Breast Feeding

Prepared by Mr’s. Raheegeh Awni

Mammary Glands

• Breast Anatomy• Each mature mammary gland is composed of 15

to 25 lobes. • The lobes are arranged radially and are

separated from one another by varying amounts of fat.

• Each lobe consists of several lobules, which in turn are made up of large numbers of alveoli

• Every alveolus is provided with a small duct that joins others to form a single larger duct for each lobe.

• These lactiferous ducts open separately on the nipple, where they may be distinguished as minute but distinct orifices.

• The alveolar secretory epithelium synthesizes the various milk constituents..

Breast Feeding

• After delivery, the breasts begin to secrete colostrum, which is a deep lemon-yellow-colored liquid.

• It usually can be expressed from the nipples by the second day.

• Compared with mature milk, colostrum contains more minerals and protein, much of which is globulin, but less sugar and fat.

Colostrum

• Colostrum secretion persists for about 5 days, with gradual conversion to mature milk during the ensuing 4 weeks.

• Antibodies are demonstrable in colostrum, and its content of immunoglobulin A (IgA) may offer protection for the newborn against enteric pathogens.

• Others include macrophages, lymphocytes, lactoferrin, lactoperoxidase, and lysozymes

Milk

• Human milk is a suspension of fat and protein in a carbohydrate-mineral solution.

• A nursing mother easily makes 600 mL of milk per day.

• Milk is isotonic with plasma. • Major proteins, including -lactalbumin, -

lactoglobulin.•

• Essential amino acids are derived from blood, and nonessential amino acids are derived in part from blood or synthesized in the mammary gland.

• Most milk proteins are unique and not found elsewhere.

• Prolactin appears to be actively secreted into breast milk (Yuen, 1988).

• Epidermal growth factor (EGF) has also been identified in human milk (Koldovsky and associates, 1991; McCleary, 1991).

• Because EGF is not destroyed by gastric proteolytic enzymes, it may be absorbed orally and promote growth and maturation of intestinal mucosa.

• Changes in milk composition by 30 to 40 hours postpartum, as increase of lactose concentration. Some lactose enters the maternal circulation and is excreted by the kidney.

• This may be misinterpreted as glucosuria unless specific glucose oxidase is used in testing.

• Fatty acids are synthesized in the alveoli from glucose and are secreted by an apocrine-like process.

• All vitamins except K are found in human milk, but in variable amounts, and maternal dietary supplementation increases the secretion of most of

• Vitamin K administration to the infant soon after delivery is required to prevent hemorrhagic disease of the newborn.

Immunological Consequences of Breast Feeding

• Antibodies are present in human colostrum and milk but are poorly absorbed

• For example, no serum antibodies have been detected in infants fed milk containing a high titer of anti-D antibodies.

• This does not lessen the importance of some of the antibodies in breast milk.

• The predominant immunoglobulin in milk is secretory IgA.

• This macromolecule is secreted across mucous membranes and has important antimicrobial functions. For example, human milk contains secretory IgA antibodies against Escherichia coli, and breast-fed infants are less prone to enteric infections than bottle-fed infants (Cravioto and associates, 1991).

• It has been suggested that IgA exerts its action by preventing bacterial adherence to epithelial cell surfaces, thus preventing tissue invasion.

• Moreover, human milk also provides protection against rotavirus infections, which cause up to 50 percent of cases of gastroenteritis among infants in the United States.

• Milk contains both T and B lymphocytes, but the T lymphocytes appear to differ from those found in blood.

• Specifically, milk T lymphocytes are almost exclusively composed of cells that exhibit specific membrane antigens.

• These memory T cells appear to be another mechanism by which the neonate benefits from maternal immunological experience

Nursing

• Currently in the United States, more than 60 percent of infants are breast fed, and the number is increasing (American College of Obstetricians and Gynecologists, 2000).

• Human milk is ideal food for neonates. • It provides species- and age-specific nutrients

for the infant.• In addition to the proper balance of nutrients,

immunological factors, and antibacterial properties, human milk contains factors that act as biological signals for promoting cellular growth and differentiation (American College of Obstetricians and Gynecologists, 2000).

• With limited sun exposure, however, infants who are breast fed exclusively may become vitamin D deficient.

• Thus supplementation with 200 IU of vitamin D per day for the first two months for such infants is recommended.

American Academy of Pediatrics Policy Statement of breast feeding benefits

• Researc hprovides strong evidence that human milk feeding decreases the incidence and/or severity of diarrhea, lower respiratory infection, otitis media, bacteremia, bacterial meningitis, botulism, urinary tract infection, and necrotizing enterocolitis. There are a number of studies that show a possible protective effect of human milk feeding against sudden infant death syndrome, insulin-dependent diabetes mellitus,

• Crohn disease, ulcerative colitis, lymphoma, allergic diseases, and other chronic digestive diseases.

• Breast feeding has also been related to possible enhancement of cognitive development.

Benefits for mother

• For example, women who breast feed have a lower risk of breast cancer, and their children have increased adult intelligence independent of a wide range of possible confounding factors (Collaborative Group on Hormonal Factors in Breast Cancer, 2002; Mortensen and associates, 2002).

• Even though the supply of milk at first appears insufficient, it becomes adequate if suckling is continued.

• Weight loss of approximately 0.5 kg per week in the first 3 months postpartum does not affect infant growth of exclusively breast feeding.

Lactation Inhibition

• Approximately 40 percent of American women currently elect not to breast feed, and many experience considerable breast pain and engorgement

• Milk leakage, engorgement, and breast pain peak at 3 to 5 days postpartum.

• As many as 10 percent report severe pain up to 14 days postpartum, and 25 to 50 percent of all women use analgesia for breast pain relief.

• In part, this decision was because bromocriptine, a commonly used drug for lactation inhibition, had been associated with strokes, myocardial infarctions, seizures, and psychiatric disturbances.

• The woman who does not desire to breast feed should be reassured that stopping milk production is not a major problem.

• During the stage of engorgement, the breasts become painful and should be supported with a well-fitting brassiere.

• Ice packs and oral analgesics for 12 to 24 hours may be required to relieve discomfort. Breast binders are used at Parkland Hospital for these women, and patient-supplied "sports bras" are used.

Contraception for Breast Feeding Women

• Three weeks after delivery, ovulation may resume, even in lactating women.

• Its resumption depends on individual biological variation as well as the intensity of breast feeding.

• Progestin-only contraceptives—mini-pills and depot medroxyprogesterone—do not affect the quality or decrease milk volume.

• They are considered the hormonal contraceptives of choice for breast feeding women by the (ACOG2000).

• Although estrogen–progestin contraceptives have been shown to reduce the quantity and quality of breast milk, under the proper circumstances they can be used by breast feeding women

Contraindications to Breast Feeding

• street drugs• alcohol use; • infant with galactosemia;• human immunodeficiency virus (HIV)

infection; • have active, untreated tuberculosis; • are undergoing treatment for breast cancer

• Although hepatitis B virus is excreted in milk, breast feeding is not contraindicated if hepatitis B immune globulin is given to infants of seropositive mothers.

• Women with active herpes simplex virus may suckle their infants if there are no breast lesions and if particular care is directed to hand washing before nursing.

Care

• The nipples require little attention in the puerperium other than cleanliness and attention to fissures.

• Because dried milk is likely to accumulate and irritate the nipples, cleaning of the areola with water and mild soap is helpful before and after nursing.

• When the nipples are irritated, it may be necessary to use a nipple shield for 24 hours or longer.

• Although inverted or retracted nipples may be troublesome, these can usually be teased out by gently pulling with the finger and thumb.

• This is best begun during pregnancy to prepare the nipples for subsequent nursing.

• This includes proper techniques for latch-on of the infant during suckling.

10 steps of breast feeding :

1-writen BF promotion policies

2-B F trainingfor all health personnel

3- prenatal BF promotion

4-B F withen 30 min postpartum

5-B F counseling to mothers in maternity wards

6-breast milk only for the newborn

7-rooming in

8-B Fon demand

9-no baby bottle or pacifiers

10-community based postnatal support

Evidence based:

The introduction of breast milk donation in Muslim country

Breast milk donation for full term babies is well known practice in Kuwait but it has never been organized formally in NICU for preterm babies

Milk donor and the recipient are required to know each other .human milk is known to decrease the incidence of necrotizing enterocolitis ,improve host defense, digestion absorption of nutrients

al-naqeeb n,etal(2000)

Drugs Secreted in Milk

• Most drugs given to the mother are secreted in breast milk.

• The amount of drug ingested by the infant typically is small.

• Cytotoxic drugs may interfere with the cellular metabolism of the infant and potentially cause immune suppression or neutropenia, affect growth, increase the risk of cancer eg. methotrexate

Common difficulties associated with breastfeeding

Engorged (swollen) breasts

• Sometimes a mother’s breasts get very full and hard, especially during the first few days after the birth.

• This can be painful for the mother and also makes her more likely to develop a breast infection.

• It can also make it hard for the baby to suck the breast. If the mother begins breastfed the baby very soon after the

birth, and feeds often, she may avoid this problem.

Engorged (swollen) breasts

But if a mother’s breasts do get swollen, she can try the following:

• Breastfeed the baby more often, both day and night (every 1 or 2 hours, and on both breasts).

• Place hot, wet cloths on the breasts for 15 to 20 minutes before each feeding.

• Put ice, cool cloths, or fresh cabbage leaves on the breasts between feedings.

• Let the milk leak freely and support the breasts with a bra or cloth.

• If the baby has trouble getting onto the breast because it is swollen, remove a little milk by hand until the breast is soft enough for the baby to take.

Flat or inverted nipples

• Some women’s nipples are flat or inverted.

• Even so, the baby can usually breastfeed without a problem.

• But the mother and baby may need some help in the first few days.

Breastfeeding with flat nipples

• Start breastfeeding right after birth — before the breasts become full.

• If the breasts are very full, remove some milk by hand to make them softer.

• Gently roll the nipple to make it stand out.• Cup a hand around the breast and pull back.

• The nipple will pop out.

Breast Fever

• For the first 24 hours after commencement of lactation, it is usual for the breasts to become distended, firm, and nodular.

• It’s accompanied by a transient elevation of temperature.

• Puerperal fever from breast engorgement is common.

• Almeida and Kitay (1986) reported that 13 percent of all postpartum women had fever that ranged from 37.8 to 39°C from this cause.

• Fever seldom persisted for longer than 4 to 16 hours.

• The incidence and severity of breast engorgement, and fever associated with it, were lower if treatment was given for lactation suppression.

• Other causes of fever, especially those due to infection, must be excluded.

• Treatment consists of supporting the breasts with a binder or brassiere, applying an ice bag, and an analgesic.

• Pumping of the breast or manual expression of milk may be necessary at first, but in a few days the condition is usually alleviated and the infant is able to nurse normally.

Mastitis

• Infection of the mammary glands is a rare complication antepartum but is occasionally observed during the puerperium and lactation.

• It is estimated to occur in anywhere from 2 to 33 percent of breast feeding women before the end of the first week postpartum and, as a rule, not until the third or fourth week.

• Infection almost invariably is unilateral, and marked engorgement usually precedes the inflammation.

• The first sign of inflammation is chills or actual rigor, soon followed by fever and tachycardia. The breast becomes hard and reddened, and the woman complains of severe pain. About 10 percent of women with mastitis develop an abscess

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Breast infection (mastitis)

Infection inside the breast can occur if the mother has sore- Cracked nipples or fullness- Engorged breasts- If she wears a very tight bra or binding clothing- If she is very tired or in poor health.Preventing these situations will help prevent breast infection.

Signs of breast infection:• abscess (painful lump in the breast)• hot, red, sore area on the breast• body aches and pains• fever of 38°C (100.4°F) or higher

• The first sign of inflammation is chills or actual rigor, soon followed by fever and tachycardia. The breast becomes hard and reddened, and the woman complains of severe pain. About 10 percent of women with mastitis develop an abscess. Constitutional symptoms attending a mammary abscess are generally severe, but in some cases the first indication of the true diagnosis often is afforded by the detection of fluctuation. Ultrasonography may be helpful to detect an abscess.

• The immediate source of organisms that cause mastitis is almost always the infant's nose and throat. With nursing, bacteria enter the breast through the nipple at the site of a fissure or abrasion, which may be quite small. In cases of true mastitis, the infecting organism can usually be cultured from milk. Toxic shock syndrome secondary to mastitis caused by S aureus has been reported (Demey and associates, 1989; Fujiwara and Endo, 2001).

• The immediate source of organisms that cause mastitis is almost always the infant's nose and throat. With nursing, bacteria enter the breast through the nipple at the site of a fissure or abrasion, which may be quite small. In cases of true mastitis, the infecting organism can usually be cultured from milk. Toxic shock syndrome secondary to mastitis caused by S aureus has been reported (Demey and associates, 1989; Fujiwara and Endo, 2001).

Treatment

• Abscess formation is more common with S aureus infection (Matheson and associates, 1988). Provided that appropriate therapy is started before suppuration begins, the infection usually resolves within 48 hours. Before initiating antimicrobial therapy, some clinicians recommend that milk be expressed from the affected breast onto a swab and cultured.

• By so doing, the organism can be identified and its antimicrobial sensitivities ascertained. Results of such cultures also provide information mandatory for a successful program for surveillance of nosocomial infections.

• antimicrobial sensitive to penicillin or a cephalosporin (American College of Obstetricians and Gynecologists, 2000). Dicloxacillin, 500 mg orally four times daily, may be started empirically (Hindle, 1994). Erythromycin is given to women who are penicillin sensitive. If the infection is caused by resistant, penicillinase-producing staphylococci, or if resistant organisms are suspected while awaiting the results of culture, an antimicrobial such as vancomycin, which is effective against MRSA, should be given. Even though clinical response may be prompt and striking, treatment should be continued for 10 to 14 days.

Breast Abscess

• Clinical suspicion for abscess development is either from failure of defervescence within 48 to 72 hours or development of a palpable mass. Traditional therapy is surgical drainage, which usually requires general anesthesia. The incision should be made corresponding to skin lines for a good cosmetic result (Stehman, 1990).

Painful lump in the breast (abscess)

If the lump is not treated, the breast can easily become infected.

If a mother has a painful lump, she should:• breastfeed frequently (every 1 or 2 hours), giving the baby the

sore breast first. • drink lots of liquid.• place hot, wet cloths on the sore breast for 15 to 20 minutes

before each feeding.• use ice or cold cloths between feedings to lessen the pain.• gently massage the lump as the baby feeds.Some women have gotten rid of an abscess by drinking 1

tablespoon of vinegar in a cup of water every hour. Putting cabbage leaves on the abscess also might help.

• Ia single incision, but multiple abscesses require several incisions, and a finger should be inserted to break up the walls of the locules. The resulting cavity is loosely packed with gauze, which should be replaced at the end of 24 hours by a smaller pack. A less invasive alternative is ultrasonographic-guided needle aspiration using local anesthesia, which has success rates of 80 to 90 percent (Karstrup, 1993; O'Hara, 1996; Schwarz, 2001, and all their associates).

Galactocele

• Exceptionally, as the result of the clogging of a duct by inspissated secretion, milk may accumulate in one or more lobes of the breast. The amount is ordinarily limited, but an excess may form a fluctuant mass that may give rise to pressure symptoms. They may resolve spontaneously or require aspiration.

Sore or cracked nipples

If a woman feels pain in her nipples while breastfeeding, thebaby is probably not in a good position. If the baby keepsbreastfeeding in a bad position, the mother’s nipples maycrack. Cracked nipples can become infected.

To treat sore or cracked nipples:• Help the mother hold the baby in a position that allows the baby to get a

large mouthful of breast.• The mother can rub breast milk into her nipple. This will prevent infection in

the cracks and keep the nipples soft so they willnot crack more.• Encourage the mother to leave her breasts open to air and sunlight when

she is not breastfeeding.• Encourage the mother to keep feeding from both breasts.

Thank you