Lecture 5.2 - Nutrition Flashcards
What is the main principle of the Baby Friendly Initiative?
Healthcare providers have to provide parents with all information about breastfeeding/alternatives so that parents can make an informed decision
How long is exclusive breastfeeding recommended? How long should breastfeeding continue once complementary foods are added to the diet?
First 6 months exclusively
+ Cont breastfeeding with complementary food for up to 2 years
What kinds of foods should be initially introduced to babies?
Iron rich foods - brain development
–> Soft meats, fortified cereals, fatty fish, eggs, beans, oats
Until 1 year of age babies should receive which supplement?
Vit D
–> 400 IU/day
Bone health, prevent rickets
Why is 6 months the age that complementary food is introduced?
Additional options needed for nutrition
Developmental milestones at this age:
–> Gut closure, mature
–> Ability to sit up independently
–> Tongue protrusion reflex has subsided
What is recommended if a baby is weaned from breastmilk before a year?
Iron rich formula recommended
–> Supplemental d/t high incidences of bacteria that use iron
What is mixed feeding?
Partial breastfeeding + formula
What unique properties of breastmilk make it ideal?
Composition changes with development of infant
Enhances maturation of GI tract + microbiome
Nutrients easier to absorb
Immunologically active components
–> IgA highest amount
–> T + B lymphocytes, epidermal growth factor, cytokines, interleukins, bifidus factor, lactoferrin
What immunoglobulin is most abundant in breastmilk?
IgA
–> Acts locally in GI tract
What kinds of protection does breastmilk provide?
Some protection against a broad spectrum of bacteria, protozoan infections
What is the composition of breastmilk?
87-88% - water
7% - carbs
1% - protein
3.8% - fat
Variations occurs with GA of infant, timing of feeds, maternal health
What is necrotizing enterocolitis? What is a risk factor for it?
Inflammation of intestines leads to Injury + death of cells
–> Perforations
Related to NBs having immature GI system –> Breastfeeding can decrease risk
What are some advantages of BF for maternal health?
Weight loss
Decreased risk of breast/ovarian cancers, rheumatoid arthritis, HTN, hypercholesterolemia, cardiovascular disease, DMII, osteoporosis.
+psychosocial benefits
When is BF contraindicated d/t maternal reasons?
Maternal HIV
–> In high income countries
Active maternal TB that is not in treatment, HSV on breast, Human T-cell leukemia virus type 1
Cancer therapy
Consider maternal substance use
–> Unregulated substances are most concerning
When is breastfeeding contraindicated for infant factors?
Galactosemia
–> Inability to process galactose
Will cause build up of bilirubin, jaundice
What maternal infections are not contraindicated to breastfeeding?
CMV, Hep ABC
Maternal HIV in low-income countries
Fever
What is the main reason why BF is stopped early?
Perceived insufficient supply and overall lack of BF and social support, which can lead to low self-efficacy
–> Practical knowledge and relevant information must be provided by HC providers
What are the functional units of the breast?
Alveoli - produce milk
Lobules - Contain many alveoli
Ducts - Carry breastmilk to the nipple (15-25 lactiferous ducts)
Montgomery glands/tubercles - small raised bumps on the areola that lubricate nearby tissue
What are Montgomery glands?
Small raised bumps on the areola that lubricate nearby tissue and secrete anti-infective substance
What are the stages of milk production?
Rapid Mammogenesis
Lactogenesis I
Lactogenesis II
Lactogenesis III
Stage IV: Involution
How much colostrum is produced by birth?
2-20ml/feed
What is rapid mammogenesis?
First half of pregnancy
–> Rapid growth of ducts and lobules, increased epithelial cells (response to progesterone and estrogen)
What is Lactogenesis II?
Secretory activation that occurs 48-72 hours PP to 8 days
–> Triggered by drop of P/E after delivery of placenta, stimulates alveoli to produce and secrete milk
–> Junctions between alveolar cells close and increased development of alveoli and ducts
–> Rapid increase in milk volume that levels off –> engorgement
What is lactogenesis I?
1st stage of milk production
–> Colostrum begins at 16 weeks
–> Prolactin is inhibited be progesterone/estrogen, dopamine (PIF)
What is lactogenesis III?
Maintenance stage (9+ days PP to weaning/involution)
–> Shift from endocrine to autocrine (supply driven demand)
Milk production regulated by feedback inhibitor of lactation that builds when alveoli are full, prevents prolactin uptake.
–> Prolactin cannot be taken up when alveoli are full d/t change in receptor shape
At what time of day does prolactin peak?
At night
How is milk production autoregulated during lactogenesis III?
Supply + Demand
–> Milk production regulated by Feedback Inhibitor of Lactation that builds when alveoli are full, prevents prolactin uptake.
–> Prolactin cannot be taken up when alveoli are full d/t change in receptor shape
What is essential for lactation maintenance?
Frequent milk removal
How much milk is being produced by two weeks after birth?
750ml/24 hours
How long does it take to establish a stable milk supply?
Can be up to 6 weeks
How often should baby eat?
8-12 feeds/day
–> or q2-4 hours + cluster feeds
Responsive feeding is best.
What are the periods of growth spurts for infants?
Day 6, 3 weeks, 6 weeks 3 months, 6 months
–> Associated with increased cluster feeding
What is Stage IV of BF?
Involution
–> Apoptosis of milk producing cells when weaning begins
Take around 40 days for involution to finish following last breastfeed
What are some unique aspects of colostrum?
Establishes microbiome + immunity
–> Higher concentration of immune cells
–> Rich in proteins d/t Igs, fat soluble vitamins, minerals. Cholesterol for myelination.
–> Natural laxative
Less fat and lactose than mature breastmilk
What is the volume of a NB stomach?
5ml
Transitional milk differs from colostrum in which ways?
Richer in fat, lactose, and calories.
The concentration of Igs gradually decreases as it transitions to mature milk.
What are the two kinds of mature milk?
Foremilk
–> Higher in protein, lactose, water
Hindmilk
–> Higher concentration of fats
What is some important teaching with breastfeeding d/t foremilk and hindmilk?
Encourage mother to let baby drain first breast before offering second
Start feeding on the breast they finished last
Where is prolactin released from? When do levels rise?
Anterior Pituitary
–> Inhibited by P/E/PIF (dopamine)
–> Prolactin levels increase after delivery of placenta d/t hormone drop and after 4 days d/t stimulation + effective drainage
What is the purpose of oxytocin in breastfeeding? Where is it released from?
Posterior Pituitary
–> Hormone of milk ejection reflex
What is the relationship between stress and oxytocin?
Oxytocin decreases cortisol and therefore stress
But high stress can inhibit oxytocin secretion.
How many MERs occur during a feed?
2-3x
–> Lasting 45 second to 3.5 minutes
What BF support can be done in the first few hours?
Skin-to-Skin ASAP
–> Allow dyad to get to know each other
Teach response to hunger cues and attempts to assess breastfeeding. Remember BF is a learned skill between two people.
When can hand-expression be helpful?
Increases self-efficacy/confidence
–> Softens tissue to make latch more comfortable for both
–> Stimulates MER for a sleepy baby
What are some early hunger cues for baby?
Quiet Alert state
–> Hand to mouth
–> Sucking/mouth movements
–> Strong rooting
–> Hunger posturing
What are late hunger cues for baby?
Crying
Irritable, frustrated, fall asleep
What are infant satiation cues?
Slowed/decreased sucking
Release of nipple or turning/arching away
Relaxed body (extension)
What is a sign that an early feed might be effective?
Good latch + sucking
–> Early feeds can take a long time, that okay
When and where is oxytocin released?
From Posterior Pituitary
–> Labour, skin-skin, orgasm, when thinking about baby, bonding/love hormone
How does colostrum prevent jaundice?
Natural laxative which promotes excretion of meconium, which has high bile concentration (and therefore promotes excretion of bili)
What are the general principles of breastfeeding position?
Tummy-to-tummy
Baby to breast, not breast to baby
Both well supported and comfortable
Eye-contact
What is mother-led latching?
Mother controls and adjusts breast and baby’s head to facilitate latch
What is baby-led latching?
Allows baby to move towards latch, baby will reach up with chin and latch
What BF position can be comfortable for someone recovering from c/s?
Side-lying
–> Takes pressure of incision
What BF positions can be more comfortable for someone with larger breasts?
Football or side-lying might be more comfortable
What are some signs of effective breast milk transfer to infant?
Baby sucks more quickly and shallowly at first, then moved to slower deeper pattern
Swallowing - chin drop w audible swallow
May see milk around mouth
Satiation position through feed
What is involved in a latch assessment?
L - Characteristics of latch itself
A - Degree of audible swallow
T - Type of nipple
C - Comfort (maternal)
H - Holding skills
Assess and work with mother.
When can uric acid crystals be normal for an infant?
Day 1-4 might be normal finding
–> Concentrated urine
What % weight loss for a baby is normal in the first 3 days?
up to 7% is normal
–> Cannot dc if greater than 10% weight loss
When do babies start gaining weight? Why?
Day 4+ - 20-35 g/day
–> Milk let down
When is birth weight regained?
Day 10-14
When is supplementation of BF indicated?
Greater than 10% weight loss/inadequate weight gain
Hypoglycemia
Still passing meconium at day 3-4, or no stooling for first 24 hours
Signs of dehydration/decreased urine output
Maternal contraindications to BF
What must be kept in mind if we are supplementing BFing?
Implement action to protect the mother’s milk supply
–> Pumping, hand expression
What is the first choice for breastfeeding supplementation?
EBM
How often and for how long should someone pump?
Minimum 6x a day (Q4) over 15-20 minutes until MER stops.
When is pumping indicated?
Premature bbs, severe tongue tie, separation from mother
If a person is exclusively pumping, why is it essential to pump at night?
Prolactin increases at night
–> Facilitates full milk supply or complications d/t milk stasis
How can EMB be stored?
3-4 hours room temperature - maybe up to 4-8
Fridge - 3-8 days
Freezer - 3-6 months
What are some alternatives to bottle feeding if the person is also BFing?
Cup, spoon, dropper
How many extra calories are needed while BFing?
500 cals/day
When does engorgement occur most often? How long does it usually last?
Often occurs day 3-5 and lasts 24 hours
–> Related to milk stasis
How can breast engorgement be managed?
Effective drainage
Warm compresses, massage to soften breast before feeding
Hand expression to make latch easier
Cool compresses between feeds for comfort
Tylenol + Advil
What is the most common cause of nipple pain with BFing?
Poor positioning, latch issues, infection, improper suck
–> Can also be thrush, vasospasm, Reynaud’s
What is the first intervention to treat nipple pain?
Correct the latch
When can expressing some milk onto nipple before feed be helpful?
For mild pain - soothes and prevents growth of thrush
What topical application can help sore nipples?
EBM, lanolin, nipple cream, hydrogel dressing
What is a blocked milk duct? What causes it?
Swollen, tender, leads to narrowing of duct with afebrile mother
–> result of inadequate emptying
What should we assess when there is pain with breastfeeding?
Thrush, tongue tie, poor latch
How can a blocked milk duct be managed?
Warm compress or massage to encourage drainage
Frequent feeding
Changing BF position - point chin to affected area can massage area
What is mastitis?
Inflammatory or infective
–> Localized pain and tenderness, red, warm
Infective will also present with sudden onset flu-like symptoms
How is mastitis managed?
Rest, care - fluids, nutrition
Effective drainage but no extra drainage to prevent overproduction
Cool compress between feedings
–> Warm can worsen inflammation
Antibiotics for infection
When is soy-based infant formula recommended?
Only when recommended by health care provider
Patients should be taught to have how much ready to feed formula available?
72 hours worth
–> In case of loss of safe water source or loss of power
