal disease, diarrhea and iron deficiency anemia.
On demand breast-feeding should continue until at least two years of age or as long as mutually acceptable for the lactating parent and child.
Introduction of complementary solid foods
Can be introduced at about six months of age.
If given at four months increases the incidence and severity of infectious illness in a breast-feeding infant.
Transition. When complementary foods are introduced creates high risk for nutrition for infants. Do not have the physiologic and development capabilities to eat a complete meal yet. Human milk or artificial infant milk should be given as a primary source of nutrients through the first year of life while the infant develop skills necessary to replace with Whole Foods.
Complementary foods should have the following characteristics.
Timely introduced when the need for energy and nutrition exceeds what can be provided through exclusive breast-feeding.
Adequate provide sufficient energy, proteins, and micro nutrients to meet a growing child’s nutritional needs.
Safe are hygienically stored and prepared with clean hands.
Properly fed they are given consistent with a child’s signal of appetite and satiety.
Introduction of non-purée complementary thirds
Introduced between six and nine months of age increases likelihood of acceptance of a broader range of food, including fruits and vegetables, at seven years of age.
Complete meals should be presented to the infant included protein, grain or starchy vegetable, and fruit or vegetable.
Ideally prepared from locally available fresh ingredients.
Frequent on-demand breast-feeding should continue from the introduction of complementary food until the infant is at least two years of age.
Children in poverty in both developed and developing countries are at a high risk of inappropriate infant feeding, early introduction of complementary foods and induction of complementary foods that are not nutritionally adequate.
Introduction of solid foods is affected by family pressure, free or discontinued manufactured foods, and poverty
Breastfeeding toddler of 1 to 3 years of age
Toddler should be breast-fed on demand while also being served three complete meals per day.
Water should be the primary fluid consume throughout the day to ensure adequate hydration.
At 12 months non-human milk can be introduced to the toddler. There is a correlation between increase growth rate among preschool age children and cows milk in developing countries but there’s also a strong link between cows milk and iron deficiency anemia and early dental cavities.
Calcium and casein inhibit the absorption of nonheme iron in the small intestine which is likely the mechanism that bovine milk increases risk of iron deficiency anemia.
Toddlers who drink more than 16 to 24 ounces of cow milk per day are at a greater risk for severe iron deficiency anemia.
Infants and toddlers who receive human milk are more accepting of new foods and have a higher variation in the foods they will eat.
Toddlers who are breast-fed directly at the breast are at an increase rate risk of forming dental cavities than those who are breast-fed for less than 12 months.
This is not true United States except in low income families.
Bottlefeeding expressed milk at night appears to be leading cause of cavities.
Light brushing of primary teeth starting at nine months preent cavities
Infants older than six months should have iron rich food incorporated into their diet.
Prevention of malnourishment
Underway, growing too slowly, or failing to thrive should be supervised by multidisciplinary team including a lactation professional, dietitian, and pediatric healthcare provider.
Childhood overweight and obesity are also markers for malnutrition.
Slow growth and failure to thrive can have many different causes including prematurely, presence of an illness, and adequate nutrient intake secondary to poor feeding technique, cultural barriers, health beliefs, social and psychological problems in the family, poverty, a strict diet, severe allergies to foods, vomiting, diarrhea, dysphasia, infections, adenoid hypertrophy, and respiratory problems.
Exclusive breast-feeding and adequate and timely introduction of complementary foods at age 6 months along with continuous breast-feeding through at least two years could save 1.5 million children younger than five years from death due to malnourishment. Parental perception of infant body size and weight gain is a causative factor in the early introduction an inappropriate introduction of solid foods.
Overweight and obesity are growing health concern for infants.
Some believe more the infants weigh the healthier they are. Particularly prevalent in low income communities.
Rapid infant weight gain, feeding practices, and high infant weight or predictors of pediatric obesity.
Exclusive use of artificial infant milk and introduction of solid foods before age 4 months has been associated with a sixfold increase in pediatric obesity. Should monitor rapid weight gain in infancy.
Factors that affect obesity include type of milk, use of food to regulate infant distress, timing introduction of solid foods, sweetened beverage consuption, age of weaning from bottle and into to solids and table foods.
Putting cereal in bottle associated with obestity
Complete avoidance of sugar sweetened drinks
No real need for juice. Put in cup not a bottle or sippy cup and not take place of milk
Macro and micro nutrient needs of infants and toddlers
Macro and micro nutrients in human milk or maintain despite parental nutritional status. Exceptions include selenium, iodine, vitamin a, vitamin D, riboflavin, thiamine, vitamin B6, vitamin B 12 and choline.
Parental diet does not influence total amount of fat in human milk but does influence fatty acid composition.
Parent needs to consume foods abundant in omega three fatty acids.
Vitamin B 12 status during pregnancy determines adequacy of concentration in milk.
Low B12 in milk cannot be rescued through supplementing parent must supplement infant.
No other food is needed for at least six months of life to ensure healthy growth and development.
Approximately 1/3 of the worlds infants and children are deficient in vitamin A. Should begin at age 6 months foods high in vitamin A. Countries where incidence of night by blindness is above 1% or the prevalence of vitamin a deficiency is above 20% children older than six months to receive a daily vitamin a supplement.
Western countries parental vitamin D deficiency is common. Vitamin D status of human milk is dependent on parental status.
All infants from birth to 12 months of age are recommended to receive 400 IU per day of vitamin D an alternative to infant supplementation is to have parent consume at least 6400 IU of vitamin D 3 or 4000 IU of vitamin D 12 daily
Human milk is low in iron but the form is highly bioavailable. By six months of age the infant requires an additional source of iron to prevent iron deficiency anemia. Daily iron supplementation for infants 6 to 23 months of age should be provided who reside in countries with poor availability of iron fortified foods ad have greater than 40% prevelence of anemia.
Avoid routine iron supplement reports of increased incidence of G.I. illness less length gain less attainment of motor milestones in infancy and worse neurodevelopment scores in infants who are unnecessarily supplemented with iron.
Over consumption of bovine milk and milk products can lead to iron deficiency anemia, early childhood dental cavities and pediatric obesity.
Zinc supplementation should be recommended when a child has active diarrhea. And given with oral rehydration.
Food allergies and intolerances
Managing food allergies in a breast-feeding dyad requires a team including a pediatrician healthcare provider and a registered dietitian and sometimes a pediatric gastroenterologist and a pediatric allergist.
Both lactating parent and infant should be referred to a registered dietitian to ensure that nutrient needs are met during period of food exclusion.
Infant must be monitored closely for growth and development.
Maternal elimination diet are often necessary when a breast-feeding infant has a food allergy or intolerance.
Parent eliminates only one food at a time. Must occur under the supervision of a dietitian.
Protein based allergies are most common. Top eight proteins-based allergies are cows milk, sorry, egg, tree nuts, peanuts, wheat, gluten and fish.
Casein cows milk proteins typically takes the longest to eliminate and are recommended to be eliminated first.
Introducing foods that contain gluten (wheat, barley, and rye) in first three months of life significantly increase the risk of developing celiac disease in children who have genetic marker for disease.
Genetic market for celiac disease likely also to carry genetic marker for Type 1 diabetes. Cows milk protein allergy (CMPA) can have an adverse effect on an infants overall health, immune function and growth. Up to 15% of infants show adverse effects when exposed to casein. Symptoms include urticaria, angioedema, vomiting, or an acute flare of atopic dermatitis, frequent regurgitation, diarrhea or constipation, blood in the stool, iron deficiency anemia, runny nose or chronic coughing, wheezing, food refusal and colic.
An adverse reaction to casein can occur within 45 minutes of exposure.
And more than 40% of cases takes up to 24 hours.
There is no reliable test for delayed CMPA therefore a complete elimination of cows milk proteins from diet is recommended.
Appears to be a genetic component for CMPA.
Exclusive breast-feeding reduces the severity of symptoms related to CMPA.
Switching to a hypoallergenic formula it’s not recommended as the first line treatment for CMPA. Instead elimination of all cows milk and casein-based products from diet of parent is primary treatment.
Reactions to other foods including egg and soy, wheat, fish, peanut, and other foods depending on the regional dietary intake may occur with the CMPA.
Should introduce these foods in a stepwise manner one at a time to assess infant symptoms.
CMPA persists in 50% of infants through first year of life while up to 20% will continue through early childhood.
Non mammilian milks and high calcium plant-based foods are the most desirable often for infants and children younger than five years of age who have CMPA.
Feeding in special populations
WHO recommends low birthweight and very low birthweight infants to be fed human milk.
Human milk from infants parent is preferred but if not available donor milk is next best option.
Low birthweight infants should be fed standard infant formula if breastmilk not available. Very low birthweight infants should be fed preterm infant formula if they do not gain adequate weight while consuming standard infant formula.
Very low birthweight infant should be given human milk fortifier‘s based on human milk not bovinemilk.
Colic is a period of uncontrolled crying that can last up to three hours per day at least three days per week and persist for at least three weeks.
Appears to spontaneously dissipate at 3 to 4 months of life.
May be a symptom of gastrointestinal or neurological distress.
25% of infants diagnosed with colic have cows milk dependent colic.
Elimination of casein-based foods from the lactating parent may have a positive affect. Switching lactating parent to a low allergen diet has been shown to improve colic in infants younger than six weeks.
Lactobacillus reuteri has been shown to reduce symptoms of colic and breast fed infants younger than three months by increasing gastrointestinal motility and function. But not consistent.
Children who consume vegan diet should receive guidance from healthcare providers and registered dietitians regarding necessary supplementation to meet micro and macro nutrient dietary requirements for healthy growth and development
At each meal a vegetarian child should receive a plant-based source of protein, a green or starchy vegetable, and a fruit or vegetable with appropriate snacks between meals. Vegetarian children should receive varied proteins sources including eggs and foods based on cows milk should not be the primary source of protein.
Proteins sources should vary and include legumes (beans, peas, and lentils), nuts, and seeds in addition to non-human milk and eggs.
Vegan lactating parents should regular take vitamin B 12 supplements and have their B12 status checked yearly.
Vegan infants and children older than 12 months should be supplemented based on their recommended daily needs.
Most vitamin B12 supplements are available in megadoses therefore daily supplementation is not recommended.
Due to differences in bio availability of heme versus nonheme iron and a higher intake a fiber in vegan and vegetarian children they have a higher recommendation for iron requiring 1.8 times more iron than current recommended daily intake
Vegan diets tend to be more deficient in omega three fatty acids and higher in omega-6 fatty acids. Supplementation with algae-based DHA via drops or sprays is recommended for vegan infants older than 12 months.
Consumption of plant-based foods that are high in omega-3 fatty acids is also recommended. Recommended that one percent of the daily caloric intake come from omega-3 essential fatty acids for vegans and vegetarians.
