infant feeding Flashcards
trend in breastfeeding rates up to 6mths in UK
marked drop off despite WHO recommendation of exclusive BF for 6mths and then alongside complimentary feeds for up to 2yrs
constituents of human milk
cytokines IL-7 enzymes milk lipids oligosaccharides lactoferrin leukocytes immunoglobulins stem cells lymphocytes growth factors vits and minerals fats carbohydrates proteins water
formula milk constituents
vits and minerals fats carbohydrates protein water
main difference between breast milk and formula
basic nutritional consituents vary
breastmilk contains many more live constituents that promote health
breast milk vs formula - water
water used to make formual can easily become contaminated - climate issues, over use of cleaning products or fluorine
breast milk doesn’t have this issue
breast milk vs formula - protein
breast milk - more whey based (60-80%) and easier to digest, main protein (alpha lactalbumin, make up >20% of total protein) has been associated with the destruction of over 40 types of cancer cells
formula - cows milk protein, associated with increased risk of baby developing juvenile onset diabetes
breast milk vs formula - carbohydrates
breast milk - lactose is 1y carb, provides ~40% of total calories
formula - lactose is also more prevalent in UK formula; may also see sucrose, fructose and glucose in soya/lactose free formula
breast milk vs formula - fats
breast milk - long chain polyuns. FAs support the development of the entire NS (incl. retinol development - improved eyesight)
formula - fats change depending on the market; currently they are mainly vegetable (rapeseed oil, sunflower oil, coconut oil, algal oil), some contain egg or fish oil
why are fats required in infants
essential for brain development and absorption of fat soluble vitamins, and are a major calorie source
breast milk vs formula - vitamins and minerals
formula - extra vits and minerals and added to the powder to ensure they are sustained for the entire shelf life so amounts vary
why are vitamins and minerals important
healing wounds
supporting bone growth
immune system
etc
examples of growth factors present in breast milk
epidermal, insulin and transforming factors which promote gut growth
when is epidermal GF higher
mothers who have preterm babies
linked to a reduction in necrotising enterocolitis (NEC) and other inflammatory repsonses
what role do growth factors play in early life
role in early life programming
may be associated with a reduced risk of obesity and cancer in later life
what is the role of transfer factors
enable effective absorption of nutrients in the milk e.g. lactoferrin
also help with absorption of fats and vitamins
role of lactoferrin
assists with absorption of iron - reduces amount of free iron which attracts batceria
also bactericidal - kills E coli
what is the role of stem cells in breast milk
have the ability to develop into many different cell types
evidence that these cells remain in the system long after BF has stopped
immunoglobulins in breast milk
IgA, IgG, IgM, IgD
IgA - provides protective coating to baby’s gut - prevents entry of pathogenic bacteria and enteroviruses (E. Coli, salmonella, streptococci, staph, pnuemococci, rotavirus etc) - protects against gastroenteritis, resp infections etc
role of leukocytes in breast milk
destroy harmful bacteria
macrophages - produces lysozyme which disrupts bacterial cell wall
oligosaccharides in breast milk
> 200 types of simple carbs in breast milk
influence the development of the microflora by increasing number of beneficial bacteria in baby’s gut - protects baby against infections e.g. otitis media, resp, urine, GI
encourage some cells in the gut to produce an adhesive protein substance which helps seal the gaps between cells in the gut wall - prevents harmful bacteria and allergens from crossing into the baby’s system
milk lipids in breast milk
damage outer surface of certain virus types
reduce infection rate in baby
enzymes in breast milk
aid digestion and absorption
some destroy bacteria
IL-7 in breast milk
linked to the size of the thymus - breast fed babies have much larger thymus than formula fed babies - stronger immune system
also has a role in stimulating antibody producing cells
plays a part in reducing risk of childhood leukaemia
cytokines in breast milk
important constituent in boosting immune system
special features of colostrum
protective factors concentrated nutrition strong anti-inflamamtory factors stimulates gut growth - helps cells and villi proliferate small volumes - intentional laxative effect
what is the role of the laxative effect of colostrum
to clear meconium
helps minimise jaundice
what is the difference between colostrum and mature breast milk
colostrum is smaller volumes and more concentrated
new born babies would find the XS water in mature breast milk difficult to process (immature kidneys)
healthy term babies don’t become dehydrated - surfeit of interstitial fluid they need to process in the first few days
not breastfeeding increases the risk of what in babies
gastroenteritis resp infections allergies - mixed evidence obesity T1 and 2 DM SIDS NEC
exclusive BF gives best protection but some is greater than none
not breastfeeding increases the risk of what in mothers
breast cancer
ovarian cancer
hip fractures
heart disease
when do babies begin to pick up their microbiome
may recieve exposure to maternal microbes in the womb
lactobacilli more prevalent in the vagina during pregnancy (friendly bacteria)
as they pass through the vagina at birth
vaginal birth, skin to skin and breast feeding
through the mother’s milk in the postnatal period and beyond
what is the role of our gut biome
generate our energy needs
produce enzymes to digest food
manufacture vitamines B, K and nicotinic acid
regulate fat storage
manufacture amino acids
help w/ iron absorption
create our individual immune system and help immune cells reproduce
train our immune system on what is safe and what to reject
benefits of the first breast feed on gut health
live constituents in the milk develop the process of setting up the microbiome w/ high levels of bifidobacteria and oligosaccharides
results of insufficient bifidobacteria in the gut
children with insufficient bifidobacteria in their gut in the first year of life have an increased risk of obesity in later life.
what is especially important if a child is born by C sectioin
miss out on vaginal transfer of microbes
prolonged skin to skin contact and breast feeding
epigenetics and breastfeeding
breastfeeding may result in epigenetic changes which impact on:
brain development
baby’s immune system
baby’s metabolic system
what is epigenetics
additional info that may be layered on top of the sequence of molecules that make up our DNA
epigenome attaches to and modifies the original gene
epigenetics and generational change
changes to our genes can be passed down to future generations via maternal line
e.g. famine in the netherlands - effect could be seen 3 gens later
childhood abuse has been shown to affect DNA patterns - link between victims and ill health in adulthood
when is our DNA most receptive to epigenetic changes
in utero - 3yrs
alters the way our organs and our predisposition to certain diseases develop
what impacts the infant’s epigenome
maternal environment during pregnancy
infant’s first recieved nutrition
breastmilk and leptin
breastmilk has the ability to turn on/off certain epigenetic changes e.g. gene for leptin
appetite is influenced by breastmilk
babies who are breastfed have higher levels of leptin at 1mth of age
formula milk may dampen leptin production and is associated with higher levels of obesity
updating the baby’s immune system at each feed
broncho-mammary pathway: pathogens inhaled
entero-mammary pathway: pathogens ingested
antibodies produced and sent to breasts
antibodies incorporated into breast milk
how does the mother affect the baby’s immune system
mother’s body works to monitor her environment and produce antibodies to current infections that she detects in her lungs/gut
antibodies are passed directly to the breastmilk so baby is provided with protection with as little delay as possible
mother and baby need to be together for this to work
how can we protect breastfeeding
international code of marketing of breastmilk substitutes - the code
UK law - hasn’t yet fully implemented the code
professional accountability
what is ‘the code’ with regards to marketing formula milk
prohibits all promotion of bottle feeding and sets out requirements for labelling and information on infant feeding.
Any activity which undermines breastfeeding also violates the aim and spirit of the Code.
The Code is not an anti-bottle feeding measure. It is as keen to make sure bottle feeding is done as safely as possible as it is to ensure the protection and promotion of breastfeeding.
the code states that companies must not…
promote their products in hospitals, shops or to the general public
give free samples to mothers or free/subsidised supplies to hospitals or maternity wards
give gifts to health workers or mothers
promote their products to health workers: any information provided by companies must contain only scientific and factual content
promote foods or drinks for babies
give misleading information
have direct contact with mothers.
UK law regarding formula milk
intended to ‘regulate labelling and restrict advertising and presentation of infant and follow-on formula so as not to discourage breastfeeding.’
not as robust as the Code and companies are able to find ways around the law. One of the biggest weaknesses is that, while the Code considers follow-on formula (i.e. milk intended for babies over six months) to be a breastmilk substitute, the UK law does not. This allows the companies to promote their brand name and logos via advertising of follow-on milks.
conflict of interest re. formula milk
Sponsored study days / smaller education sessions / meetings offered for staff or parents on public service premises
Staff attending sponsored study days
Individual staff engaging with the companies e.g. by speaking at sponsored events, writing articles, blogs etc. for the companies
Awards and other gifts being made to individual staff by the companies or by a separate organisation which is being sponsored by the companies.
what parents using formula need to know
1st milks for 1st yr - no need for follow on all brands are similar information on prep and sterilising cow's milk from 1yr responsive bottle feeding
what is responsive bottle feeding
baby is held close and feeds are paced
important to reduce overfeeding and obesity
what are the 3 stages of lactation
lactogenesis 1 - breast development and colostrum production from ~16wks gestation
2 - onset of copious milk secretion occurring between 32 and 96hrs after birth
3 - maintenance of milk production
what does lactogenesis 1 involve
differentiation of alveolar epithelial cells into lactocytes that secrete colostrum from ~3-4mths of pregnancy
what causes lactogenesis 2
occurs in response to risk in prolactin and a decrease in pregnancy hormones
milk will come in regardless of whether a woman wants to breastfeed or not
external changes to the breast during pregnancy - Montgomery’s tubercles
appear on the areola to secrete an antiseptic sebum to lubricate the area
sebum also creates a scent to entice the baby to begin to search in the area for their first feed
changes in hormones after birth
oestrogen and progesterone levels drop
prolactin and oxytocin levels rise in response to touch, smell and sight of baby
baby begins spontaneous breast seeking behaviour
mothering behaviours initiated
prolactin-receptor theory
the more early, frequent surges of prolactin there are, the greater the number of receptor sites that become primes
max number of receptor sites = max numbers of functioning lactocytes from that point onwards, max triggering of the mothering response
prolactin - role, responsive to, levels highest, long term production
responsible for milk production
responsive to touch and stimulation
levels higher at night
frequent contact/feeds sets up for long term production
oxytocin - role, levels highest, what can delay ‘let down’
responsible for milk delivery
acts on muscle cells in pulsatile action
levels higher when baby is near
stress can temporarily delay ‘let down’
rise and fall in prolactin levels
increase the most in the immediate postpartum period
rise and fall in proprotion to the frequency, intensity and duration of nipple stimulation
concentration in the blood doubles in response to suckling and peaks ~45mins after the beginning of a breastfeeding session
levels fall ~50% in the first week after birth in breasfeeding women
if women don’t breastfeed, levels reach non-pregnant levels by 7 days postpartum
oxytocin release
levels will remain high as long as baby is kept close and milk will start to be release in response to early feeding of behaviour clues
if baby is away from mum these early clues might be missed, if mum can only respond when her baby is crying and distressed her own cortisol levels will be raised and compete w/ oxytocin
prolactin and oxytocin - mum and baby bonding
prolactin and oxytocin work together to help a new mother feel calm yet protective of her baby
oxytocin helps form a bond between mother and baby
feedback inhibitor of lactation (FIL)
Circulating prolactin within bloodstream controls milk production especially in the early weeks post birth.
Volumes can be irregular at first so mothers may experience full breasts and leaking as the supply and demand establishes itself.
As breasts become very full either through ineffective milk removal or long spacing of feeds a whey protein in the milk called FIL slows down synthesis by signalling to the cells to stop production.
In addition it is believed that the down regulation (reduced milk production) is also caused by pressure within the full breast flattening and expanding the cells and the receptor sites, making it difficult for prolactin to attach to and enter the cells.
oxytocin - the love hormone
works on feeling and emotions lowers BP and improves sleep reduces stress levels by 'taking on' cortisol reduces pain sensitivity boosts immune system
skin to skin contact - baby friendly standard
all mothers have skin to skin contact w/ baby after birth at least until after the first feed and for as long as they wish
all mothers are encouraged to offer the first feed in skin contact when the baby shows signs of readiness to feed
mothers and babies who are unable to have skin contact immediately after birth are encouraged to commence skin contact as soon as they are able
why should skin contact be prolonged
triggers lactation and mothering hormones
regulates temp, HR and breathing in baby
colonises baby w/ microbes from mother, father and their environment
stimulates feeding behaviour
reduces stress hormones in mother and baby
why is skin to skin still important in bottle fed babies
triggers mothering hormones
regulates temp, HR and breathing in baby
colonises baby w/ microbes - esp important if not recieving breastmilk
reduces stress hormones in mother and baby
starts mother-baby bond
9 stages baby goes through after birth
birth cry relaxation awakening activity rest crawling familiarisation suckling sleeping
stage 1 - birth cry
after birth
distinctive cry familiar to midwives as baby expands his lungs
stage 2 - relaxation
after birth cry
no mouth movement
hands and body totally relaxed
stage 3 - awakening
2-4 mins after birth
small thrusting movements of head and body
eyes beginning to open
some shoulder movement
stage 4 - activity
4-12 mins after birth
stable open eyes, rooting, salivating, hand to mouth, hand to breast to mouth, tongue protrusion
stage 5 - rest
frequent after birth
lots of rest periods after activity
stage 6 - crawling
18-54 mins after birth
crawling, sliding, leaping and drawing up knees to push forward
lots of rooting searching
stage 7 - familiarisation
29-62 mins after birth
VERY important stage - can last 20 mins or more
licking nipple, touching, massaging breast
begins to interact with mum and dad
stimulating mum’s hormones
stage 8 - suckling
49-90 mins
self attaches after working out best approach and begins to feed
stage 9 - sleeping
90-120 mins
catecholamine levels in baby after birth
raised after birth - help support transition to extra uterine life
these decrease when baby begins to feel safe in a known environment
as levels drop baby begins to display activity and becomes more awake and interested in their environment
what is the role of the rest periods during the instinctive search
enables baby to consolidate and integrate what they have already experienced
all to do with imprinting and shouldn’t be rushed
what is the role of the crawling stage
helps baby move closer to the breast
massages mother’s uterus, helping it to contract - important for oxytocin release but also helps prevent PPH
what is the role of familiarisation
baby approaches mother’s breast, spends time imprinting and working out how best to approach and attach for feeding
if rushed by staff (putting baby onto the breast) this can result in baby struggling to attach at subsequent feeds - biggest reason many mothers stop breastfeeding in the early weeks
separation and stress
term baby separated for 6 hrs has increased stress
pre-term baby receiving high-tech care has greatly increased stress
one hour of skin contact can reduce stress hormone levels by 75%
what can skin contact help with
attachment challenges - overhelped, pain and discomfort
boosting milk supply
unsettled babies and mothers
breast refusal
postnatal depression or low mood - oxytocin and prolactin and released which are both mood boosters, baby will also feel nurtured and safe
just because it feels good - mums and dads
