Breast Feeding

• Breastfeeding gives children the best start in life.
• It is estimated that over one million children die each year from diarrhoea, respiratory and other infections because they are not adequately breastfed.
• Many more children suffer from unnecessary illnesses that they would not have if they were breastfed.
• Breastfeeding also helps to protect mothers’ health.
• The World Health Organization and UNICEF recommend exclusive breastfeeding from birth for the first 4-6 months of life, and sustained breastfeeding together with adequate complementary foods up to 2 years of age or beyond.

• Mammary buds are laid by the 18-19th week of intrauterine life.
• The buds do not develop until Thelarche when they increase in size, pigmentation of the areola secondary to the effect of estrogen and progesterone.

Structure of the Human Breast

• The Human breast are modified sweat glands responsible for lactation (milk production).
• The breast contains adipose tissue and fibrous connective tissue.
• Different hormones are responsible for the development of the breast and changes that occur during pregnancy.
• The major hormones affecting breast development and enlargement are estrogen, progesterone, and prolactin.
• Each breast contains about 20 lobes, each lobe contains several lobules which at the end have alveoli in which milk is produced.
• Milk production and secretion are responsive to two major hormones – prolactin and oxytocin; and the sucking reflex.
• After production of milk in the alveolus, the milk moves through the ducts and is stored in the lactiferous sinus. When the infant latches on the breast, milk is expressed from the sinuses.

• To start breastfeeding, the mother has to slightly touch her nipple to the baby's lower lips.
• The baby will root for the breast and rapidly lift the breast to its mouth.
• The baby latches on the breast.
• Latching stimulates sucking receptors in the nipple and areola.
• This stimulation sends a message to the hypothalamus, which in turn stimulates the release of prolactin and oxytocin from the pituitary gland.
• The sucking reflex arc is a hormonal positive feedback mechanism.
• The sucking of the breast by the infant stimulates the nipple, sending messages to the spinal cord and brain.
• Prolactin is released from the anterior pituitary for milk production, and oxytocin is released from the posterior pituitary for milk letdown.
• Prolactin receptors are established within the first eight days of delivery.
• Suckling at the breast increases prolactin levels, leading to higher levels at each feeding and more milk production.
• Oxytocin:
• Secreted from the posterior pituitary gland.
• Responsible for the "let-down reflex" – it stimulates the muscle cells around the areola to contract, making the milk collected in the alveoli flow along the ducts to the lactiferous sinuses.
• Its release is faster and it also helps in uterine contraction.

BREASTFEEDING REFLEXES

• Rooting: A natural reflex for babies. The baby opens its mouth wide and its head moves quietly from side to side searching for the nipple. To initiate, stroke the lower lip or cheek of the baby with the nipple.
• Latching: The baby grasps the mother's nipple with its mouth wide open and compresses the lips. It is a skill that must be learned, so the baby has to be helped.
• Suckling: The process of the baby rhythmically drawing milk from the breast through suction and compression. This involves the baby taking the nipple and areola into its mouth, using its tongue and jaw to create a vacuum and extract milk. Suckling stimulates the release of hormones like prolactin and oxytocin, which support milk production and let-down reflex.

MECHANISM OF NORMAL SUCKLING

• Suction of 4-6cm of the areola.
• Compression of the nipple against the palate.
• Stimulation of milk injection by initial non-nutritive sucking.
• Extraction of milk from the lactiferous sinuses by a slower suck-swallow rhythm of approximately 1/sec.

• Fat: The main lipids found in human milk are triglycerides, phospholipids, and essential fatty acids. These fats are important for the baby's energy and brain development.
• Protein: Human milk contains two main types of protein: whey and casein. Whey proteins include lactoferrin, lysozymes, immunoglobulins, and A-lactalbumin. Casein is present in lower concentrations in human milk compared to cow's milk.
• Carbohydrate: Human milk contains lactose, a complex carbohydrate that provides energy and supports the growth of beneficial bacteria in the baby's gut. It also contains oligosaccharides that have important roles in the infant's immune system and gut health.
• Leukocytes: Breast milk contains various types of white blood cells, including neutrophils, macrophages, and lymphocytes. These cells contribute to the baby's immune defense and protection against infections.
• Non-Protein Nitrogen: Substances like urea and uric acid are present in breast milk, contributing to its nutritional content.
• Other Constituents: Breast milk also contains other important components such as steroid hormones, peptides, insulins, growth factors, minerals, vitamins, and lipase, which aids in digestion of fats.

Types/Forms of Human Breast Milk:

• Colostrum or Early Milk: Produced in the late stage of pregnancy until 4 days after delivery. It is rich in antibodies and provides essential nutrients to the newborn.
• Transitional Milk: Produced from day 4 to 10 after delivery. It has a lower protein content compared to colostrum and serves as a transition between colostrum and mature milk.
• Mature Milk: Produced from approximately ten days after delivery until the termination of breastfeeding. It can be further categorized into fore milk and hind milk.

Variations in the Composition of Breast Milk:

• Colostrum: Produced in the first few days after delivery, it is thick and yellowish or clear in color, providing essential immune factors for the newborn.
• Mature Milk: Produced after a few days, it becomes larger in quantity, making breasts feel full, hard, and heavy. This phase is often referred to as the breast milk "coming in."
• Fore Milk: Produced early in a feeding session, it appears bluer and is rich in protein, lactose, and other nutrients. It quenches the baby's thirst and provides essential nourishment.
• Hind Milk: Produced later in a feeding session, it appears whiter and contains a higher fat content. This fat provides energy and sustenance for the baby. Allowing the baby to feed until satisfied ensures proper intake of hind milk.

Benefits of Breastfeeding to Infants:

• Helps in gastrointestinal development and function.
• Aids in the development of the immune system.
• Contributes to the cognitive development of the infant.
• Reduces the risk of infections compared to formula-fed infants.
• Decreases the risk of obesity later in life.
• Reduces the risk of sudden infant death syndrome, Hodgkin's lymphoma, leukemia, and type 1 diabetes.
• Lowers the risk of infections such as otitis media, lower respiratory tract infection, diarrheal diseases, allergies, eczema, meningitis, and inflammatory bowel diseases.

Benefits of Breastfeeding to Mothers:

• Enhances early maternal-infant bond.
• Aids involution of the uterus.
• Long-term breastfeeding helps in losing the excess weight acquired during pregnancy.
• Prolonged breastfeeding prolongs anovulation.
• Documented long-term effects of breastfeeding include a reduced risk of breast, ovarian, and endometrial cancers.

Socio-economic Benefits of Breastfeeding:

• Income savings - an average of $1000 - $1200 per infant per year.
• Reduced risk of infections and diseases leading to fewer hospital visits and medical costs.
• Mothers are more economically productive as they spend less time caring for a sick child.
• Advantages to society include reduced healthcare costs due to lower illness incidence in breastfed infants and reduced employee absenteeism for infant care.

• The mother should be comfortable.
• The infant should be held close to the mother, facing the breast with the infant's ear, shoulder, and hip in a straight line (belly to belly).
• The infant's mouth should be open wide just before attaching. If properly attached, the lips are curled outward, with the tongue over the lower gum.
• Sucking involves: suction of 4 to 6cm of the areola, compression of the nipple against the palate, stimulation of milk ejection by initial rapid non-nutritive sucking, extraction of milk from the lactiferous sinuses by a slower suck-swallow rhythm.

• Frequent feedings 8-12 times daily.
• Intermittent episodes of rhythmic sucking with audible swallows should be heard while the infant is nursing.
• Infant should have about 6-8 wet diapers in a 24-hour period once breastfeeding is established.
• Infant should have a minimum of 3-4 bowel movements every 24 hours.
• Stools should be about one tablespoon or larger and should be soft and yellow after day 3.
• Average daily weight gain of 15-30g.
• Infant has regained birth weight by day 10 of life.

Barriers to Effective Breastfeeding:

• Lack of confidence in mother.
• Belief that breast milk is not sufficient.
• Lack of an adequate support system.
• History of previous breast surgery.
• Breast engorgement, cracked and sore nipples.
• Retractile nipples.
• Embarrassment by mother.
• Jealousy by partner and siblings.
• Chronic illness in mother: psychosis, cancer.

Good Breastfeeding Techniques:

• The baby should be properly positioned to achieve effective latching.
• The mother should wear comfortable apparel, with the breast well exposed for the infant to be able to latch.
• The infant’s mouth, chin, and umbilicus should be lined up with the head in a neutral position.
• The infant is brought to the breast, with the nose touching or close to the breast.
• The gum line should overlap the areola, and the nipple straight back into the mouth.
• The tongue moves forward beyond the lower gum, cupped and forming a reservoir.
• Milk is removed from the lactiferous sinuses, the jaw moves down creating a negative pressure gradient that helps transfer milk to the pharynx.

Cradle Hold:

• This is the most common position used by mothers.
• Infant’s head is supported in the elbow, the back and buttock are supported by the arm and lifted to the breast.

Football Hold Position:

• The infant is placed under the arm, like holding a football.
• Baby’s body is supported with the forearm and the head is supported with the hand.
• Many mothers are not comfortable with this position.
• Good position after operative procedures.

Side Lying Position:

• The mother lies on her side propping up her head and shoulder with pillows.
• The infant is also lying down facing the mother.
• Good position after Caesarean section.
• Allows the new mother some rest.
• Most mothers are scared of crushing the baby.

Cross Cradle Hold Position:

• Ideal for early breastfeeding.
• Mother holds the baby crosswise in the crook of the arm opposite the breast the infant is to be fed.
• The baby's trunk and head are supported with the forearm and palm.
• The other hand is placed beneath the breast in a U-shaped to guide the baby's mouth to your breast.

Australian Hold Position:

• This is also called the saddle hold.
• Usually used for older infants.
• Not commonly used by mothers.
• Best used in older infants with a runny nose, ear infection.

Launched in 1991 by WHO and UNICEF (after the 1990 Innocenti declaration at the World Summit for Children, which aimed to protect, promote, and support breastfeeding). The initiative aims to re-orient health workers and facilities towards adopting policies and practices that encourage breastfeeding. This is achieved through the observation of the ten steps to successful breastfeeding:

1. Every facility providing maternity services and care for newborns should have a breastfeeding policy that is routinely communicated to all health staff.
2. Train all healthcare staff in the skills necessary to implement the breastfeeding policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within half an hour of birth.
5. Show mothers how to breastfeed and maintain lactation if they are separated from their infants.
6. Give newborn infants no food or drink, unless medically indicated.
7. Practice rooming-in; allow mothers and babies to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them upon discharge from the hospital or clinic.

• Sore/cracked nipples
• Breast tenderness and engorgement
• Mastitis
• Breast abscess
• Breastfeeding jaundice
• Breastmilk jaundice

• Intense exertion (↑BM lactic acid)
• Alcohol intake (↓ Oxytocin)
• Caffeine (interferes with iron bioavailability)
• Smoking (Nicotine alters BM taste)
• Food (some foods alter the taste of BM, some cause colic, and some cause food allergies)

When storing breast milk, consider the following guidelines:

• Human milk can be stored at room temperature for 6-8 hours.
• Expressed milk can be stored in an insulated cooler bag with icepacks for 24 hours.
• Breast milk can be stored in the refrigerator for about 5 days at around 40°F.
• It can also be kept in the freezer compartment of a fridge for up to two weeks at 0 - 5°F.
• Breast milk can be stored in a deep freezer for about 3-12 months.
• Always use BPA (Bisphenol A)-free containers for storing breast milk.

• Breastfeeding is the best source of nutrition for a healthy term infant.
• The American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and World Health Organization (WHO) recommend exclusive breastfeeding for the first six months of life and for at least twelve months of life.
• Human milk is specifically designed for humans and contains essential nutrients for proper newborn growth and development.
• Breast milk provides benefits to both infants and mothers.