WCS21 Physiology Of Lactation, Breast Feeding And Infant Feeding 1

Question 1

Breast feeding

Answer 1

1. Principles of infant feeding
2. Benefits of breast feeding
3. Promotion of breast feeding
4. Physiology of lactation
5. Breast problems
6. Medication during breast feeding

Question 2

Principles of infant feeding

Answer 2

1. Adequate nutrition for maintaining homeostasis and for growth and development
2. Food easily digested and absorbed
3. Clean source of food, prevention of infection
4. Avoid early exposure to foreign protein + development of atopy
5. Special requirements for preterm infants, infants with metabolic diseases and other conditions

Question 3

1. Adequate nutrition for maintaining homeostasis and for growth and development

Answer 3

Energy: ***110 kcal/kg/day
- 20% required for growth
- 80% for activities, maintenance of body temperature

Carb:
- main source of energy

Protein:
- growth
- certain special amino acids found in breast milk —> brain development
- **Taurine: deficiency found to cause irreversible damage to retina
- **Cysteine: newborn lack enzyme to convert Met to Cys

Fat:
- energy + specific essential fatty acids —> brain development
- **LC-PUFA (long chain polyunsaturated fatty acids)
- **MCT (medium chain triglycerides)

Mineral (esp. Fe, Ca) + Vitamins

Question 4

Nutritional need of infant, child and adult

Answer 4

Kcal/kg/day
- 0-12 months: 110-85
- 1-3 years: 95-85
- 3-12 years: 85-60
- Adult: 40

Nitrogen (mg/kg/day)
- 0-12 months: 120
- 1-3 years: 120
- 3-12 years: 110
- Adult: 100

Question 5

2. Food easily digested and absorbed

Answer 5

Newborn digestive system not fully developed yet
- no teeth
- stomach less able to handle solids
- casein curds in stomach more difficult to digest and absorb compared to ***whey protein

Fat encased in lipase containing membranes in breast milk more easily absorbed

Question 6

3. Clean source of food, prevention of infection

Answer 6

• GE: commonest cause of infant death in developing counties
• Infection also ↑ energy requirement of infant
• recurrent infection is a cause of ***stunted growth

Question 7

4. Avoid early exposure to foreign protein + development of atopy

Answer 7

Exposure of infant in first few months of life to foreign protein:
- ↑ chance of eczema + asthma
—> Immature intestinal tract more susceptible to sensitisation?

Atopy: inherited susceptibility and exposure to antigen

SpC OG:
Eczema:
- Some studies suggest protective effect
- Other studies have shown either no association or even a detrimental effect
- Modification by family history of atopy is also variable
- Overall, literature suggests exclusive breastfeeding for at least 3-4 months is not associated with a lower incidence of eczema in either low-risk or high-risk infants

Asthma:
- ↓ no. of symptomatic URIs —> ↓ incidence of recurrent wheezing during 1st 2 years of life
- Wheezing in later childhood likely represent atopic asthma
- Association unclear

Allergic rhinitis:
- Insufficient studies to draw conclusions

Food allergy:
- Exclusive BF in 1st 4 months may decrease risk of cow’s milk allergy in early childhood
- A more general or long-term impact remains to be determined

Evidence is controversial

Question 8

5. Special requirements for preterm infants, infants with metabolic diseases and other conditions

Answer 8

Preterm infants:
- **higher energy requirement
- more susceptible to **LC-PUFA deficiency, ***Cysteine deficiency

Metabolic disease:
- infants with galactossaemia need ***lactose free diet (∵ lactose —> glucose + galactose)

Infection:
- higher energy requirement

Chronic lung problems:
- higher energy requirement

Question 9

Benefits of breastfeeding

Answer 9

Infant:
1. Nutritional value
2. Easily digested / absorbable
3. Prevention of infection
4. Prevention of atopy
5. Breast milk from mothers who deliver preterm suits special need of the preterm infant (i.e. has a different composition)

Mother:
1. Fertility control
2. Bonding
3. Uterine involution
4. Weight loss (BF: considerable energy expenditure)
5. Protection against **ovarian / premenopausal **breast cancer / ***osteoporosis

Society:
1. Birth control
2. Spacing out pregnancy, decreasing maternal death from childbirth
3. Prevention of infection and death in infancy
4. Much less costly than bottle feeding

Question 10

Contraindications to breastfeeding

Answer 10

1. Breast cancer (current)
2. Chemotherapy
3. HIV positive mother
   - if no safe alternative to breastfeeding, it should still be advised

(***Hep B carrier is OK!!!)

4. Infants with galactossaemia

Question 11

Promotion of breastfeeding

Answer 11

1. Understand blocks to breastfeeding
   - home / work environment
   - attitude of society
   - lack of public facilities
   - lack of family support
   - lack of support from health profession
   - promotion from formula milk companies
   - lost tradition
2. Education: public, school, antenatal, postnatal

Question 12

WHO 10 steps to successful breastfeeding

Answer 12

1. Have a written ***breastfeeding policy that is routinely communicated to all health care staff
2. ***Train all health care staff in skills necessary to implement this policy
3. ***Inform all pregnant women about benefits and management of breastfeeding
4. Help mothers initiate breastfeeding within **0.5 hour of birth, **early uninterrupted skin-to-skin contact ***>=1 hour after birth
   - Keep baby warm + calm
   - Promote bonding
   - Enhance immunity of baby (skin flora)
   - Facilitate breastfeeding
5. Show mothers how to breastfeed, how to maintain lactation even if they should be separated from their infants
6. Give newborn infants ***NO food / drink other than breast milk, unless medically indicated
   - Expressed breast milk should be 1st choice when supplementation needed
7. Practice ***rooming-in, allow mother and infant to remain together 24 hours a day
   - Mother learn how to respond to baby’s need
   - Reduce hospital acquired infections
8. Encourage breastfeeding ***on demand (showing signs of hunger)
   - Early cues: Increased activity, Look at mother, Turn to side to suck fingers
9. Give ***NO artificial teats / pacifiers to breastfeeding infant (baby has memory —> causing nipple confusion, cannot remember how to suck on mother’s nipple)
   - Cup feeding when giving supplementation
10. Foster establishment of breastfeeding ***support groups and refer mothers to them on discharge from hospital / clinic

(11. Respect + support mother who made an informed choice not to breastfeed
- Show mother how to prepare formula + sterilise bottles and teats

12. Promote and support Mother Friendly Care
    - Promote natural birth, non-pharmacological pain relief method —> pethidine, opioid can cause incoordination of suckling of baby, lose hand to mouth reflex
    - TENS —> stimulate endorphin release to relieve pain
    - Birth ball —> encourage baby head downwards for favourable position
    - Birth massage
13. Encourage + facilitate staff members to continue breastfeeding when return to work
14. Comply with the International Code of Marketing of Breastmilk Substitutes of the WHO
    - No advertising of all breastmilk substitute in hospital to public
    - No free samples / gifts to pregnant women / mothers
    - No gifts / personal samples to health workers
    - Health workers should never pass products on to pregnant women and mothers
    - Information to health workers must be scientific and factual
15. Support mothers to breastfeed infants in public areas of hospital + provide baby care room when necessary)

Question 13

Anatomy of breasts, Mammary growth and development

Answer 13

• Alveoli
• Mammary ducts / Lactiferous ducts
• Adipose tissue
• Areola
• Nipple

Puberty:
- Estrogen: **Milk duct proliferation
- Progesterone: **Alveolar development

Pregnancy:
- Estrogen + Progesterone: Further Alveolar hypertrophy but **inhibit milk production
- Prolactin (and Human placental lactogen) stimulate **secretory activity (milk production)

Question 14

Lactation

Answer 14

Initiation:
Estrogen + Progesterone ↓ rapidly after delivery
—> remove inhibition on milk production

Maintenance:
- Prolactin: milk **production reflex
- Oxytocin: milk **ejection reflex

Weaning:
- pressure built up by milk accumulating in alveoli —> ↓ milk production

Question 15

Milk production reflex and Milk ejection reflex (Let-down reflex)

Answer 15

Milk production reflex (Milk for next feed):
Suckling
—> afferent nerve
—> Hypothalamus
—> inhibit ***Dopamine release
—> removal of Dopamine inhibition on Prolactin release in anterior pituitary
—> ↑ Prolactin

Milk ejection / Let-down reflex (Milk for this feed):
Suckling
—> afferent nerve
—> Hypothalamus
—> production + transportation of ***Oxytocin to posterior pituitary (levels higher when mother hold baby)
—> Myoepithelial cells contraction
—> Squeeze around alveolus to propel milk down lactiferous duct
(—> Also stimulate uterine contraction)

Question 16

Prolactin and Oxytocin

Answer 16

Prolactin:
- Milk production: milk for next feed
- Depends on suckling
- Receptors need to be primed early (∵ Prolactin will drop after 1 month)

Recommendations:
1. Correct attachment
2. Demand feeding
3. Early feeding skin contact
4. Early + frequent expressing required if baby cannot feed
5. Together trigger lactation and mothering

Oxytocin:
- Milk ejection: milk for this feed
- Levels higher when mother holds her baby
- Induces well being
- Love hormone: calm mother + baby —> regular RR, BP, Pulse

Recommendations:
1. Ensuring relaxed, positive environment at delivery with facilitation of skin-to-skin contact
2. Keeping mother + baby together
3. Breastfeeding helps to stimulate mother infant bonding

Question 17

Ovulation suppression during lactation

Answer 17

Suckling ↑ sensitivity to Estrogen feedback
—> ↓ Pulsatile GnRH release
—> ↓ FSH, LH
—> No ovulation

Question 18

How to establish lactation

Answer 18

1. Early + Frequent suckling
2. Correct positioning
3. Avoid pacifiers
4. Avoid fatigue and anxiety

Correct position of suckling
- **whole areola in baby’s mouth
- tongue **presses on milk duct
- gums not chewing nipple
—> stimulate effective milk ejection + less engorgement

Question 19

Maternal problems in lactation

Answer 19

1. Sore nipples (mostly ∵ incorrect position)
2. Breast engorgement (mostly ∵ incorrect position) (occur early)
3. Blocked ducts
4. Mastitis (progressed from blocked ducts)
5. Breast abscess

Progression:
- Blocked duct —> Milk stasis —> Non-infective mastitis (2-3 weeks) —> Infective mastitis —> Breast abscess (6 weeks)

Question 20

Breast engorgement vs Blocked duct vs Mastitis

Answer 20

Breast engorgement
- Onset: Gradual, Day 3-5
- Site: Bilateral
- Swelling + heat: Generalised, nipple become shorten due to swelling
- Pain: Generalised (~2 stones on chest)
- Temp: <38.4
- Systemic symptoms: Well

Blocked duct
- Onset: Gradual, after feeding
- Site: Unilateral
- Swelling + heat: May shift (∵ plug may move) / little / no heat
- Pain: Mild + localised
- Temp: <38.4
- Systemic symptoms: Well

Mastitis:
- Onset: **Sudden, after 10 days
- Site: Usually unilateral
- Swelling + heat: **Localised red, hot, swollen
- Pain: **Intense but localised
- Temp: **>38.4
- Systemic symptoms: Flu-like symptoms

Question 21

Breast engorgement

Answer 21

• Gradual onset
• Day 3-5
• **Bilateral and **Generalised

Management:
1. **Proper positioning + latching on
2. **Frequent feeding
3. **Don’t skip feed esp. in night time (∵ milk produced + accumulate at night)
4. **Hot compress before feeding (only **2 mins to bring oxytocin to alveolar cells, too long will promote circulation and produce more milk)
5. **Express milk manually before feeding to soften the areola for baby to latch on
6. Analgesic
7. ***Cold compress over breast if engorgement persist after feeding
8. Supportive bra

Question 22

Blocked ducts

Answer 22

• Gradual onset
• After initiation of feeding
• ***Unilateral
• ***More localised
• If ignored / untreated —> may lead to mastitis
  —> Lump —> Hard swelling
  —> Tender —> Severe pain
  —> Localised redness —> Red area
  —> No fever —> Fever
  —> Well —> Ill

Causes:
1. Abundant milk supply
2. Not adequately drained each breast

Predisposing factors:
1. Incomplete drainage (skipped feeding / constrictive bra)
2. Stress

Management:
1. **Continue feeding
2. **Warm compress
3. ***Massage
4. Change position of baby (allow baby’s tongue to remove plug)
5. Effective removal of milk
6. Antibiotics NOT needed

Question 23

Mastitis

Answer 23

• Inflammatory condition of breast
• ***2-3 weeks after delivery (when breastmilk become plentiful)
• May / May not accompanied by infection
• Non-infective vs Infective mastitis (***Staph. aureus)

Causative organisms:
- Commonest: Staph aureus, Staph. albus
- Sometimes: E. coli, Streptococcus
- Others: Candida, Cryptococcus —> Fungal mastitis

Causes:
1. Non-effective removal of milk
2. Milk stasis and infection

Predisposing factors:
1. Fatigue / Stress
2. Blocked ducts / Engorgement
3. Constrictive bra
4. Skipped feeding
5. Cracked nipple (allow bacteria to enter breast)

Management (Treat promptly + adequately):
1. **Effective milk removal
- Expression / Breastfeeding
- Moist heat, Massage, Warm compress, Change position
- Resting in bed with infant to increase frequency of breastfeeding —> improve milk removal
2. **Continue breastfeeding
3. Adequate fluid intake
4. Analgesic
5. Antibiotics (severe cases)
- severe symptoms
- presence of nipple fissure
- persistent symptoms despite improved milk removal after 12-24 hours
- positive bacterial culture
—> Dicloxacillin
—> Amoxicillin (Augmentin)
—> Erythromycin
—> Cephalexin
—> Flucloxacillin

Question 24

Breast abscess

Answer 24

• uncommon
• more commonly in first ***6 weeks
• complication of mastitis

Management:
1. Drainage
- Small abscess: Aspiration
- Large abscess: Incision + Drainage
2. Antibiotic
3. Selfcare measures

Question 25

Drug use during breast feeding

Answer 25

Route of drugs from mother to baby via breastmilk:
Maternal gut + liver (oral bioavailability varies)
—> Maternal plasma (dilution of all drugs)
—> Milk alveolus (only drugs that are NOT protein-bound (i.e. fat-bound) can pass into milk)
—> Infant gut (oral bioavailability varies)
—> Infant plasma (usually very low level)

5 barriers:
1. Oral bioavailability varies (maternal gut / liver)
2. Concentration varies (maternal plasma)
3. **Non-protein bound drugs can pass (milk)
4. Oral bioavailability varies (infant gut)
5. Usually very low (infant plasma) (i.e. usually not harmful to baby, ∴ most of the time no need stop breastfeeding, unless e.g. **chemotherapy)

Question 26

Principle of maternal prescription

Answer 26

1. Only used medication when needed
2. Medications that can be used in infants are safe
3. Medications that are safe in pregnancy may ***NOT be safe in lactation (∵ no placenta to filter drugs)

Rule of thumb:
- Infant get ~1% of total maternal dose of drug administered to mother
- **Anti-cancer / **Anti-metabolic / ***Radioactive drugs (e.g. I131) should NOT be given

Use medications with:
- ***Highest plasma protein bounding
- Lowest plasma concentration
- Lowest oral bioavailability
- Lowest milk-plasma ratio
- Shortest t1/2
- Least toxicity

Question 27

SpC OG: Breastfeeding: Normal physiology of a healthy full term baby

Answer 27

• Baby cannot tolerate large amount of milk
• Small colostrum feeding are appropriate for the small size of newborns stomach and are sufficient to prevent hypoglycaemia
• Colostrum is thick + viscous + easy to manage while newborn learns to coordinate sucking, swallowing, breathing

Question 28

Get breastfeeding to good start

Answer 28

1. Start skin-to-skin contact right after birth
2. Recognise baby’s early feeding cues
3. Start feeding ASAP
4. Responsive / On demand feeding
5. 8-12 feeds / 24 hours

Question 29

Breastfeeding positions

Answer 29

1. Across the lap
2. Cradling
3. Football hold
4. Lying down

Key points of good position:
1. Baby’s head and body in line (all facing mother)
2. Baby held close to mother’s body
3. Baby’s whole body supported
4. Baby able to tilt head back
5. Nipple pointing to baby’s nose (instead of mouth) —> tongue able to work on skin instead of nipple —> less pain to mother

Key point to good attachment:
1. Baby’s mouth widely open (130-160o)
2. Chin indenting the breast (下巴頂住乳房) (so nose can move away from breast —> breathe freely)
3. Lower lips turned **outward (so tongue can work on skin)
4. **Rounded cheek
5. ***Bottom lip touches breast well away from base of nipple
6. No pain for mother (if have pain —> have problem)

Question 30

SpC OG: Neonatal Teaching: Infant Feeding
Developmental maturation of GI tract

Answer 30

• Fetal swallowing as early as 11 weeks
• GIT anatomically complete by 24 weeks
• Functional development continues into infancy
• Peristalsis at 28 weeks
• Coordinated suckling and swallowing at 33-36 weeks
• Gastroesophageal reflux common

Digestion:
- Lactase induction after birth
- Protein digestion efficient
- Fat - malabsorb 10-30% fat in preterm infants

Question 31

Normal daily requirement for Term and Preterm

Answer 31

Free water (ml/kg)
- Term: 100-120
- Preterm: 120-140

Energy (Cal/kg)
- Term: 100
- Preterm: 120

Carbohydrates (g/kg)
- Term: 10
- Preterm: 12-14

Fat (g/kg)
- Term: 1.5-2.2
- Preterm: 3.0-4.0

Calcium (mg/kg)
- Term: 45-60
- Preterm: 120-230

Iron (mg/kg)
- Term: 1
- Preterm: 2-4

Vitamin D (IU per 100Cal)
- Term: 40-100
- Preterm: 75-270

Question 32

Caloric density of human milk

Answer 32

Energy density (cal/g)
1 month postpartum: 680
2 month postpartum: 643
3 month postpartum: 625
4 month postpartum: 644

Question 33

Factor associated with changes in composition of human milk

Answer 33

1. During a nursing or feed
2. Time postpartum or stage of lactation
3. Diurnal rhythm
4. Between breasts
5. Gestational age at birth
6. Diet, region
7. Mother’s weight
8. Infection, metabolic disorders
9. Medications
10. Parity
11. Season (related to diet)
12. Age of mother
13. Infant’s birth weight
14. Processing – milk banking
15. Individuality

Question 34

How to establish milk flow

Answer 34

1. Optimal delivery room care
   - Early skin-skin contact of mother and infant
   - Breastfeeding within the 1st hour after birth
2. Optimal postdelivery hospital routines
   - Continuous rooming-in
   - On demand feeding schedules
   - Guidance to mother on successful initiation of BF
   - Scheduling a primary care appt 24-48 hrs after discharge (MCHC or day center)
3. Optimal postdischarge care
   - Evaluate within 24-48 hrs with assessment of adequate fluid intake, exam for evidence of jaundice or dehydration
   - Detect any BF problems
   - Provide additional support and/or resources to parents as needed
4. Feeding on demand
   - In response to infant cues:
   —> Move hands toward the mouth
   —> Suck on fists and fingers
   —> Fussiness, agitation, flailing of extremities
   —> Loud, persistent crying (= late sign: may have difficulty latching on)
   - Feeding in response to early cues
5. One side or both sides
   - Offer both sides each for 20-30 minutes during the initial period
   - Mainly on 1 side +/- other side when milk flow is established. The first breast offered should be alternated in consecutive feedings
6. Duration - depends in part upon efficiency
   - 20-30 minutes on each side initially
   - 8-15 minutes when milk flow is well established
7. Nursing frequency
   - 1st week —> On demand or when 4 hours have elapsed since the last feeding (wake them up from sleep for feeding to avoid hypoglycemia)
   - 8-12 times / day for the 1st 1-2 weeks postpartum
   - Subsequent weeks: 7-9 times per day by 4 weeks (after established milk flow)
   - Thorough emptying promotes lactogenesis (feedback mechanism)

Question 35

Is my baby getting enough?

Answer 35

Factors:
1. Diaper change
- Day 0: 1-2 wet diapers, 1 BO (Meconium: Dark green)
- Day 1: 1-2 wet diapers, 1 BO (Meconium)
- Day 2: 2-3 wet diapers (heavier), 2 BO (changing stool)
- Day 3: 3 wet diapers (heavier), 2 BO (changing stool)
- Day 4, 5: 3 BO (yellowish stool)
- Day 6 and beyond: 6 wet diapers (heavier)

2. Sense of let-down
3. Swallowing
4. Sense of satisfaction
   - Infant’s voluntary release of nipple and relaxation of facial muscles and hands
5. Weight gain
   - not a very good indicator to assess baby’s feeding during the first 10 days
   —> Weight loss of **5-7% up to 5 days is normal after delivery
   —> Baby’s body carries extra fluid and nutrients at birth
   —> Pass meconium & remove extra body fluid
   —> Regain birth weight by 1-2 weeks (~10 days)
   —> **15-40 g / day once BF is established

Question 36

Signs of dehydration

Answer 36

1. ***Sunken fontanelle (moderate)
2. ***Reduced level of consciousness (late sign, severe)
3. Sunken eyes, tearless
4. Dry mucous membrane
5. Reduced tissue turgor
6. Tachypnea
7. Tachycardia, hypotension, Peripheral vasoconstriction
8. ***Oliguria (early sign)

Risk of dehydration:
1. Hyperbilirubinemia (jaundice)
- ∵ ↑ Enterohepatic circulation esp. when feeding is minimal in first 2-3 days of life (∵ ↑ intestinal transit time)

2. Hypernatremic dehydration
   - Poor breastfeeding techniques
   —> insufficient lactation secondary to ineffective milk removal
   —> low volume intake of breast milk
   - High levels of Na in breast milk closely related with lactation failure
   - Complications: seizures, intracranial haemorrhage, vascular thrombosis or death

Question 37

Infant formula

Answer 37

1. Cow’s protein formula
2. Soy formula
3. Lactose free formula
4. Hydrolysed formula
5. Aminoacid formula
6. Goat’s milk
7. Cow’s milk
8. Evaporated milk
9. Skimmed milk

Constituting formula
- Boiled tap water at >=70oC (wait for 15min after boiling)
1. Distilled water
2. Mineral water
3. Rice water

Preparing bottles
1. Hygiene and sterilisation
2. Boiling water for 5-10 minutes
3. Chemical sterilisation

Soy formula / Soy milk:
- Low fat
- Low calcium
- Lactose free
- Not suitable for preterm infant
- Do not reduce allergy

Question 38

Supplementary Water intake / Fruit juice

Answer 38

Supplementary Water intake:
- Not necessary before introduction of solid food

After 6 months:
1. Plain water
2. Distilled water
3. Mineral water

Fruit juice:
- Not to start before 6 months
- Contains vitamin C and carbohydrates
- Reduces appetite to milk
- Dental caries
- AAP recommends fresh fruits than fruit juice

Question 39

Adding solids

Answer 39

• From 4-6 months onward
• Child has greater desire
• Nutritionally complimentary to breast milk
• Oromotor and gastrointestinal maturation
• Plain rice cereal / congee
• Gradually add puree of meat / vegetables / fruits

Question 40

Cow’s milk, Skimmed milk

Answer 40

Cow’s milk: after 1 year old
Skimmed milk: after 2 years old

Question 41

Postnatal growth of preterm infant

Answer 41

Can we achieve normal rate of intrauterine growth? (15-20g/kg/day)
1. Increased energy expenditure
- Temperature loss
- Digestion
- Stress
2. Disease condition (e.g. PDA limits intake)
3. Low intake of protein and energy
4. Fecal loss

Question 42

Parenteral nutrition

Answer 42

• Nutritional support when enteral nutrition is not feasible / not adequate to support nutritional needs
• Required energy 20% less than enteral:
  —> More elemental nutrients (reduces energy for digestion)
  —> No fecal loss
• Central venous catheter required because of high osmolality of infusate

Complications:
1. Venous catheter-related
2. Infection
3. Metabolic derangement
4. Liver derangement

Question 43

Common feeding problems

Answer 43

1. Cow’s milk protein intolerance / allergy
   - 2% in young infant, <0.5% in adults (UK)
   - Symptoms:
   —> GIT
   —> Systemic
   —> Failure to thrive
   - Recommend breastfeeding if strong family history / hydrolysed protein formula
2. Secondary lactase deficiency (Lactose intolerance)
   - Chinese: 12.2% at age 3-5 years, 33.1% at age 7-8 years, and 30.5% at age 11-13 years
3. Three-month colic
   - Rule of 3s
   —> Unexplained crying that begins sometime after 3rd week
   —> Lasts for >=3 hours each day
   —> Occurs on >3 days per week
   —> Continues for >=3 weeks
   —> Usually subsides by 3 months

Question 44

Summary

Answer 44

1. Breast milk is the best
2. Optimal nutritional support for preterm infants: early enteral nutrition (fortified breast milk) with TPN supplement
3. Nutritional requirements differs for different disease conditions
4. Nutritional support has short and long term effects on infant growth, development and survival

Question 45

Expressed breast milk

Answer 45

Usage:
- Baby staying in hospital because it was born too early or is too sick
- Mother can’t stay with the baby all the time because of work, travel or other reasons
- Usually start pumping the milk 2 weeks before back to work

How to express breast milk:
1. Breast pump (electric / manual)
2. Hand expression:
- Press (back towards chest) —> compress —> relax
- Can be challenging if large volume of breastmilk, but preferred in colostrum

Storage:
- Room temp up to **4 hrs
- Refrigerator up to **3-5 days
- Freezer up to ***9 months (thawed can be safely stored in standard refrigerator for up to 24 hrs)