Breast Feeding

This article was checked by pedagogue

This article ws checked by pedagogue, but later was changed. Checked version of the article can be found here. See also comparation of actual and checked version.

Breastfeeding

Woman breastfeeding

The World Health Organization (WHO) recommends breast milk as the only food or drink offered to infants during the first 6 months of life . To promote breastfeeding, mothers should be empowered to initiate skin-to-skin contact with their infant immediately after birth for at least one hour . Exclusive breastfeeding is recommended for the first 6 months, with continued breastfeeding for 2 years or more, with the appropriate introduction of solid foods .

The first milk produced by the mother is known as colostrum. This thick creamy milk is rich in protein and antibodies, which help the baby ward of infection . Colostrum is highly nutritious and is the perfect first food for the infant .

Exclusive breastfeeding promotes optimal growth and development. In developing countries, “the most important benefit of breastfeeding is the infant’s immediate survival ”. The chance of survival in the early months is at least six times greater among children who are breastfed compared to those who are not . Breastfeeding reduces the risk of death from acute respiratory infection and diarrhea, as well as other infectious diseases .

Each mother’s milk is unique and provides the right amount of protein, carbohydrate, fat, vitamins and minerals for her infant at each stage of development . In addition to its nutritional components, breast milk also contains immune factors that help protect the infant from infection and disease . Breastfeeding supports the development of the infant’s immune systems and helps decrease the risk infection and illness during childhood, as well as the risk of chronic conditions, such as obesity and diabetes later in life .

Vitamin D

Vitamin D is necessary for proper bone development. Vitamin D deficiency may occur among breastfed infants who do not receive much exposure to sunlight . In developed countries, mothers are recommended to give breastfeed infants Vitamin D drops to help prevent deficiency. Breast milk substitutes are fortified therefore supplementation is not necessary in infants who are not breastfed.

Importance of Breastfeeding

There are many reasons why a mother should breastfeed. Breastfeeding is associated with important short and long-term health outcomes for both mother and child. Breastfed infants are at lower risk of ear infections, respiratory illnesses, allergies, diarrhea and sudden infant death syndrome . Long term, breastfed children are at lower risk of childhood leukemia, diabetes, asthma, obesity, and have higher IQ scores .

For the mother, breastfeeding helps reduce the risk of post-partum haemorrhage, postpartum depression, and delays the return to fertility. Long term mothers who breastfeed are at decreased risk of osteoporosis, ovarian and breast cancer . Both mother and child benefit from early skin-to-skin contact as this helps to establish a bond that promotes healthy social emotional development .

Complementary Feeding

At 6 months, the child’s nutritional needs begin to change and developmentally they are ready to begin eating small amounts of family foods. Breast milk continues to be the child’s main source of nourishment well beyond the first year of life . At 6-8 months, the child should be offered small meals of complementary foods 2-3 times per day. The first foods introduced should be smooth in texture to minimize the risk of choking. Parents and caregivers should be encouraged to increase the quantity of food, as the child gets older, while maintaining frequent breastfeeding . By 9 months, meals of complementary foods should be offered 3-4 times per day with nutritious snacks offered between meals 1-2 per day .

Parents and caregivers should offer a variety of foods to ensure the child’s nutrient needs are met . Early on, iron rich foods are particularly important because by 6 months the infant’s iron stores have been depleted . Therefore, meat, poultry, fish or eggs should be eaten daily, or as often as possible .

Continue to modify the texture, progressing from smooth to a slightly more lumpy texture, and finally to small pieces of food when the child is developmentally ready . As the child continues to grow, offer a variety of foods from each food group. Parents and caregivers should be encouraged to pay attention to their child’s hunger and satiety cues, sit with their child while eating, and make meal times pleasant.

Contraindications to breastfeeding

Absolute contraindications:

• from the child's side:
  • classic form galactosemia with zero activity of gal-1-puridyltransferase in erythrocytes;
• on the mother's side:
  • HIV/AIDS infection (applicable only in developed countries);
  • HTLV 1, 2 infection.

Partial Contraindication:

• from the child's side:
  • phenylketonuria – according to individual phenylalanine tolerance;
  • other metabolic defects – according to consultation with the center of metabolic defects;
• on the mother's side:
  • drug abuse.

Temporary Contraindication:

• on the mother's side:
  • herpes zoster, herpes simplex on the breast – do not breastfeed the child from the affected breast until the lesions disappear (regularly express and pour milk), you can breastfeed from the other breast;
  • cytomegalovirus – for premature babies of seropositive mothers, consider the benefits and risks of breastfeeding;
  • chickenpox that appears within 5 days before delivery and within 2 days after delivery - isolate the mother from the child until the blisters burst, give the child varicella-zoster immunoglobulin; the baby can be given expressed mother's milk;
  • active tuberculosis – separate the mother from the child until the treatment begins to work and the mother is no longer infectious, give the child vaccination and chemoprophylaxis; the baby can be given expressed mother's milk;
  • radioactive isotopes – use radionuclides with the shortest possible half-life; interrupt breastfeeding for a period 5 times longer than the half-life;
  • chemotherapy;
  • some drugs (the list is available on the website TOXNET).

Medicines absolutely contraindicated during breastfeeding:

• cytostatics, immunosuppressants, estrogens (they reduce lactation), addictive substances (heroin, cocaine, amphetamine); ergot alkaloids (bromocriptine, ergotamine), lithium, gold salts, radioactive isotopes.

'No contraindications:

• on the mother's side:
  • hepatitis A, B, C (consider breastfeeding in acute HBV infection of the mother, i.e. if the mother is HBsAg and HBeAg positive and anti-HBe negative);
  • febrile conditions, viruses, mastitis, vaccination, diseases of the digestive or uropoietic tract;
  • smoking – the mother is advised to stop smoking;
  • occasional consumption of alcohol 2 hours apart from the next breastfeeding.

Physiology of Lactation

File:Breastfeeding.webm

Breastfeeding (video).

Breast milk is formed 'in the epithelial cells of the alveoli of the mammary gland and is secreted into the alveoli, from where it flows through the small and large milk ducts into the wide sinuses in the area of ​​the areola. These sinuses then open on the nipple. Growth and differentiation of the mammary gland as well as milk production are under endocrine control.

After the expulsion of the placenta during childbirth, a large amount of prolactin is released from the adenohypophysis, which triggers the production of milk in the first days after childbirth. The hormone prolactin plays a key role in lactation. Frequent breastfeeding early after birth stimulates the development of prolactin receptors in the mammary gland. Delaying suckling after birth leads to lower prolactin levels and thus fewer stimulated prolactin receptors.

'During sucking of the baby, nerve impulses are sent from the breast to the neurohypophysis, which releases oxytocin. Under the influence of oxytocin, the myoepithelial cells of the milk ducts contract and the milk moves from the alveoli towards the nipple ("milk ejection reflex" or "let-down reflex"). Initially an unconditioned reflex, it soon becomes conditioned and can be inhibited by anxiety and pain.

Initially, lactation is hormonally controlled and colostrum production occurs independently of suction. Colostrum is thick, produced in small quantities (4-14 ml at each feeding). Over the next 48-96 hours, milk production increases significantly and the amount produced is controlled by suction and demand (the amount of milk removed). These events are crucial for the continuation of lactation. After 1-2 weeks, the average milk production is 700-800 ml/day (with significant individual variability of 450-1200 ml/day). At the end of each feeding, about 100 ml of milk remains in the breast. Infants appear to be able to self-regulate their milk requirements to grow normally, so assessment of breast milk intake is only appropriate if weight gains are unsatisfactory.

Milk is produced while it is being removed from the breast. The rate of milk production may differ between the two breasts if the length and frequency of sucking is not the same. It can be concluded from this that autocrine regulation of milk secretion occurs in each breast separately, by the formation of a local factor (the so-called feedback inhibitor of lactation).

Main principles of breastfeeding

Development of lactation in the maternity ward':

• support breastfeeding without limiting the length and frequency - breastfeed according to the child's taste;
• put the child to the breast at least 8-12 times in 24 hours (possibly even more often);
• breastfeed from both breasts during one feeding;
• signs of the child's readiness for breastfeeding: alertness, activity, opening the mouth and seeking the breast; crying is a late sign of hunger.

Developed lactation after discharge from maternity hospital:

• during the first examination of PLDD, assess the child's nutritional status, evaluate the success of breastfeeding according to the number of stools (3-6 per day in the first 6 weeks, then the absence of stool for several days is possible), wet diapers (6-8 per day) and observation of breastfeeding, assess icterus;
• breastfeed only from one breast during one feeding;
• a healthy breastfed baby does not need any other fluids, food, food supplements or other milk in addition, except for medically indicated cases;
• in the case of indicated supplementary feeding, administer complementary feeding in an alternative way, i.e. through a breast or finger probe, a cup, a spoon or from a supplementer;
• do not use bottles and pacifiers - they spoil the breastfeeding technique, especially in the first 6 weeks, before breastfeeding stabilizes;
• do not routinely use nipple caps - use only for inverted or flat nipples;
• after breastfeeding, only spray if there is an excess of milk;
• take into account the need for more frequent breastfeeding during growth spurts, i.e. 3rd and 6th week, 3rd and 6th month;
• monitor weight gain - between weeks 2 and 3, the baby should reach its birth weight and then gain an average of 125-200 g per week in the first 6 months; growth along percentile graphs.
• a nursing mother should follow the principles of proper nutrition, not smoke, not drink alcohol; she should not lose weight rapidly (when fat is mobilized, harmful substances such as polychlorinated biphenyls, chlorinated hydrocarbons and heavy metals would be released into breast milk); from the point of view of preventing allergies in the infant, no specific dietary measures for the mother are recommended;
• you can breastfeed during the next pregnancy.

Composition of breast milk

The composition of breast milk corresponds to the needs of the newborn. In the first days after birth, colostrum is formed, which is rich in immunoglobulins and has a lower lactose content. After a few days it turns into mature milk. The caloric value of breast milk is approx. 67 kcal/100 ml. Composition of breast milk - carbohydrates: 10 g/100 ml, fats: 5 - 6 g/100 ml, proteins: 1.5 g/ 100 ml.

Colostrum (colostrum)

• Produced during the first week.
• Contains more protein', less fat and carbohydrates.
• Rich in macrophages, lymphocytes, granulocytes, secretory IgA.
• It has a lower energy content, approx. 56 kcal/100 ml.

• Thick, creamy yellow liquid.
• It is well adapted to the needs of the fresh newborn - the kidneys are not yet able to eliminate the fluid load, low production of lactase in the intestine, vitamin A and E protect before oxidative stress, vitamin K reduces the risk of hemorrhage.

Transition milk

• Formed 2nd to 3rd week after birth.
• Contains less protein, more fat and carbohydrates.

Mature breast milk

• Formed about 3 weeks postpartum.
• Breast milk does not have a constant composition. Significant changes occur not only during lactation, but also during the day and during each feeding.
• Energy content is about 60-70 kcal/100 ml.

Proteins

• Breast milk (MM) contains 'about 1 g of protein per 100 ml, which is relatively little.
  • The protein content of mammalian milk probably corresponds to the postnatal growth rate of the young. In humans, the postnatal growth of children is very slow compared to other mammals, and the protein content of breast milk is also very low. E.g. cow's milk contains about 3.5 g of protein per 100 ml.
• Proteins are represented by ``primarily whey and casein. Whey represents about 60% of all proteins in MM and is of high nutritional value, containing many essential amino acids. The ratio of whey : casein is 70 : 30.
  • Cow's milk (KM), on the other hand, is dominated by casein and whey makes up only 20% of the protein. Casein can coagulate at low pH (e.g. in an infant's stomach) to form lumps ("curds").
• α-lactalbumin is the most abundant in MM serum, followed by lactoferrin.
  • The main protein in cow's milk whey is β-lactoglobulin, which is completely absent in human MM and is therefore potentially antigenic for children. α-lactalbumin is contained in cow's milk, lactoferrin is present only in small amounts.
• MM contains twice more cysteine than KM, and the methionine/cysteine ​​ratio is 7× lower in MM than in KM. Cystathionase, the enzyme that converts methionine to cysteine, develops later, so cysteine ​​could be an essential amino acid for newborns.
• MM contains relatively 'little tyrosine and phenylalanine - probably because the child is not sufficiently able to metabolize these amino acids.

• Very high in non-protein nitrogen (about 25% in MM, while 6% in KM) - free amino acids, urea, creatinine, creatine, uric acid and ammonia. From a nutritional point of view, free amino acids should be counted as proteins. For other non-protein sources of nitrogen, it is not clear whether they have any nutritional value.
• MM contains significantly more taurineu (free amino acid) than KM. Taurine deficiency leads to retinal dysfunction.
• At the beginning of lactation, there is significantly more protein in MM than in mature MM. Declining protein content may reflect the infant's declining need or may simply be the result of mammary gland maturation.

Fats

• Fat content in individual MM

mothers is very variable. It usually increases at the beginning of lactation (in the first 1-2 weeks) and then decreases. The fat content rises significantly during one breastfeeding/feeding up to about double, according to other sources even up to 4-5 times.

• Fats are the main energy source. They cover 50% of the energy needs of infants.
• They are a source of essential fatty acids (linoleic, α-linolenic, arachidonic, docosahexaenoic acid) and fat-soluble vitamins. Sour. arachidonic and docosahexaenoic are very important for the development of the CNS and the retina.
• Main lipid is triglycerides (90 to 98%).
• Of the fatty acids, about 42% are saturated and 58% are unsaturated.
• The representation of individual fatty acids is significantly influenced by the mother's diet' (fish and seafood → more long-chain polyunsaturated fatty acids, especially docosahexaenoic acid (DHA); vegetarianism → more fatty long-chain acids than with a mixed diet).
• MM contains lipase, which facilitates the absorption of fats.
• MM and KM have a similar fat content, but the main difference is the representation of individual fatty acids. MM contains more unsaturated fatty acids and more essential fatty acids than KM. Fatty acids are esterified with glycerol mainly in the first position, unlike KM, which facilitates their absorption. MM contains 2-3 times more cholesterol than KM.
• Humans and gorillas are the only mammals that also have lipase in their milk (therefore they have enzyme and substrate) because pancreatic lipase secretion is not yet sufficient.
  • Lipase is activated by bile acids in the intestine, it is thermolabile, it is degraded by overcooking.

Carbohydrates

• MM contains 7 g of lactose per 100 ml (KM 4.7 g/100 ml).
• Lactose facilitates the absorption of calcium in the intestines, lowers stool pH, supports the growth of bifidobacteria and lactobacilli in the intestinal flora, and limits the growth of E. coli.
• Galactose is a monosaccharide contained in lactose. It is important for brain growth and calcium resorption.
• Oligosaccharides are complex carbohydrate structures bound to lactose, often containing fructose and sialic acid. After lactose and fat, it is the 3rd largest component of breast milk (in colostrum they are even in twice the amount). They have a prebiotic effect' - they support the growth of bifidobacteria. They have a similar structure to epithelial cell receptors, bind bacteria, bacterial toxins and viruses. They affect the adhesion of circulating leukocytes to endothelial cells and inhibit the pathogenicity of Campylobacter jejuni, enteropathogenic E. coli, Streptococcus pneumoniae and Vibrio cholerae. They increase the weight and frequency of stool. In KM, oligosaccharides are present only in trace amounts.
• Lactobacilli and bifidobacteria make up 90% of the intestinal flora of exclusively breastfed newborns. Gut flora influences the development of the infant's immune system.
  • Lactobacillus growth is also affected by another sugar from breast milk - the so-called "bifidus factor" - an oligosaccharide containing N-acetylglucosamine - which is not found in cow's milk at all.
  • → Infants fed with modified cow's milk are mainly colonized by coliform and putrefactive microflora and pH stools are higher than when breastfed.

Vitamins

• vitamin A – its amount is significantly higher in mother's milk than in cow's milk, it is mainly contained in colostrum.
• vitamin K – its content is high in colostrum, then decreases, after two weeks it begins to be produced by bacteria in the intestine. After birth, each full-term newborn receives 1 mg i.m. of vitamin K to prevent vitamin K deficiency bleeding. If administered orally, 1 mg of vitamin K per week must be administered to exclusively breastfed infants until 12 weeks of age.
• vitamin D – its content is low in breast milk. From the 2nd week of life, breastfed and formula-fed children are given preventively vitamin D (cholecalciferol) in a dose of 500 IU (1 drop) per day during the entire first year and then during the winter months in the 2nd year of life.< ref name="Recommendation 2014-23" />
• the content of water-soluble vitamins varies according to the mother's intake, usually their content is sufficient.

Mineral substances

• MM contains significantly less of all major minerals (K, Cl, Ca, P, Na, Mg) than KM. Minerals and proteins contribute to the high renal load of solutes of BM.
• MM initially has significantly more sodium (up to 10 times) than mature MM.

• Calcium (Ca)

is better absorbed from breast milk (better ratio to phosphorus – 2:1).

• • The high concentration of phosphates in cow's milk leads to their preferential resorption and to the tendency to hypocalcemia.
  • In addition, unabsorbed Ca together with FFAs become soaps in the intestine, which disrupt the absorption of fats and can even cause perforation of the intestine.

Breast milk provides a sufficient intake of calcium in the first 6 months, after which it is necessary to supply it, for example, from white yogurt.

Trace elements

• In MM and KM, the representation of trace elements (Zn, Fe, I, Cu, Mn) and also their bioavailability differ. For example, MM has less zinc and more copper. Iron and other minerals are more bioavailable in MM than in KM.
• Colostrum contains more copper, iron and zinc than mature MM.
• Zinc is part of 78 metalloenzymes involved in metabolism and immunity.

Iron

• MM contains a very small amount of iron, but it is very well absorbed (about 80% compared to 4-6% in fortified formulas).
• A full-term newborn has about 250-300 mg of iron (75 mg/kg body weight) in his body, which will cover his needs during the first 4-6 months of life. After that, his need for iron increases significantly (to about 0.7-0.9 mg/day until the end of the first year of life, which is a lot considering his body size). An infant almost doubles its iron stores (and triples its weight) during the first year of life.
• Hypotrophic neonate has lower iron stores at birth, therefore will be iron deficient earlier. In addition to birth weight, other factors such as the amount of iron in the mother during pregnancy or placental transfusion during delivery (delayed umbilical cord cutting increases the amount of iron in the baby) affect the initial iron store.
• Iron deficiency anemia is common in childhood, often asymptomatic.
• When introducing complementary foods, it is important to serve a diet rich in iron (e.g. red meat) or a diet enriched with iron.

• Iron – up to 70% of iron is absorbed from breast milk (30% from cow's milk).
  • the acidity of the environment is also good for absorption.
  • Lactoferrin in breast milk carries iron and prevents its uptake by bacteria.
  • Timely administration of non-dairy supplements does not have a good effect on iron (e.g. pear chelates it).

Fluorine

Breast milk is low in fluorine, so breastfeeding mothers are advised to take 200 μg of iodine per day unless they consume at least 2 servings of marine fish per week.

Other components of breast milk

• Breast milk contains many substances that regulate the growth and development of the child.
• Mammary gland acts as a polyfunctional endocrine organ (affects both mother and child).

Immunological aspects of breastfeeding

Breast milk (MM) contains immunoglobulins, mainly ``secretory IgA, which reaches its highest concentrations in the first days after birth. Secretory immunoglobulin A is relatively resistant to low pH and proteolytic enzymes and can be detected in the stool of breast-fed infants. It has a protective effect probably only in the intestine and in the respiratory tract.

Furthermore, there is a relatively low concentration of IgG in breast milk and it is not certain whether it is absorbed. Various types of antibodies against viruses, bacteria and their toxins have been detected in MM, but their significance and fate in the gut is unclear. MM also contains relatively low concentrations of complement components, but their significance is not clarified either.

MM is a rich source of ``lysozyme, which in vitro participates together with IgA in the lysis of E. coli and some salmonella, but its effect has not been confirmed in vivo.

Lactoferrin, an iron-binding protein, reduces the level of free iron, which is a growth factor for pathogenic organisms. In vitro, lactoferrin has a bacteriostatic and bactericidal effect, in vivo its protective role is uncertain. The level of lactoferrin rises significantly during lactation, so it could be a growth factor.

• The mammary gland is a very powerful organ of immunity in its entire complex.
• Human colostrum contains 1–3 × 10⁶ leukocytess.
  • 80-90% of these are macrophages filled with phagocytosed lipids, phagocytose yeast and bacteria.
  • 10% are lymphocytess, of which half are B and half are T.
• Effect of lactoferrinu – competitive uptake of Fe (Fe is a growth and pathogenic factor of most bacteria).
• Lysozyme – has a direct bactericidal effect, it is practically not found in cow's milk
• Secretory IgA – a basic factor in the protection of the intestine against viruses and bacteria.
  • the so-called homing phenomenon - colostral IgA is specifically directed against the microbes of the mother's intestinal microflora.
  • Microbes in the mother's GIT stimulate lymphocytes in the GALT, which travel to the mammary gland.