March242015Dr.ElskeHildes-Ripstein-ChildHealthandPediatrics
Outline1. Toreviewthephysiologyofbreastmilkproductionand
lactation2. Tounderstandthenutritionalbenefitsofbreastfeeding
andthehealthbenefitsforbothinfantandmother3. Tobecomeawareofcommonbarrierstosuccessful
breastfeeding4. Tounderstandhowthe10stepsofBFI“BabyFriendly
Initiative”supportsbreastfeedinginhospitalsettings5. Toacknowledgewhatcanbedoneinanindividual
practice
Mammogenesis� Duringpubertyalveolarbuddingstartswithinmammarygland/tissue
� Itcontinuesundertheinfluenceofmenstrualcycleestrogenandprogesteroneuntiltype1,2and3lobulesarepresent.
� Type4lobulesdeveloponlyundertheinfluenceofHumanChorionicGonadatropinduringpregnancy
HormonalinfluencesonMammogenesis,LactogenesisI,IIand
Galactogenesis
LactogenesisI(Secretoryini;a;on;latepregnancy>20weeks)� HCGfromplacentacausesterminalbudding(type4lobulesofbreastwithsecretoryacini)
� HighProgesteronefromplacentainfluencesfurtherdifferentiationandbeginningofsecretoryactivity(colostrumsecretionbeginsandcolostrumaccumulateswithinaveoli).Insulin,cortisol,humanPlacentalLactogenalsonecessary.
� Colostrumisthe“firstmilk”ayellowishwaterysubstancecontainingcaseinandlactoseandsecretoryIgA;
� ThehighpregnancylevelsofProgesteroneandEstrogeninhibitprolactinstimulatedmilksecretionuntildelivery
Lactogenesis-;melineandhormonalinfluences
LactogenesisII� DuringLabouranddeliverythereisapeakofcortisolandprolactinwhichresultsinaburstofmitoticactivityinmammaryglandandmilksecretion/production.
� Therapiddeclineofprogesteroneandestrogenaftertheplacentaisdeliveredallowtheprolactinstimulationofmilksupplyandsecretion.
� Thetransitionbetweencolostrumand“breastmilk”isusualbetweenday2-3butmaybeaslateas7days.
� Thisphasecanbedelayedwithdiabetes,C-section,placentalretention,stressfulvaginalbirthetcastheyaffecthormonalfeedbackloop
GalactogenesisorLactogenesisIII� Thisphaseisthemaintenancephaseoflactationextendingfromtheproductionofmaturemilkuntilweaning.
� Localmechanismsforhormonalreleaseandfeedbacksuchasinfantsuckling-mechanicalstimulation;infantcry-neuroendocrinereceptorsbrain;removalofmilk-pressurereceptorsinbreastdownregulateprolactinreceptorsetc
� Prolactinisreleasedfromanteriorpituitaryinburstsinresponsetoinfantsuckling(stimulationofmilksupplyandproduction)whileoxytocinisreleasedfrompostpituitary(ejectionreflex-myoepithelialcellcontraction)
HumanBrMilkComposi;on� Nutritionalqualityishighlyconservedacrossindividualsandpopulations
� Mainlylactose,proteinandfat� 3sourcesofmajorcomponentsofBreastMilk;eithersynthesizedinlactocyteviareceptormediatedtransportacrossmammaryepitheliumfrommaternalstoresoccinfluencedbymaternaldiet-egfattyacids,producedbycellsinBrmilk
Bioac;veFactorsinHumanMilkFactors Examples RoleImmunoglobulins IgG,IgM,sIgA Antibacterial
Cytokines TGF-Beta,IF6-10,TNF-alpha
Immuneactivationandanti-inflammatory
Cellularcomponents Macrophages,stemcells Antibacterial
GrowthFactors- IntestinalGF(EpidermalGFandneuronalGF,tissueGF,vascularendothGF,Erythropoetin)
PromotesIntestinalmaturationandhealing,vascularanderythrocytegrowth/production
CytokineInhibitors Anti-inflammatory
Antimicrobialproteins lactoferrin,lactadherin Anti-bacterialproperties
Oligosaccharides, glycans;mucins,HumanMilkOligosaccharide
Anti-infectivepropertiesNon-nutritive,promotesprobioticorganisms
Hormones, ghrelin,adiponectin,leptin,calcitoninandsomaostatin
Anti-infantobesity,energycontrol,appetitecontrol,antinflammation
GoodForInfant� DecreaseInfectiousMorbidity(innateimmunefactors) OM3.6foldincreaseFormulavsBrfedinfants GIinfections2.8xriskFormulavsBrfed NECinprematureinfants2.4xriskFormulavsBrfed
� Decreasesasthma,atopicdermatitis1.4-1.7xriskFormulavsBr
� Decreasesriskofobesity?inconclusivestudiesbutBreastmilkcontainsadipokinesandmayregulateenergyintake.
� DecreasesSIDS1.6-2.1xriskFormulavsBrfed.
GoodForMom� DecreasesRiskBreastCancer(NeverBrfed2.4xriskpremenopausalBrCa)
� DecreasesOvarianCa(NeverBrfed1.3xrisk)� Metaboliccost=500kcal/dayforbreastfeeding.promotesweightlossandfavorableglulevel,lipidmetabolismandBP.
� Differencesinmetabolismpersist-(Neverbrfedmetabolicsyndrome1.3xrisk,Myocardialinfarction1.3xriskandType2DM1.7xrisk)
CanadianPediatricSocietyGuidelines
Recommend:� ExclusiveBreastfeedingforthefirst6months(plusVitDsupplement)
“howeverintroductionofcomplementaryfoodsshouldalsobeledbyinfant’ssignsofreadinessandmayoccurfewweeksbeforeorafter6months.Beyond6months-delayincreasesriskofirondeficiency”
� EncourageBreastfeedingfor2yearsandbeyond(whileprovidingappropriatenutritionalguidance)
www.cps.ca-positionstatementsPaediatrChildHealth2013;18(4)
Factorsinfluencingsuccessoflacta;on(ini;a;onanddura;on)� Skintoskincontactatdeliveryforfirsthour.(increasesprolactin)
� Nolimittoinfantsuckling;frequentfeeds� RoominginandFeedingondemand� SupportExclusiveBrFeeding-noformulamarketingpacks(volumeinterfereswithfreqsuckling)
� Noartificialnipplesuntillactationestablished(bottleorpacifiers-differenttongueactionandflow)
� Resources(Peersupport;lactationconsultantsinhospandcommunity-lalecheleague-midwife)
WHO1981Interna;onalCodeofMarke;ngBreastMilksubs;tutes� TheMemberStatesvotedtoapprove118-yeswith1abstention:
“Consciousthatbreast-feedingisanunequalledwayofprovidingidealfoodforthehealthygrowthanddevelopmentofinfants;...........protectsinfantsagainst
disease;andthatthereisanimportantrelationshipbetweenbreast-feedingandchild-spacing;
Recognizingthattheencouragementandprotectionofbreast-feedingisanimportantpartofthehealth,nutrition.....andthatbreastfeedingisanimportantaspectofprimaryhealthcare;Consideringthat,whenmothersdonotbreast-feed,oronlydosopartially,thereisalegitimatemarketforinfantformula......butthat(it)shouldnotbemarketedordistributedinwaysthatmayinterferewiththeprotectionandpromotionofbreast-feeding;”
BabyFriendlyIni;a;ve� Bornfromthe“InnocentiDeclaration1990”-promotingandhelpingtoestablishexclusiveBreastFeedingasthenorm
� In1991theBabyFriendlyHospitalInitiativewasestablishedbyWHOandUNICEF;andupdated2009basedonrecentevidence
� Canada’sProgramisknownastheBabyFriendlyInitiativeandiscomposedof10stepsthatareknowntoimproveBreastfeedingoutcomes.ForBFIaccreditationhospitalorcommunityprogramhastocomplywithall10steps
10Components/StepsofBFI“BabyFriendlyIni;a;ve”
1.WrittenBrFeedingPolicyinplace2.TrainallHealthCareProvidersinBrFeedingSupport3.InformallpregnantwomenofthebenefitsBrfeeding4.Placeinfantskintoskinforatleast1hourimmediatelyafterbirth5.ShowhowtoBrfeedandmaintainlactation(handexpression)6.NofoodordrinkotherthanbreastmilktoBrfeedinginfant(unless
medicalindication)7.Practiceinfantandmotherrooming-in8.EncourageBrfeedingondemand-mothersalerttofeedingcues9.Supportmotherstocareforandfeedwithnoartificialnipples/
pacifiers10.EstablishBrfeedingsupportgroupsfordischargedmothers� BFIsupportsinitiationanddurationofBreastfeeding
RecentdatafromManitobaHospitaldischargeabstractsbyregionNorecentManitobaDataonDurationofBreastfeeding
BreasTeedingatdischargefrombirthhospitaliza;on(MB2012/13)*
Wpg ThePasn=339
Thompsonn=806
Brandonn=1666
BoundryTrailsn=944
HSCn=5400
StBn=57oo
AnyBreastfeeding
83% 70% 65% 84% 93%79%
87%
ExclusiveBreastFeeding
43% 51% 20% 49% 74%41% 44%
*SourceExcelsheetfromLindaRomphf(LactationConsultantandBFIadvisor
2009/10CanadianCommunityHealthSurvey-dura;onExclBreastFeeding
2009/10CanadianCommunityHealthSurvey-MatReasonsdiscon;nua;onExclBreastFeeding
Opportuni;esforPromo;ng/Suppor;ngBreasTeeding–aPhysician’srole1. DuringPregnancyoratdelivery
2. DuringBirthHospitalisation
3. DuringHealthVisitswithin1styr
4. CommunityAdvocacy
1.DuringPregnancyordelivery� exploremother’sknowledgelevelaboutBrfeedingandDispelmyths,
� Ensureskintoskintimeandfirstfeedwithin1hour.� Supportcolostrumtransportasnecessaryforprems/IDM
� Ensurenophysical/medicalbarrierstobrfeeding-hypotonia,cleftpalateetc
2.DuringBirthHospitalisa7on� Impartknowledgeandcorrectmisconceptions;(notenoughmilk,wantotherstobeabletofeedbaby,)
� Supportandreassure-goovernormalweightpatterns(10-15%lossnotuncommon)
� Ensuresafefeedingplanforinfant.Adequatecaloriesprovidedtoeachinfantforgrowth(canusecuporsupplementalsystemforEBMorformula.)Avoidhypoglycemia-butcantrialglucosegelratherthanformula
� Ensureaccesstocommunitysupports/resources(PublicHealth,Breastfeedinghotlineandclinics,lalecheleague)
3.HealthVisitswithin1styr� AskaboutandSupportSustainedBrFeedingeveryvisit.Answerquestionsandtroubleshootorgivemotheradequateresourcesforinfo/help.
� SupportExclusiveBreastfeedinguntil6monthsage� Remindanyamountofbreastisbeneficial!;(preventsinfection;manybenefitsandconveniences-alwayswarm,neverrunout,noneedtosterilizeitems
� Discusstheamazingcapacityandflexibilityofmilkproduction(rightamountattherighttimefortherightage)
4.CommunityAdvocacyAsidefromindividualpatientadvocacy:
� SupportyourhospitaltobecomeBFIcertified� Beawareofandavoidformulacompanymarketing� AdvocateforHumanMilkBanking;� ProvidePublicandSocietywithcurrentknowledgetosupportnormalizationofbreastfeedingfor2yrsandbeyond(workplaceaccommodationsforBrfeedingmoms;rootsofempathyprograminschoolsetc,publichealthbenefitseducationetc).
WorkingwithHealthcareteam,NursingLacta;onconsultants,Publichealth
� Proudandgratefulfortheteamapproach!� Dependonnurses/midwivesskintoskin;firstcolostrumandfeedat30minutesage;teachhowtopositionandlatchanewborn.
� GratefulfortheLCteammedicationsinbreastmilk,helpingprematureinfants,oruniqueordifficultcases
� PublicHealthearlyhomevisit,weigh,monitorjaundiceandtroubleshootfeedingissues
Lactogenesis-hormonalinfluences
HumanMilkComposi;on(PedClinicsNAmericaFeb2013)Macronutrient(g/dL)andenergy(kcal/dL)
Proteing/dl(Casein)
Fatg/dl Lactoseg/dl Energymeankcal/dl
TerminfantsMaturemilkn=581(1991)
1.2(0.9-1.5) 3.6(2.2-5.0) 7.4(7.2-7.7) 70(57-83)
DonormilkN=415(2009)
1.2(0.7-1.70) 3.2(1.2-5.2) 7.8(6.0-9.6) 65(43-87)
MaturemilkRefStdn=2553(1990)
0.9(0.6-1.4) 3.6(1.8-8.9) 7.2(6.4-7.6) 67(50-115)
Preminfant<29weeksN=52(2011)
2.2(1.3-3.3) 4.4(2.6-6.2) 7.6(6.4-8.8 78(61-94)
32-34weeksN=20
1.9(1.3-2.5) 4.8(2.8-6.5) 7.5(6.5-8.5) 77(64-89)
Donorpremn=47(2012)
1.4(0.8-1.9) 4.2(2.4-5.9) 6.7(5.5-7.9) 70(53-87)
%ExclusiveBreastFed %AnyBreastFed
01020304050607080
birthhospd/c
~3.5mthage
non-Aboriginal
Aboriginal*p=0.004
01020304050607080
birthhospd/c
~3.5mthage
non-Aboriginal
Aborigianl
combined
BreastfeedingatBirthand4months1996
*p=0.018
%Motherscon;nuedBreasTeedingofthoseini;a;ng
0
10
20
30
40
50
60
~3.5mthsage
non-Aboriginal
Aboriginal
P=0.22NS
2009/10CanadianCommunityHealthSurvey-dura;onBreastFeeding6months-ethnicity
2009/10CanadianCommunityHealthSurvey-dura;onBreastFeeding6monthsbymatage
WHO1981Interna;onalCodeofMarke;ngBreastMilksubs;tutes� WHOandUNICEF(UnitedNationsChildren’sFund)emphasizedtheimportanceofmaintainingthepracticeofbreast-feeding—andofrevivingthepracticewhereitisindecline—asawaytoimprovethehealthandnutritionofinfantsandyoungchildren
� noteddeclineofbreastfeedingforavarietyofreasons:“includingthepromotionofmanufacturedbreast-milksubstitutes,andurged"Membercountriestoreviewsalespromotionactivitiesonbabyfoodstointroduceappropriateremedialmeasures,includingadvertisementcodesandlegislationwherenecessary”
Creden;als:� PediatricianatChildren’sHospitalofWpg-DeptofPediatricsandChildHealth-(inpatientwardsandoutpatientclinic)
� ServiceChieffortheHealthyNewbornWardsatWomen’sHospital(2008-present)
� FacultyatUniversityofManitoba-teachmedstudents,internsandpediatricresidentsaboutwellinfantandchildcare
� MScthesison“infantcarepractices”‘95/96(asrelatedtoSIDS;includedsomebreastfeedingsurveydata)
� Proudmotherof4breastfedchildren!