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- 1. Breast feeding 1. 1. MOTHER’S MILK DR PRIYANKA GUPTA RESIDENT II DEPARTMANT OF PEDIATRICS 2. 2. BREAST FEEDING A WINNING GOAL FOR LIFE 3. 3. Role of a pediatrician • They should be able to answer • Why ? • How? • How long to continue ? • Contraindications to breastfeeding? 4. 4. Why to breast feed? • Good for the baby • Good for the mother • Good for the nation 5. 5. Mother’s Milk – The best milk for Infant Under any circumstances, “Mother’s Milk” is the ideal food for infant. No other food is required till 6 months of age. 6. 6. Why mother’s milk??? The mother’s milk: 1. Always available – No preparation time. 2. Proper temperature. 3. Clean & Fresh. 4. Free of contaminating agents. 5. Cheap. 7. 7. Breast is best? • Contains all the nutrients , growth factors and hormones that an infant needs in the right amounts . Its composition changes as the baby grows. • Anti infective properties: Macrophages, lymphocytes and polymorphs, Secretory IgA, Lyzozyme, Lactoferrin (inhibits growth of E.coli.), anti-viral agents. 8. 8. Advantages of Breast Feeding To the infant: 1. Meets the full nutritional requirement of infant. 2. Less incidence of allergy & intolerance. 3. Contains antimicrobials factors against various diseases. 9. 9. Infant health outcomes Strong or causal evidence: • GI tract infections • Upper and lower respiratory tract infections • Otitis media • Acute lymphoblastic leukemia • Sudden infant death syndrome Evidence in development: • Cognitive development • Atopic allergies • Asthma • Other pediatric cancers • Childhood obesity 10. 10. Maternal benefits of breastfeeding • Breastfeeding may confer immediate and long term benefits to mothers, especially if recommendation for exclusivity and duration are met. • Such benefits may strengthen motivation and commitment to breastfeeding 11. 11. Maternal benefits of breastfeeding Reason to Initiate breastfeeding • Reduce maternal bleeding after delivery 27% deaths are due to postpartum haemorrhage • involute uterus • Facilitate positive metabolic changes • Reduce stress • Delay ovulation 12. 12. Maternal benefits of breastfeeding Reason to continue breastfeeding • Increase postpartum weight loss • Prolong lactational amenorrhea • Decrease visceral adiposity • Reduce type 2 diabetes risk • Reduce cardiovascular risk • Reduce breast cancer risk • Reduce ovarian cancer risk 13. 13. Maternal health outcomes Strong or causal evidence: • Postpartum weight loss • Lactational amenorrhea • Breast cancer Evidence in development: • Ovarian cancer • Type 2 diabetes • Cardiovascular disease • bonding 14. 14. EVIDENCE BASED MEDICINE • THE RESET HYPOTHESIS Stuebe AM, Rich-Edwards JW. The reset hypothesis: lactation and maternal metabolism. Am J Perinatol 2009;26(1):81–8 • 1)50% higher risk of developing type2 diabetes among women who never exclusively breastfed • 2)28%lower risk of developing ovarian cancer among women who exclusively breast fed. • 3) 4 to 12% reduction in risk of diabetes for every 12 months of lifetime lactation • 4)Risk of breast cancer decreases by 4.3% for each year of breast feeding 1) Schwarz EB, Brown JS, Creasman JM, et al. Lactation and maternal risk of type 2 diabetes: a population-based study. Am J Med 2010;123(9):863–6. 4 )p. S, Chung M, Raman G, et al. A summary of the agency for healthcare research and quality’s evidence report on breastfeeding in developed countries. Breast- feed Med 2009;4(1):S17–30. 15. 15. HUMAN MILK • HUMAN MILK COMPOSITION • TERM MILK VERSUS PRETERM MILK • MOTHER’S MILK VERSUS TOP FEED • FOREMILK VERSUS HIND MILK 16. 16. Mother’s MILK • Dynamic, multifaceted fluid • Contains nutrients and bioactive factors 17. 17. Colostrum in Human Milk • Thick, yellow fluid • Provides 58-70 cal/100 ml. • High in protein, electrolytes, sodium, potassium, chloride and vitamin A. • Low in fat and carbohydrate. • Lactobacillus bifidus factor. • Contains antibodies immune system cells.
- 2. 18. 18. Colostrum Benefits of colostrum feeding: 1. Perfect food for infants in initial days. 2. Laxative effect – clears infant’s intestines of initial stools; prevents jaundice. 3. Contains leukocytes which prevent infection. 4. Contains IgA which also provides immunity. 19. 19. Change in Milk Composition During Feeding • Foremilk – Released first – Higher in carbohydrate – Lower in fat • Hindmilk – Resembles cream – Higher in fat – Lower in carbohydrate – Released after 10-20 minutes into the feeding 20. 20. Foremilk and Hindmilk Baby starts feeding Foremilk Low fat, High Lactose milk MILK EJECTION REFLEX Milk & sticking fat on ducts squeezed Hindmilk High fat milk 21. 21. Specific Nutrients in Human Milk Human Milk Composition (per liter) Milk Component Early Milk Mature Milk Lactose (g) 20-30 67 Total protein (g) 16 9 Fat% 2 3.5 Calories 0 2730-2940 Retinol (mg) 2 0.3-0.6 Caretenoids (mg) 2 0.3-0.6 Riboflavin (ug) 0 400-600 Niacin (mg) 0.5 1.8-6.0 Vitamin B6 (mg) 0 0.9-0.31 Pantothenic acid (mg) 0 2-2.5 Biotin (ug) 0 5-9 Folate (ug) 0 80-140 Vitamin B12 (ug) 0 .5-1.0 Vitamin C (mg) 0 100 Vitamin D (microgram) 0 0.33 Vitamin E (mg) 2-12 3-8 Vitamin K (microgram) 2-8 2-3 Calcium (mg) 250 200-500 Phosphorus (mg) 120-160 120-140 Magnesium (mg) 30-35 30-35 Copper (mg) 0.5-0.8 0.2-0.4 Iron (mg) 0.5-1.0 0.3-0.9 Zinc (mg) 8-12 1-3 22. 22. Hind milk • Hind milk has been successfully used to improve growth outcome of very premature infants • Recommended for their nutritional management Valentine CJ. Optimizing human milk fortification for the preterm infant. PNPG Building Block for Life 2011;34(4):9–11. 1 23. 23. Preterm Vs term milk • Preterm milk contains more protein and fat • Preterm milk contains higher levels of EGF than term milk • BDNF can enhance peristalsis, a function frequently impaired in preterm gut. • Preterm milk contains less VEGF than term milk Liao Y, Alvarado R, Phinney B, et al. Proteomic characterization of human milk whey proteins during a twelve-month lactation period. J Proteome Res 2011; 10(4):1746–54. 1 . Gao X, McMahon RJ, Woo JG, et al. Temporal changes in milk proteomes reveal developing milk functions. J Proteome Res 2012;11(7):3897–907. 24. 24. Composition of breast milk vs cows milk • Carbohydrate: Human milk 7% Cows milk 4.5% lactose • Fat : mother’s milk is rich in PUFA, • Minerals Cows milk contains more of all the minerals (esp sodium, calcium and phosphate) except iron and copper. • Vitamins Cows milk is low in vitamin C and D but more thiamine and riboflavin. 25. 25. Mature Human Milk • Provides 65kcal/100ml • High in linoleic acid and cholesterol content for brain development • High in fat content and lactose • Docosahexaenoic acids (DHA) – Used for synthesis of brain tissues, central nervous system and eyes • DHA and cholesterol not found in human milk substitutes 26. 26. Mature Human Milk- PRO • Protein – Low content • Dependent on infant’s age – Antiviral and antimicrobial effects – Whey (lactalbumin and lactoglobulin) • Major protein in mature milk • Easily digestable • Ideal ratio of cystine, taurine and methionine to support development of CNS AND PNS 27. 27. Mature Human Milk- CHO • Lactose – Dominant carbohydrate in human milk. – Enhances calcium absorption. • Other carbohydrates – Monosaccharides ( glucose) – Stimulate the growth of bifidus bacteria in the gut • Inhibit the growth of E. coli and other bacteria 28. 28. Micronutrients • Vary in human milk according to maternal diet and body stores. • Continuing multivitamins during lactation is recommended. • Vitamin K is extremely low in human milk. • Vitamin D is low in human milk. 29. 29. Bioactive components and their sources • CELLS macrophages: protection against infection stem cells : regeneration and repair • Immunoglobulins : IgA, IgM,IgG • Cytokines :IL-6,IL-7,IL-8 ,IL-10, IFN-y , TGF-beta • Chemokines : G-CSF, MIF 30. 30. BIOACTIVE COMPONENTS • GROWTH FACTORS- EGF, VEGF, NGF, IGF, Erythropoetin • HORMONES- calcitonin,somatostain • Antimicrobials –lactoferrin,lactadherin/ MFG • METABOLIC HORMONES- Adiponectin, leptin, ghrelin
- 3. 31. 31. Why NO to top feed????? Mother’s Milk • Wide range of composition • Dynamic • Varies with in a feeding • Diurnal variation FORMULA FEED • Narrow range • fixed 32. 32. Why no to top feed????? • Formula feeding delays lactogenesis • Formula feeding increases the risk of engorgement . • It alters infant intestinal flora • Formula feeding affects bioactive factor interactions within the intestine • Formula feeding is associated with increased childhood acute and chronic illnesses 33. 33. WHAT STUDIES SAY A study by Davis, California found that after 4 months postpartum, the macronutrient concentrations of human milk are associated with: • maternal body weight for height • Protein intake • Parity • Return of menstruation • Nursing frequency . Nommsen LA, Lovelady CA, Heinig MJ, et al. Determinants of energy, protein, lipid, and lactose concentrations in human milk during the first 12 month of lacttion: the DARLING Study. Am J Clin Nutr 1991;53(2):457 34. 34. What studies say • Some evidence that Erythropoetin may help protect against mother to child transmission of HIV • Erythropoetin may reduce the risk of necrotizing colitis. • One study found a 9 fold increase in risk of diarrhoea who were not breast fed Shiou SR, Yu Y, Chen S, et al. Erythropoietin protects intestinal epithelial barrier function and lowers the incidence of experimental neonatal necrotizing entero- colitis. J Biol Chem 2011;286(14):12123–32. . Arsenault JE, Webb AL, Koulinska IN, et al. Association between breast milk erythropoietin and reduced risk of mother-to-child transmission of HIV. J Infect Dis 2010;202(3):370–3. . Claud EC, Savidge T, Walker WA. Modulation of human intestinal epithelial cell IL-8 secretion by human milk factors. Pediatr Res 2003;53:419–25. 35. 35. Potential novel therapeutics based on human milk components 1)Lactoferrin may significantly reduce late onset sepsis 2) Stem cells are also found in mother’s milk, use is under trial 1)Agennix. Phase 1/2 study of talactoferrin oral solution for nosocomial infection in preterm infants: Available at: http://clinicaltrials.gov/ct2/show/NCT00854633. Accessed August 23, 2012. 2)Indumathi S, DhanasekaranM, Rajkumar JS, et al. Exploring the stem cell and non-stem cell constituents of human breast milk. Cytotechnology 2012. [Epub 36. 36. EVIDENCE BASED MEDICINE 1) 72% lower risk of hospitalisation for respiratory infections. 2)One study reviewed breast fed infants have 64% less chances of contracting GI infections. 3) Studies have reported that infants breastfed greater than 6 months had a 24% reduction in risk of ALL 1.Bachrach VR, Schwarz E, Bachrach LR. Breastfeeding and the risk of hospitalisation for respiratory disease in infancy: a meta-analysis. 2.p S, Chung M, Raman G, et al. A summary of the agency for healthcare research and quality’s evidence report on breastfeeding in developed countries. Breast- feed Med 2009;4(1):S17–30. ) . Arch Pediatr AdolescMed 2003;157(3):237–43 3. Kwan M, Buffler P, Abrams B, et al. Breastfeeding and the risk of childhood leukemia: a meta-analysis. Public Health Rep 2004;119(6):521–35. 37. 37. Achieving MDG’S • So breast feeding helps a nation to acheiving MDG • Decreasing poverty • Education for all • Equality of sexes • Decreasing infant mortality rate • Improving mother’s health • Environmental conservation • National and international support 38. 38. FOLLOW • A • L • P • A • C