Lactation (2) Flashcards
1
Q
Lactation Ability
A
Determined by…
- Intact mammary tissue and development of milk producing cells (alveoli) ducts and nipples
- Initiation and maintenance of milk secretion
- Ejection of milk from alveoli to nipple
99% success at initiation of lactation when attempted
2
Q
Lactogenesis - Stage 1
A
- Last trimester and 1st few post-partum days
- Milk begins to form
- Lactose and protein content increases
- Suckling not necessary to initiate production
3
Q
Lactogenesis - Stage 2
A
- 2-5 Days → 2 weeks post-partum
- Onset of copious milk secretion
- When milk “comes in”
4
Q
Lactogenesis - Stage 3
A
- 10-14 days post-partum
- Milk composition becomes stable
- Full lactation
5
Q
Prolactin in Lactogenesis
A
- Stimulates milk production
- Secretion stimulated by sucking
- Inhibits ovulation
6
Q
Oxytocin in Lactogenesis
A
- Secretion stimulated by sucking
- stimulates milk ejection, letdown
- Promotes uterine contractions
7
Q
Let-Down Reflex
A
- When “gates open”
- Affected by emotional or psychologic factors
- Simulated by:
- Crying baby - even if its not your own baby
- Thought of baby
- Crying baby - even if its not your own baby
- Inhibited by:
- Embarrassment
- Stress
- Signs of successful letdown
- Dripping milk before feeding
- Dripping milk from breast opposite nursing breast
- Contractions of uterus during feeding, often causing slight pain or discomfort
- Tingling sensation in breast
8
Q
Human Milk Volume
A
- Baby demands frequent feedings
- Mother must be available at all times or use pump
- Malnutrition first affects quantity of milk
- Volume variabls depending on demand
- Average: 750-800 cc/day
- Range: 450-1200 cc/day
- Fluid requirements increase
- Feeding on demand is best way to maintain lactation → the more often the breast is emptied, the greater the volume
9
Q
Composition of Human Milk
A
- Affected by severe malnutrition
- If well nourished, independent of nutrition state except for Vit and fat content
- Basic content varies:
- mom to mom
- with stage of lactation
- with times of the day
- with gestational age of infant
10
Q
Colostrum
A
- “First Milk”
- Initiatial breast secretion first few days post partum
- Thin, yellowish, milk liquid → yellow color = high carotene content
- High in immunoglobulins → to fight infection and give baby Ab’s
- Higher that mature milk in…
- Vit A
- protein
- Na
- K
- Cl
- Lower in…
- Fat
- carbs
- calories (15 kcal/oz)
11
Q
Transitional Milk
A
- Secreted from 3-10 days post partum
- As protein content decreases → lactose and fat content increases
12
Q
Preterm Milk
A
- Mother’s body adjusts to meet needs of baby
- There is preterm milk for all types of milk, except it is different throughout all stages
- Higher in…
- Protein
- Immunoglobulins
- Ca, Na, K, Cl, P, Mg
- MCT (medium chain triglyceride)
- LCT (long chain)
- Total fat
- **Lower in lactose **
- Requires supplementation → Fe and Ca, which are normally stored during 3rd trimester - milk does not fully compensate
- Human Milk Fortifier (HMF) supplement added to milk after pumping
13
Q
Protein Synthesis
A
- Most milk proteins are specific to mammary secretions
- Formation of milk protein is induced by prolactin and further stimulated by other hormones
- Protein derived from 2 sources:
- De novo synthesis in mammary
- Plasma
- Major milk proteins:
- Casein
- Alpha-lactalbumin
- Beta-lactalbumin
- Synthesized from AA precursors
14
Q
Protein Composition - Mature Milk
A
- Lower in protein than cow’s milk → protective effect on kidneys
- Casein: phosphorus-containing proteins that occur only in milk
-
Whey
- Thin liquid of milk remaining after curd
- Contains lactalbumin and lactoferrin
- Made in mammary gland
- Not affected by maternal protein intake, unless protein malnutrition is chronic
- AA content ideal for human infant (vs. cow’s milk)
- Higher in taurine → necessary for bile acid conjucation and brain development
- Higher in cystine → necessary for growth and development
- Lower in methionine
- Cystathionase late to develop, impairing conversion of methionine → cysteine
- Hypermethioninemia may damage CNS
- Lower in phenylalanine and tyrosine
- Tyrosine aminotransferase and parahydroxyphenyl pyruvate oxidase late to develop
- Difficult to convert AA
- High levels can affect CNS
15
Q
Lipids - Mature Milk
A
- Varies
- Woman to woman
- with parity
- with season of year
- **Foremilk < Hind Milk **
- Important to empty breast completely so baby gets hind milk
- Fa profile varies with diet
- 90% of fat in form of triglycerides
- Higher levels of cholesterol and EFA’s
- Lipid content benefits
- Rapid growning CNS
- **Developent of enzymes necessary for cholesterol degradation**
16
Q
Carnitine
A
- Necessary for metabolism of LCFA’s
- Exogenous sources
- Human milk
- Cow’s milk
- Meat (carne) products
- Endogenous synthesis from lysine and methionine
- May be conditionally essentially, especially for preterm infants
- In severe stress, your requirements may exceed endogenous production
17
Q
Carbs - Mature Milk
A
-
Lactose
- Predominant carb
- Content not affected by diet
- Stimulates growth of beneficial microorganisms in infant gut, which synthesize B vitamins
- Improves absorption of Ca, P, Mg
- Synthesis cobines glucose and galactose
- Other sugars present in small amounts
- Contains amylase, which aids digestion (we cannot mimic outside the body)
18
Q
Minerals (Fluoride) - Mature Milk
A
- Strikingly different than cow’s milk
- Lower in Ca and P
- Contains almost all necessary trace elements
-
Fluoride supplementation for baby
- Rec. at 6 months for exclusively breast fed infants
- Only small amounts found in breast milk
- Maternal fluoride supplementation does not effect milk content or change rate of cavities
19
Q
Iron and Zn - Mature Milk
A
- Lower content
- Higher bioavailability (50% vs. 10% absorption)
- Fe supplementation rec by 5-6 months in breast fed infants → stores built up during pregnancy has depleted by this time, but this is okay because infant cereal usually introduced at this time and is fortified
- Lower mineral content of breast milk positively affects the amount of waste product provided to kidney
20
Q
Calcium - Mature Milk
A
- Lower than cow’s milk
- not affected by maternal diet → if dietary Ca for mom is insufficient, Ca for the baby gets taken from mom’s bones
- Maternal bone loss may occur
- Adaptations in hormonal pattern may maintain bone health in women with marginal intake
21
Q
Vitamins - Mature Milk
A
- Maternal vitamin intake does influence content of milk
- Concentrations of water-soluble are more responsive to dietary intake than fat-soluble
22
Q
Vit D - mature milk
A
- Affected by maternal diet and sun exposure
- Breast milk < Cow’s milk
- Supplementation
- Rec for breast fed infants
- 400 IUD daily beginning during first 2 months of life
- Risk factors
- Inadequate vit d intake
- Decreased sunlight exposure
- Northern latitude
23
Q
Vit E
A
- Human > Cow
- Levels in formulas now match breast milk
24
Q
Vit K
A
- Human < Cow’s
- Infant gut lacks flora to make vit K for first several days
- Newborns routinely receive Vit K at birth → Vit K shot to minimize potential bleeding
25
Vit A
Supplementation not recommended
26
B6
* Levels too low to meet the RDA for infants
* Most likely **deficient** Vitamin\*\*
27
B12
* Behaves like a **fat soluble - storage form**
* Maternal intake does not greatly affect content
* High risk groups may need supplementation
* Vegans
* gastric bypass
* Crohn's disease or disease that compromises absorption of B12
28
Resistance Factors - Mature Milk
* Favorable growth of beneficial bacteria
* Maternal antibodies pass to infant
* Antibacterial, antifungal, antiviral components
* Immune benefits not seen with maternal malnutrition
29
Potential Contaminants
Pesticides, pollutants, lead, mercury
Meds/Drugs
* Type of drug
* Route of administration
* Dose and dosing schedule
* Best if meds taken immediately after breast feeding to decrease peak affect on baby
30
Nicotine
* Enters milk of smoking moms
* Can reduce milk vol
* **Better to smoke and breast feed than to smoke and bottle feed **
* General health of baby is better vs. bottle feeding
* Respiratory illness (asthma and infection) is better
* Colic, acid reflux
* SIDS
* no evidence to document whether nicotine presents health risk to infant
* **Removed from adverse effects list i**n 2001
31
Caffeine
* Passes into breast milk
* Moderate intake not a problem in most babies
* Can cause wakefulness, fussiness and hyperactivity
* Some women may need to restrict
32
ETOH
* Controversial
* Passes into milk
* Can affect milk let down and ejection
* Impairs sleep time for infant
* Occasional 1-2 drinks not shown to be harmful to baby
* Don't want to discourage mom from breastfeeding
* If mom overindulges, use storage milk and throw away pumped milk for that day
2010 DGA Alcohol during lactation
* No earlier than 3 months
* Single drink
* Wait 4 hours before breastfeeding
33
Breast Feeding and Aids
* **Can be transmitted (5-40%)** from mother to infant through breast milk
* CDC and WHO advise against breastfeeding if **"replacement feeding is acceptable, feasible, affordable, sustainable and safe"**
* In US, if you have HIV/AIDS, do not breastfeed
* Otherwise, WHo supports breastfeeding for women with AIDS in developing countries
* Risk of death from diarrheal disease \> risk of transmission of AIDS
34
Diet for Nursing Mother
* Nutrients needed at higher level than nonpregnant status
* Needs based on volume of milk
* Lactation is a high priority process
* Nutritional wellbeing of mother may be affected
35
Nursing Energy Reqs
0-6 Months: +330 kcal/day
6-12 Months: +400 kcal/day
For the initial 3 months of lactation, 100-300 kcal/day are provided by maternal fat stores
Severe restriction of calories inhibits lactation
36
Nursing Fluid
Baseline requirements + water content of milk volume
Breast milk ~87% water
37
Nursing Protein
+ 25 g/day
Supplementation of certain vitamins and minerals may be required
Usually continuing prenatal vit is advised
38
Infant benefits of Lactation
* Human milk designed exclusively for human infants
* Nutritionally superior to any alternative
* Bacteriologically safe and always fresh
* Avoids risk of improper dilution of formula
* Provides **immunity** to viral and bacterial disease
* Stimulates infant's own immunologic defenses
* **Decrease** risk of **respiratory** and **diarrheal** diseases
* Promotes correct **development** of **jaws**, **teeth** and **speech** patterns
* Protective against **NEC** in pre-term babies
* Protective against **SIDS**
* From 4th month of life, bottle-fed infants **gain weight** **faster** than breast fed infants
* May provide **cognitive advantage**
* **Straighter teeth**
* **Delayed** onset of **celiac** disease
* Prevents or reduces the **risk of allergy**
* Breast feeding \> 6 months may protect from:
* certain childhood **cancers**
* Childhood **obesity** and adult obesity
* **Crohn's** disease
* **IDDM**
* Sleep apnea
39
Maternal Benefits of Lactation
* Allows for daily **rest periods** for mom
* Facilitates **positive self-esteem** for mom
* Promotes **physiologic recovery** from pregnancy
* unterine involution
* decreases risk of postpartum hemorrhage
* increases period of postpartum anovulation
* Eliminates need to mix, prepare, use and wash feeding equipment
* Cost effective
* **Reduced** risk of **breast** and **ovarian** **cancer**
* **Reduction of maternal fat stores**, especially around thighs
40
Shared Benefits
* Promotes frequent tender physical contact iwth mother
* Facilitates maternal-infant attachment
* Promotes psychological attachment
41
Incidence and Trends
* **1970: 82% bottle** feeding
* 1980's: Peak at 60%
* **WIC ~25% lower** rate
* Mother's employment status, age, race, education level, socioeconomic level and marital status affect incidence
* Full time employment decreases breast feeding
* Highest in western states, lowest in southern states
* Change in medical attitude in favor of breastfeeding has had a great influence
42
Decision to Breastfeed
* Made early in pregnancy
* Factors that influence decisions:
* Complex and interrelated factors
* Health care professional's support of lactation
* Father's opinion
* Grandmother's method of feeding
* Opinion of other family members
* Use of outside influences to promote breastfeeding is effective
* Concerns of mother should be addressed
* Effective techniques
* Emphasize benefits to mother and infant
* Prenatal preparation of nipples
* Explanation of the process
43
"Baby Friendly" Hospital Initiative
* 10 evidence based components of hospital care that influence breast feeding success
* Hospitals
* 2003: 38
* 2006: 55
* 2009: 86
* 2014: 172
44
Prenatal Preparation for Breastfeeding
* 99% of preparation in the head
* Access to classes and consultants
* 1% in nipple
* visual assessment
* address lumps, cysts, reduction or augmentation procedures
* everted nipples are ready for nursing
* Most inverted nipples can be everted
45
Breastfeeding in Postpartum Period
* Make mother feel at ease
* introduce breast as soon as possible
* Include father for instructions and feeding
* Positions:
* recumbent/lying down
* Sitting
* football hold
* Correct "latching on"
* most baby intuitively respond
* Some babies need to be taught
* lactation consultant can help overcome problems
* tickle baby's upper lip with nipple
* baby's mouth should be adjacent to nipple
* Wide open mouth is key
46
Reasons Breastfeeding is Abandoned
* Lack of knowledge by hospital staff
* Short hospital stays
* Outdated policies on water and formula feedings
* Time limitations at breast
* Commercial formula provided in discharge packs
* Sore nipples
* Inadequate milk supply
47
Feeding Frequency
* Baby nees frequent access to breast
* Feeding "on schedule" can be detrimental
* Newborns need to nurse 10-12 times/day
* Nursing should be every 2-3 hours
* When in doubt, feed the baby
* Length of feedings will vary
* Frequent and prolonged feeding encouraged
* Patterns of growth and feeding change
* Supplementation with formula will decrease milk supply
48
Adequacy of Feeding in Newborns
* Listening for swallowing sounds
* **6-8 wet diapers**/24 hours
* **1-3 milk stools** per day
* Alert when awake
* Return to **birth weight by 2 weeks**
* After 2 weeks, weight gain of **1 lb per month**
* Minimum of **8 feedings/day**
49
Anxiety of Sufficiency of Milk
* Once let-down established, **insufficient milk supply is rare**
* Women who really want to breast feed are usually able
* Infant growth and wet/soiled diapers assure adequate milk
* Babies cry for other reasons than hunger
* Adequate maternal diet → adequate milk supply
* Adverse reactions to maternal food occasionally occur
* **Rest and adequate fluid intake** is necessary for mother
* Exclusive breast feeding can be adequate even at **15 months**
* Occasionally, oversupply of breast milk
50
Sore Nipples
* Some discomfort is part of normal lactation
* Prevention with prenatal nipple assessment, intervention to evert nipples
* Correct "latching on" technique is key
* Air drying of nipples
* Avoidance of soap, nipple creams and nipple shields
51
Breast Engorgement
* "Overfilled" breasts
* Preventable with unlimited access to breast
* Must be corrected to prevent difficulty with latching
* Treatment:
* manual expression of milk
* breast pump
* application of warm compresses, warm shower
* Cold compresses between feedings to reduce swelling/pain
* Cabbage leaves
52
Mastisis
* bacterial infection
* Avoid engorgement and plugged ducts
* Painful, hard breasts, fever, flu-like symptoms
* Requires immediate attention
* Incidence 3-20%
* How is it treated?
53
Herpes or Thrush
* Consultation with lactation specialist
* Consultation with physician for appropriate medication
* Usually mom and baby need treatment
* Continued breast feeding is recommended in most cases
54
Use of Herbs during Lactation
* Use with caution
* Scientific information limited
* No testing for safety or efficacy
* Toxic contaminants
* Use of external gels/oils not recommended
* Unsafe:
* chamomile, echinacea, ginseng
* St. John's wort, ephedra, aloe
* Safe:
* Fenugreek
* Goat's rule
* Herbal teas
55
Milk Supply during Separation
* Manual expression for short separation
* Breast pump for longer separation
* Frequent pumping to maintain supply for sick or premature infant
* Adequate fluid intake
* Relaxed surroundings
* Store milk properly
56
Storage of Breast Milk
* Safe for 6-8 hours at room temp
* Safe for 5 days in refrigerator
* 3-6 months in self-defrost freezer
* Glass or hard plastic containers with tight sealing covers
* Freezer milk bags
* Do not boil or microwave
* Thaw in cool tap water, do not refreeze
57
Role for Supplementation
* Premature infants often need additional fortifier
* Certain conditions call for supplementation:
* Down syndrome
* weak or ineffective sucking
* heart defects, neurologic impairments
* Low weight gain, FTT, adopted infants, re-lactation
58
Maternal Illness
* Postpartum illnesses
* Hemorrhage
* Infection
* Hypertensive Disorders
* Surgery
* Initiate and maintain breastfeeding with infant or through pumping
* In case of chronic illness and medicaiton use, nursing may or may not be advisable
59
Duration of Breastfeeding
* In many parts of the world, women breastfeed for 2-3 years
* Current rec in US
* Breast feed for first year of life
* Exclusive breast feeding for first 6 months
* Factors to consider:
* convenience
* Psychological and physiological needs of child
* Availabilty to alternative foods
* Customs in the community
60
Multiple Births
* Milk supply can be adequate
* Time availability is usually main obstacle
61
Employment
* Preferably 4-6 weeks at home to establish lactation
* Can be compatible with breastfeeding
* Decreased illness in infant → decreased days of missed work
* Manual expression or pumping necessary while away from infant
62
Lactation During Pregnancy
* Physiologically possible
* Substantial physioloical and psychological demands
* Uterine contractions may require weaning
* Milk supply may decrease
63
Relactation
* Length of interlude influences chances of success
* High motivation required
* Stimulation with hormones, medication, sucking and manual stimulation required
64
Adoption
* Usually very difficult without pregnancy
* Not generally advised
* Hormone therapy usually required
* Very time consuming / frequent pumping required
* Success increased with previous pregnancy and lactation
* Recent weaning increases success rate
* Previous bottle feeding reduces success
65
Teenage Lactation
* physiologically possible
* Functional breast tissue may be reduced
* Advantages and disadvantages should be discussed with mother
* Conflict with schooling needs to be addressed
* Requires considerable support
* Less likely to overcome problems
66
Poor Milk Production
* Hypothyroidism
* Excess antihistamine use
* Oral contraceptive use
* Excess caffeine use
* Illness
* Poor diet
* Retained placental fragment
* Fatigue
67
Poor Let Down
* Stress / anxiety
* Some drugs
* HTN
* Smoking
68
Infant Growth Rate Evaluation
* Let down and milk supply should be evaluated
* Start supplemental feeding
* Dehydraion and marasmus are hallmark signs
69
Lactation Failure
* Poor maternal attitude is primary barrier
* Emotions interfering with let down
* Lack of information and support
* Inadequate milk supply
* Not feeding on demand
* Lack of rest
* Early introduction to solid foods
70
Rare Contradictions
* Transmittable viral diseases
* ETOH, drug addiction
* Malaria, active untreated TB
* Severe chronic diseases resulting in malnutrition
* Contamination from environment pollutant
71
Galactosemia
* Absolute contrindication
* Rare, inherited disease
* Inability to convert galactose to glucose
* Galactose accumulates in blood → estensive tissue damage and death
* Vomiting, large liver, jaundice
* Treatment is life-long
* Requires galactose and lactose restriction
* Soy-based formula required
72
Weaning
* Signals the end of exclusive breastfeeding
* Should be led by the baby, not the mother, but often is led by the mother
* Sign of infant maturity
* Should begin at 6 months when solid food introduced
