BREASTFEEDİNG

Prof. Dr. Emel Gürİ.Ü. Cerrahpaşa Tıp Fakültesi

Çocuk Sağlığı ve Hastalıkları A.B.D.

RECOMMENDATIONS

• Start breastfeeding within ½-1 hour of birth

• Breastfeed exclusively from 0-6 months of age

• Give complementary foods to all children from 6 months of age

• Continue breastfeeding up to 2 years of age or beyond

Prevalences of Breastfeeding in the World

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10

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l<6mo.HM

20-23 mo.Continue

UndevelopmentDevelopingWorldTürkiye

UNICEF-2006

PREVALENCES OF BREASTFEEDING IN OUR COUNTRY(TNSA-2008)

Year BreastfeedExclusive Breastfeed (0-3 ay)

Exclusive Breastfeed(4-6 ay)

BreastfeedAnd others ( 0-3 ay)

1993 95.2 10.3 4.3 53.3

1998 95.2

9.4 1.3 52.5

2003 95.2 27.3 7.6 37.2

2008 96.7

41.6

23.6

25.6

COMPOSITIONS OF HUMAN MILK AND COW MILK

Contents ( 100 ml. ) Human milk Cow milk

Calories ( kcal ) 70 67

Water ( ml ) 87.6 87.2

Protein 1.1 3.2

Lactose ( g. ) 7.1 4.7

Fat ( g. ) 4.5 3.8

Mineral ( mg. ) 0.20 0.71

Kidney solid load (mosm ) 80.0 220.0

Oral solid load (mosm) 250.0 263.0

COMPOSITIONS OF HUMAN MILK AND COW MILK

Contents (g/dl) Human milk Cow milk

Total protein 1.1 3.2

Casein (% protein) 40.0 82.0

Whey protein (%) 60.0 18.0

Alfa lactalbumin 0.25 0.12

Betalactoglobulin eser 0.30

Lactoferrin 0.17 eser

Albumin 0.05 0.30

Lysozyme 0.05 eser

IgA 0.10 0.003

NPN (mg N/dl ) 50.0 28.0

COMPOSITIONS OF HUMAN MILK AND COW MILK

Contents Human milk Cow milk

Ca mg/dl 34.0 120.0

P mg/dl 15.0 95.0

Fe mg/L 0.5 0.5

I µg/L 30.0-70.0 47.0

Fl µg/L 5.0-50.0 70.0-220.0

Vit A IU/L 1988.0 1025.0

Vit C IU/L 43.0 11.0

Vit D IU/L 22.0 14.0

Vit K IU/L 16.0 60.0

COLOSTRUM

• Colostrum is produced in the first five days after delivery (7-123 ml/day)

• “Coming in”:Increasing of milk production 40 th hour (3-5 th days)

• It is thick and yellowish • Antibody rich• Many white cells• Protein rich (lactose and fat poor)• Zn rich • Growth factors• Vitamin A rich• Purgative

MATURE MILK• It is produced after 15 days• Quantity larger • Fore milk: is produced early in feed• Hind mil is produced later in feed• Fore milk is bluer than hind milk • Fore milk provides plenty of protein, lactose, other

nutrients, water• Hind milk is more whiter than fore milk,• Hind milk contains more fat and provides much of

the energy or a breastfeed• 4-6 th wk: 800 ml/day• 6 th mo. 750-1000 ml/ day

Contents ( 100 ml. ) Colostrum Mature milk

Calories ( kcal ) 67.0 75.0

Protein 2.3 0.9

Whey/casein 90:10 60:40

Lactose ( g. ) 5.7 7.3

Fat ( g. ) 3.0 3.8

Mineral ( mg. ) 0.30 0.20

PROTEINS OF HUMAN MILK

• sIgA,IgM, IgG• Lactoferrin

• Lactalbumin

• Lysozyme• Casein

• İmmun protect• Anti-infective, Fe transport

• Synthesis of lactose• Ca transport

• Anti-infective• Prevent mucosal adhesion Growth factor of

Bifidobacterium bifidum

CARBONHYDRATES and LIPIDS OF HUMAN MILK

Carbohydrates• Lactose• Oligosaccarides• Glucoconjugates

Lipıds• Trigliserid• FFA• LC-PUFA

• Source of energy• Antimicrobial• Antimicrobial

• Source of energy• Anti-infective• Development of brain and

retinea

ANTİMICROBİAL FAKTORS OF HUMAN MILK

• Protein• Lactoferrin• Lysosym• Fibronectin,C3• SIgA• Mucin• Κ-casein• Oligosaccarides• Lipids

Anti-inflamatuar Factors of Human Milk

• Vitamin A,C,E• Catalase• Glutation peroksidase• PAF asetil hidrolase• Αlfa- 1-Antitripsin• PGE 1,2• EGF• TGF-α• TGF-β• IL-10

IMMUNOMODULATORS OF HUMAN MILK

• IL-1-5• IL-6• IL-8• IL-10• IL-12• TNF-α• TNF-β• IFN-γ

GROWTH FACTORS OF HUMAN MILK

• Epidermal Growth Factor(EGF )

• Transforming Growth Faktör-α (TGF- α)

• Transforming Growth Faktör-β (TGF-β)

• Insulin, Insulin-like Growth Factor I-II

• Nerve Growth Factor (NGF )

• Relaxin

• Eritropoetin

• Taurin, Etanolamin, Fosfoetanolamin

Hormones

• Prolactin

• GH, GHRH, Somatostatin

• TRH, TSH, T4, T3, reverse T3

• GnRH, LH

• Parathormon, calsitonin

• Estrogen, progesteron, adrenal steroids

ENZYMES OF HUMAN MILK

• Lipase

• Lipoprotein lipase

• Galactosll transferase

• Sülfidril oksidase

• Lactoperoksidase, tiyosiyanat, hidrojen peroksit

• Lysosyme, peroksidase

ADVANTAGES OF BREASTFEEDING

• Protect the babies from diarrheal disease

(Shigella sp, E.coli G.lambilia,rotavirus)• Protect the babies from

respiratory disease (H.influenzae tip b S.pneumoniae) • Protect the babies from

other infections: urinary infection, AOM, sepsis, meningitis• Prevent allerjik reactions,

diaper rash

• Prevent some chronic disease:• IDDM, Çölyak hast., Ülseratif

kolit, crohn hast.• Prevent obesity, atherosclerosis• Higher scores on intelligence

tests• Establish bonding between

mother and baby• Protect the mothers from breast ca., over ca., anemia, spinal and pelvis fractures Family Planning Economical

More diarrhoea respiratory

infections

Persistent diarhoea

Malnutrition

More likely to die

More allergy Milk intolerance

İncreased risk of chronic diseases

Overweight

Lower scores on intelligence tests

İncreased risk of anemia,Ovarian, breast cancer, Fracture of mothers

oMore likely to die

May become pregnant sooner

LACTOGENESIS

• Stage 1

Pregnancy

Second trimester

• Stage ll

Delivery

• Estrogen, progesteron, placental prolactin produced ductal ve alveolar maturation

• Estrogen, progesteron decrease, prolaktin level is

high Proactin stimulated breast

gland and milk production starts

PHYSIOLOGY OF LACTATION

• Infant sucks

• Prolaktin

(milk production)

• Oksitosin

(milk secretion)

• Message reaches Hypothalamus

• Oxytocin is secreted from posterior pituitary gland

• Prolactin is secreted from anterior pituitary gland

• Situmulates milk producing cells and milk production can start

• Stimulates the contraction of the myoepithelial cells around the milk glands, ducts. Milk is transported to lactiferous sinuses.

Muscle cells

Milk secreting cells

ducts

Lactiferous sinuses

areola

Montgomery’s glands

AlveoliSupporting tissue and fat

ANATOMY OF THE BREAST

Oksitocin reflex

Things lovinglyof babySound of babySight of babyCONFIDENCE Worry

StressPaindoubt

ADVANTAGES OF ROOMİNG-IN DEMAND FEEDING

Advantages of rooming in

Mother can respond to baby

Babies cry less, so less

temptation to give bottle feeds

Mothers more confident about

breastfeeding

Breastfeeding continue longer

Advantages of demand feeding

Breastmilk comes in

sooner Baby gains weight faster Fewer difficulties such

as engorgement Breastfeeding more

easily estabilished

MORE FEEDING=MORE SIGNALS=MORE MILK

(PROVIDED THAT THE SUCKING

IS EFFICIENT)

HOW TO HELP A MOTHER WİTH AN EARLY BREASTFEED

• Avoid hurry and noise

• Ask the mother how she feels and how breastfeeding is going

• Observe a breastfeed

• Help with positioning if necessary

• Give her relevant information

• Answer the mothers questions

CONFIDENCE AND SUPPORT SKILLS

• Accept what a mother thinks and feels• Recognize praise what a mother and

baby are doing right• Give practical help• Give a little, relevant information• Use simple language• Make one or two suggestions, not

commands

BREASTFEED OBSERVATION

• Body position

• Responses

• Emotional bonding

• Anatomy of breast

• Suckling

• Time spend suckling

HOW TO HELP A MOTHER TO POSITION HER BABY

The Four Key Points:• Mother should hold baby’s body close to

hers• Baby’s head and body should be straight

line• Baby’s face should face the breast • If baby is newborn,baby’s bottom

supported

Annenin bebeği tutma şekli

HOW TO HELP A MOTHER TO HELP THE BABY ATTACH

HOW TO HELP THE BABY ATTACH

• Touch her baby’s lips with her nipple

• Wait until her baby’s mouth is opening wide

• Move her baby quickly on to her breast, aim his lower lip below the nipple

SIGNS OF WELL ATTACHMENT TO BREAST AND SUCKLİNG

• Mouth wide open

• Lower lip turned outwards

• Cheeks round

• More areola above baby’s mouth

• Slow deep sucks

• Can see or hear swallowing

CAUSES AND RESULTS OF POOR ATTACHMENT

CAUSES

• Inexperienced mother

• Small or weak baby• Use of feeding bottle• Breast poorly

protractile• Lack of skilled

support

RESULTS• Sore nipples• Fissures• Engorgement• Baby unsatisfied, wants

to feed a lot• Baby refuses to suckle• Baby fails to gain

RELIABLE SINGS THAT A BABY MAY NOT BE GETTING ENOUGH

BREASTMILK

• Poor weight gain

• Passing small amount of concentrated urine

• Less than 500g a month

• Less than birth weight after 2 weeks

• Less than 6 times a day, yellow and strong smelling

POOSIBLE SINGS THAT A BABY MAY NOT BE GETTING ENOUGH BREASTMILK

• Baby not satisfied after breastfeeds• Baby cries often• Very frequent breastfeeds• Very long breastfeeds• Baby refuses to breastfeed• Baby has hard, dry or green stools• No milk comes when mother express• Breasts did not enlarge (during pregnancy)• Milk did not come in (after delivery)

COMMEN REASONS WHY A BABY MAY NOT GET ENOUGH

BREASTMILK

BREASTFEEDİNG FACTORS

• Delayed start• Infrequent feeds• No night feeds• Short feeds• Poor attachment• Bottles• Complementary feeds

MOTHER:PSYCHOLOGICAL

FACTORS

• Lack of confidence• Worry , stress• Dislike of

breastfeeding• Rejection of baby• Triedness

RARE REASONS WHY A BABY MAY NOT GET ENOUGH BREASTMILK

MOTHER:PHYSICAL CONDITION

• Contraceptive pill, diuretics

• Pregnancy• Severe malnutrition• Alcohol• Smoking• Retained piece placenta• Poor breast development

BABY’S

CONDITION• Illness• Abnormality

THIS DO NOT EFFECT THE BREASTMİLK SUPPLY

• Age of mother

• Menstruation

• Returning to a job

• Age of baby

• Caesarian section

• Many children

• Simple, ordinary diet

CONTRENDİCATIONS OF BREASTFEEDING

• Mother with severe disease• Mother with psychosis or severe depression• Mothers with HIV infection• Mothers with HTLV-I (İnsan T-cell lymphotrophic virus-

I) infection• Mother with active pulmoner tuberculosis• Mother with active HSV infection on her nipple• Mothers treated with radioactive substances and

chemoterapy • Infants with rare metabolic diseases (galactosemia,

phenylketonuria and maple syrup urine disease)

BREASTFEEDING WILL BE SUCCESSFUL IN MOST CASES IF :

• The mother feels good about herself

• The baby is well attached to the breast so that he suckles effectively

• The baby suckles as often and for as long as he wants ( at least 10 minutes)

• The environment supports breastfeeding

HOW HEALTH SERVICES CAN SUSTAIN BREASTFEEDING

• Praise all mothers who are breastfeeding• Help mothers to breastfeed in the most healthy

way (breasfeeding counselling)• Encourage mothers to come for help before

they decide to start artificial feeds• Remember to encourage breastfeeding when

you see a mother for a reason• Help mothers to continue breastfeeding in

difficult situations ( returning to work, twin, LBW newborn)