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Breast feedingHuman milk is the ideal & uniquely superior food for infants for the first year of life and is the sole source of nutrition for the first 6 months.
Advantages of breast feeding :
For the baby:1- human milk is the natural food for the infant for the first months of life & it supplies the necessary nutrients except fluoride & after several months vit.D
2- always readily available at a proper temp. &needs no preparations
3-fresh & sterile
4- protects the infant from allergy
5- provides immunity to the infants because it has many immunological factors
There is decreased incidence of OM ,meningitis , pneumonia, UTI , GE, & certain chronic diseases as IDDM, celiac disease & others in breast fed infant as compared to bottle fed infant
6-sphycological advantages
Increase bonding between the mother & the baby
7- increase intelligence
for the mother :-
1- psychological advantage
Prolactin causes relaxation to the mother
2- natural contraceptive for the first 6 months after delivery provided that the mother is ammenorrheic & the baby is exclusively BF
3- protects the mother from diseases as breast, uterine & ovarian CA.
4-not costy .
Physiology of lactation;
When the infant sucks the breast this cause production of 2 hormones1- Prolactin which is produced by the anterior pituitary & acts on milk producing cells to produce milk
2- Oxytocin which is produced from the posterior pituitary & acts on myoepithelial cells & causes ejection of milk from the breast (Let down reflex)
↑ Frequency of feeding …….↑ prolactin & oxytocin………..↑milk production
The level of prolactin increased at night so night feedings increase milk supplyBreast feeding basics:
There are three major types of infant feeding:A- Full breast feeding which include;
1- Exclusive BF (no other food as solids, liquids, is given to the infant even medications)
2- Almost exclusive BF (the infant is given water, juice, vitamins, not more than twice per day)
B- Partial BF
1- High partial BF in which >80% of the feeds is from the breast
2- Medium partial BF 20-80% of the feeds from the breast
3- Low partial BF <20% of the feeds from the breast
C- Token BF: episodes of BF
The best method of feeding of the infant is exclusive BF during the first 6 months of life
Complementary feedings
should be started at the 6th month of life with the breast milk is the principle food during the first year of life.
commercially prepared or homemade food are used . should avoid food with high potential for allergy as egg, fish, peanuts, dairy products especially if there is family history of allergy.
grape ,popcorn & nuts are associated with risk of airway obstruction so should be avoided
Weaning should be at the second year of age
The newborn infant should be started on BF as early as possible after birth provided that the infant is clinically stable & can tolerate feedingIn NVD the BF should be started within the first ½ hour after delivery & in C.S. the BF started 4-6 hrs after delivery with frequent unrestricted BF which has
benefits for the mother & the baby
1- Provides the baby with colostrum
2-contracts the uterus of the mother so prevent PPH
3-prevent neonatal jaundice because colostrums is laxative & help to get rid of meconium which is rich in bilirubine
4- Prevent breast engorgement
5-increase milk supply
Signs of satisfactory BF;
1- Weight gain 113-227g/week
2-Bowel motions 2-4 /day
3-wet diapers per day 6-8
The immunological properties of human milk are:-
1- Cellular factorsThe total cell count of human milk is 4000cell\mm3
The predominant cell is macrophage (90%) which produce lysozymes, lactoferrine & responsible for phagocytosis
Other cells are PMN leukocytes, lymphocytes which produce Ig
2- Humoral factors (Ig)
The major Ig present in human milk is sIgA (90%) is synthesized in the mammary alveolar cells
IgA level increased immediately after birth in colostrums
Other Ig as IgG, IgM, IgE are also present
3- Bifidus factor
A specific factor supports the growth of L.B. bacteria which is G +ve non motile anaerobic bacteria inhibits the growth of pathogenic bacteria in the intestine
4- Resistance factor
A specific factor acts against staph. Aureus
5- Lysozymes
Are bacteriostatic act against G +ve bacteria & enterobacteria
6-lactoferrine
Is iron binding protein has strong bacteriostatic effect against staph. Aureus & E.coli by depriving the M.O. from iron
Iron therapy saturates it & decreased its effectiveness
The conc. Of it is high in colostrum
7- Interferones
Has antiviral activity
8-Complement mainly C3, C4
9- B12 binding protein
Binds vit. B12 & prevents bacteria from utilizing it like E.coli & bacteroids
10- Bile salt stimulated lipase
It inhibits Giardia Lamblia growth
Maternal drug use:
Few therapeutic drugs are absolutely contraindicated; these include radioactive compounds, lithium, and certain antithyroid drugs.
If a woman is unable to discontinue drug use, she should not breastfeed. Expression
Biochemistry of human milkThe milk of the first 3-5 days postpartam is called colostrum
From the 7th -14th day postpartam called transitional milkAfter the 14th day called mature milk
Colostrum
Is thick yellow in color , the S.G. is 1.040-1.060.it gives energy about 67Kcal\dlThe total volume per day may reach 100ml
The yellow color is due to β-carotene
The ash content is high (Na,K,Cl,…..) more than mature milk
The protein & fat soluble vitamins are also higher than mature milk
Fat & CHO are lower than mature milk
It contains high conc. Of Ig (sIgA) & mononuclear cells
Benefits of colostrum are:-
It facilitate the growth of L.B. floraIt’s a laxative help in the passage of meconuim
Protective against infection (contain high conc. Of Ig) & cells
Contain antioxidants which trap the O2 metabolites generated by neutrophils
Mature milk:
PH is 6.7-7.4
It provide 75Kcal \dl
S.G. is 1.031-1.032
It contains;
1- Water:
Form 70-80% of the volume of milk
2- Lipids (T.G., FFA& phospholipids)
Forms 35% of the volume of milk (as in cows milk)
It provides 50% of the energy
Is the most variable content of human milk
Variations of the content of lipids inhuman milk;
1- It vary during each feed
The milk which comes early in the nursing is called fore milk & its light yellow in color, rich in water & CHO, low in fat content
The milk which come at the end of the feed is called the hind milk & is white – yellow in color & rich in fat
Fore milk – hind milk imbalance
Is a condition characterized by poor weight gain, excessive crying, frequent greenish watery stool due to the feeding of the infant from both breasts at each feed & the infant take the fore milk of both breasts only
2- The stage of lactation:
Weaning milk has high fat content
When the interval between the feeding increase the fat content is decreased & when the interval decreased the fat content increased because frequent feeding increase the volume of milk & fat content
3- Diurnal variation; the fat content in the milk during afternoon & evening is higher than the night
(Less mov. Cause redistribution of fat away from the breast)
4- Parity;
Primiparus women has more fat in the milk than multiparus women
5-Seasonal variation;
Low fat during rainy seasons
Human milk contain essential F.A. linolenic acid & linoleic acid which are essential for the development of the brain, eye & for myelin formation
3- Proteins;
1.5% of the milk volume (3.5% in cow's milk)
65% of human milk protein is whey protein (α-lactalbumine, lactoferrine& immunoglobulin)
35% is casein which are group of specific proteins that form complexes with Ca++)
Cows milk protein is mainly casein which is difficult to be digested)
20 a.a. are present in human milk & 8 of theme are essential
The a.a. taurine is not present in cows milk & is acts as neurotransmitter & neuromodulator in the brain & retina (its essential for preterm & LBW baby)
(Good vision of LBW babies fed human milk)
4- CHO;
Forms 7.5% of the milk content (4.5%in cow's milk)
The main CHO is lactose which is synthesized by the breast .
Glucose & galactose are also present
Fructose is present in human milk & not present in cow's milk & important in the growth of L.B.
5- Minerals ;( ash)
0.2% of the content (cows milk 0.6-0.7%)
Na+.K+, Ph-, Ca++, Cl- …)
6- trace elements;
Like iron present in a conc. Of 100μg /dl & is more efficiently absorbed than iron in cows milk or formula
About 50% of the iron in humans milk is absorbed while only 10% of the iron in cow's milk & 4% of iron in the formula is absorbed
7- Vitamins
Vitamin A, E, D,C are more common in human milk than cows milk
Vitamin K in breast milk is less than the requirement & less in human milk than cows milk
Vitamin B complex is more in cow's milk
Maternal illness & breast feeding
1- Cardiac problems & HT
BF is of benefit to the mother because prolactin relaxes the mother
All drugs used are compatible with BF
2- Carcinoma
A mother with CA can BF her infant
If she needs radioactive substances or chemotherapy the mother should express the milk & discard it during therapy & return back to BF after completing the therapy
3- Chicken pox
If the mother has CP within 5 days of labour .the mother should be separated from the baby, the milk should be expressed & given to the baby
If she has CP after 5 days of labour no need for separation of the baby
4- Cholera, typhoid fever
BF is protective
5- Cold, flue
Is compatible with BF because the baby is exposed to infection before the mother is symptomatic
6- CMV
Is transmitted to the baby transplacentally also the Ab to CMV is transmitted transplacentally
CMV & Ab to CMV are present in the breast milk & cause no problems
7- Food poisoning
Not CI to BF
8- Giardiasis
Not CI
9- Hepatitis A
Compatible with BF
10- Hepatitis B
Compatible with BF & the baby should receive Ig & vaccine within 12 hrs after birth
Hepatitis C is compatible with BF
11- HIV infection
Can be transmitted through BF but BF is of benefit to the baby of HIV infected mother because it contain a factor that inhibit the binding of the virus to T-lymphocytes
The baby is at risk to die from malnutrition in developing countries if not BF so BF should not be stopped but in developed countries BF can be stopped because the risk to die from malnutrition is low
12- TB
If the mother has active TB after birth the baby should be separated from the mother until the mother is not infectious (2wksafter therapy) the n BF is continued
If the mother is not infectious she start BF after birth
The infant should receive BCG at birth
Formula feeding
Cow's Milk-Based Formulas
Unmodified cow's milk is unsuitable for feeding in infancy as it contains too much proteins & electrolytes& inadequate iron & vitamins.
Cow's milk based formulas are alternative to human milk & are iron-fortified formula, which permits adequate growth of most infants and is formulated to mimic human milk.
No vitamin or mineral supplements (other than fluoride after 6 months) are needed with such formulas.
The carbohydrate is generally lactose, although lactose-free cow's milk-based formulas are available. The caloric density of formulas is 20 kcal/oz (0.67 kcal/mL), similar to that of human milk.
Formula-fed infants often gain weight more rapidly than breastfed infants, especially after the first 3 to 4 months of life.
Formula-fed infants are at higher risk for obesity later in childhood
Cow's milk-based infant formulas are used as substitutes for breast milk for infants whose mothers choose not to or cannot breastfeed or as supplements for breastfeeding
Soy Formulas
Soy protein-based formulas provide an alternative to cow's milk-based formula when intolerance occurs from immune reactions to cow's milk proteins.A significant proportion of infants allergic to cow's milk protein also are allergic to soy protein.
The soy protein is supplemented with methionine to improve its nutritional qualities. The carbohydrates in soy formulas are glucose oligomers (smaller molecular weight corn starches) and sometimes sucrose.
The fat mixture is similar to that used in cow's milk formulas.
Caloric density is the same as for cow's milk formulas.
Soy protein formulas do not prevent the development of allergic disorders in later life, and clinical intolerance to soy protein or cow's milk protein occurs with similar frequency.
. Soy protein-based formulas are not recommended for premature infants with birth weights less than 1800 g.
Soy based formulas has disadvantages as it contain high aluminum contents and phytoestrogens a plant substance that mimic endogenous estrogens
These formulas provide 20 Kcal per ounce (oz)
Each ounce (oz) = 28 ml
Should be prepared by adding one scoop for each ounce of water
Therapeutic Formulas
Therapeutic formulas are designed to treat digestive and absorptive insufficiency or protein hypersensitivity.
Some formulas contain protein hydrolysate. The major nitrogen source of each of these products is a casein or whey hydrolysate, supplemented with selected amino acids. These formulas contain an abundance of essential fatty acids from vegetable oil
Also certain formulas provide substantial amounts of medium chain triglycerides, which are water soluble and are more easily absorbed than long chain fatty acids; this is a useful feature for patients with malabsorption resulting from such conditions as short gut syndrome, intestinal mucosal atrophy or injury, chronic diarrhea, or cholestasis. Elemental formulas also are available that contain synthetic free amino acids and varying quantities and types of fat components. These are especially designed for patients with protein allergy or sensitivity.
The carbohydrate content of these specialized formulas varies, but all are lactose free; some contain glucose oligomers and soluble starches.