Breastfeeding - KSG PDF

BREASTFEEDING Kyle S. Gonzales, MD  OBJECTIVES At the end of the lecture, the student should be able to: Describe the physiology of lactation. Differentiate colostrum, transitional and human mature milk. Compare the quantitative and qualitative properties of breast milk...

BREASTFEEDING Kyle S. Gonzales, MD  OBJECTIVES At the end of the lecture, the student should be able to: Describe the physiology of lactation. Differentiate colostrum, transitional and human mature milk. Compare the quantitative and qualitative properties of breast milk and cow’s milk. Enumerate the advantages of breast milk over cow’s milk. MILK Breast milk Evaporated Milk Condensed Milk Humanized Milk Cow milk-based Soy-based Goat’s milk-based Hypoallergenic  PLASMA HORMONE LEVELS DURING PREGNANCY HORMONAL CONTROL OF LACTATION  LET- DOWN REFLEX COLOSTRUM Secreted from 1st sucking day – 5 days Characteristics Deep yellow Alkaline reaction pH 7.7 Specific gravity 1.040 – 1.060 10 – 40 ml/day COLOSTRUM Nutrient Composition Lower lactose (sugar) and fat content Higher protein & Ig (esp. sIgA) content (95% of the proteins) Richer in Vit. A, minerals like Na+, K+, and trace elements like Fe Increased amount of macrophages for phagocytosis TRANSITIONAL MILK 4th – 10th day of lactation Fats, lactose and most B vits gradually increase Phosphorus is higher than in either colostrum or mature human milk HUMAN MATURE MILK Secreted beyond 10th day of lactation Characteristics o Bluish and watery o pH 6.8 – 7.4, ave. 7 o Sp. gr. 1.026 – 1.036, ave. 1.031 Nutrient Composition o High levels of fats, lactose and most B vitamins o Lower proteins, immunoglobulins, Mature Milk Colostrum minerals, and fat-soluble vitamins MILK COMPOSITION NUTRIENT MATURE HUMAN COW’S MILK COMPOSITION MILK Water (ml) 87.1 87.2 Energy (kcal/dl) 69.0 66.0 Protein (g/dl) 1.1 3.5 Fat (g/dl) 4.5 3.7 Lactose (g/dl) 6.8 4.9 Ash (g/dl) 0.2 0.7 CALORIC DISTRIBUTION IN HUMAN MILK NUTRIENT % OF TOTAL CALORIES Carbohydrates 47% Fats 50% Proteins 3% LACTOSE Major and dominant human milk carbohydrate Why? Disaccharide Glucose  energy Galactose & glucose  cerebrosides  CNS development LACTOSE: ADVANTAGES Facilitates intestinal absorption of Ca+2 and Mg+2 Favors protein absorption Promotes growth of intestinal bacteria Promotes growth of microbial flora → ↓ pH → prevents growth of pathogens Promotes predominance of fermentative stool flora Less sweet than sugar OLIGOSACCHARIDES/ COMPLEXCARBOHYDRATES Small amounts of N2-containing complex CHOs N-acetylglucosamine Sialic acid-containing oligosaccharides and polysaccharides Bifidus factor – beneficial microbes Bifido bacteria and Lactobacillus species Crowds out harmful GIT pathogens (eg. E coli) Probiotic preparations – prevent NEC, treatment of colic and gastroenteritis in children Lactobacillus shirota strain in Yakult, Chamito PROTEIN NITROGEN FRACTION HUMAN MILK COW’S MILK PROTEIN (g/dl) 1.1 3.5 Protein nitrogen 1.43 5.03 a. Casein* 40% 82% b. Whey 60% 18% COMPOSITION OF PROTEIN NITROGEN A. PROTEIN NITROGEN HUMAN MILK COW’S MILK Whey α-lactalbumin 0.42 0.17 Lactoferrin 0.27 traces β-lactoglobulin - 0.57 Lysozyme 0.08 traces Serum albumin 0.08 0.07 IgA (sIgA) 0.16 0.005 IgG 0.005 0.096 IgM 0.003 0.005 COMPOSITION OF PROTEIN NITROGEN CONTENT HUMAN MILK COW’S MILK B. NON-PROTEIN NITROGEN 0.50 0.28 Urea 0.25 0.13 Creatine 0.37 0.009 Creatinine 0.035 0.003 Uric Acid 0.005 0.008 Glucosamine 0.047 - α-amino Nitrogen 0.002 0.006 ESSENTIAL AMINO ACIDS* (mg/100 ml) CONTENT HUMAN MILK COW’S MILK Histidine 22 95 Isoleucine 68 228 Leucine 100 350 Lysine 73 277 Methionine 25 88 Phenylalanine 48 172 Threonine 50 164 Tryptophan 18 49 *L-isomers NON-ESSENTIAL AMINO ACIDS* (mg/100 ml) CONTENT HUMAN MILK COW’S MILK Arginine 45 129 Alanine 35 75 Cysteine 22 32 Glutamate 320 680 Glycine 0 11 Proline 80 250 Serine 69 160 Tyrosine 61 179 FATS Major energy source Important for CNS myelinization Most variable component Effect of Maternal Diet Diets high in fish (Inuits, Japanese) – high PUFA Diets high in vegetable oil – high PUFA Diets high in CHO – *high SFA *Increased glucose pathway of milk lipid synthesis FATS Most variable component Diurnal Variation Lowest in early mornings Peaks at evenings Higher at end of breastfeeding (“hind milk” vs. “fore milk”) FATTY ACID PROFILE CONTENT HUMAN MILK COW’S MILK Total Fat 4.5 3.7 Unsaturated Fatty Acids 48 33 Saturated Fatty Acids* 49 67 Unclassified Fatty Acids 3 Essential Fatty Acids 7 3 *Form precipitates with Ca+2 MINERALS CONTENT HUMAN MILK COW’S MILK Calcium (mg/100 ml) 340 1170 Phosphorus (mg/100 ml) 140 920 Sodium (mEq/L) 7 22 Potassium (mEq/L) 13 35 Chloride (mEq/L) 11 29 IRON CONTENT HUMAN MILK COW’S MILK Iron 0.50 0.50 % Absorption 45 10 FAT-SOLUBLE VITAMINS CONTENT HUMAN MILK COW’S MILK A (IU) 1898 1025 D (IU) 22 14 E (IU) 2 0.4 K (IU) 15 60 H2O-SOLUBLE VITAMINS CONTENT HUMAN MILK COW’S MILK Vit. C ↑ ↓ Niacin ↓ ↑ Thiamine ↓ ↑ Riboflavin ↓ ↑ Vit B12 ↓ ↑ Pyridoxine ↓ ↑ EVAPORATED MILK EVAPORATED MILK Cow’s milk evaporated at 55 – 60 °C → reduced to 50% of its volume Homogenized Sealed, autoclaved at 160 °C Pasteurization causes some damage to protein quality COMPOSITION OF HUMAN MILK VS. EVAPORATED MILK COMPOSITION FACTORS HUMAN MILK EVAPORATED MILK Energy (kcal/dl) 69 152 7.8 Protein (gm/dl) 1.1 (100% casein) Fat (gm/dl) 6.5 4.3 (coconut & corn oil) - filled milk - inc. sat FA Lactose (gm/dl) 6.8 6.8 COMPOSITION OF HUMAN MILK VS. EVAPORATED MILK COMPOSITION FACTORS HUMAN MILK EVAPORATED MILK Calcium (mg/L) 340 2750 Phosphorus (mg/L) 140 2112 Sodium (mg/L) 7 55 Potassium (mg/L) 13 77 Chloride (mg/L) 11 46 Iron (mg/L) 0.5 2.43 COMPOSITION OF HUMAN MILK VS. EVAPORATED MILK COMPOSITION FACTORS HUMAN MILK EVAPORATED MILK Fat-Soluble Vitamins A E K (IU) Same same D (IU) 22 420 ↑ B 1 B2 B6 H2O-Soluble Vitamins ↓ Vit. C  SWEETENED CONDENSED MILK COMPOSITION OF HUMAN MILK VS. CONDENSED MILK COMPOSITION FACTORS HUMAN MILK CONDENSED MILK Energy (kcal/dl) 69 67 Protein (gm/dl) 1.1 1.6 (casein predominant) Fat (gm/dl) 4.5 1.6 (100% veg. oil) – inc sat FA Carbohydrates (gm/dl) 6.8 11.7 lactose lactose 43.7 sucrose HUMANIZED MILK NON-PREMIUM FORMULA COMPOSITION OF HUMAN MILK VS. NON-PREMIUM FORMULA COMPOSITION FACTORS HUMAN MILK NON-PREMIUM FORMULA Energy (kcal/dl) 69 67 Protein (gm/dl) 1.1 1.5- 1.7 Casein 40% 60-70% Whey 60% 30-40% Fat (gm/dl) 4.5 3.2 – 3.5 (milk fat) (65 – 100% veg. oil) Carbohydrate (gm/dl) 6.8 7.1 – 7.4 (lactose) (lactose & sucrose) Minerals slightly ↑ Vitamins Fat Soluble slightly ↑ Water Soluble slightly ↑ PREMIUM FORMULA PREMIUM FORMULAS Intended for healthy, uncompromised, and non-problematic babies From birth up to 6 months of age Relatively expensive COMPOSITION OF HUMAN MILK VS. PREMIUM FORMULA COMPOSITION FACTORS HUMAN MILK PREMIUM FORMULA Energy (kcal/dl) 69 67-68 Protein (gm/dl) 1.1 1.5 Casein 40% 40% Whey 60% 60% Fat (gm/dl) 4.5 3.4 – 3.7 (milk fat) (100% veg. oil) Carbohydrate (gm/dl) 6.8 7 – 7.2 (lactose) (lactose) Ash 0.2 0.4 – 2.5 Minerals ↑ HIGH PROTEIN FORMULA HIGH-PROTEIN FORMULAS Other Name: Follow-up formulas For babies 6 months and above Rapid body growth and development Need for more proteins Relatively more expensive COMPOSITION OF HUMAN MILK VS. HIGH-PROTEIN FORMULA COMPOSITION FACTORS HUMAN MILK HIGH-PROTEIN FORMULA Energy (kcal/dl) 69 67 Protein (gm/dl) 1.1 2.9 – 3.1 Casein 40% 40% Whey 60% 60% Fat (gm/dl) 4.5 2.6 – 2.75 (milk fat) (20 – 100% veg. oil) CHO (gm/dl) 6.8 7.4 – 8 (lactose) (lactose, sucrose, maltodextrin) Ash (gm/dl) 0.2 0.5 – 0.6 Minerals ↑ Vitamins ↓ Thiamine, Riboflavin, Pyridoxine ↑ Niacin, Folic Acid, Vit. C, Vit. B12 and Fat - soluble Vits. PREMATURE FORMULA PREMATURE FORMULAS For low birth-weight infants For premature babies To promote growth at intrauterine rates without disrupting metabolic processes COMPOSITION OF HUMAN MILK VS. PREMATURE FORMULA COMPOSITION FACTORS HUMAN MILK PREMATURE FORMULA Energy (kcal/dl) 69 81 Protein (gm/dl) 1.1 1.9 – 2.2 Casein 40% 40% Whey 60% 60% Fat (gm/dl) 4.5 4.32 – 4.4 (milk fat) (corn oil, coco oil, MCT) CHO (gm/dl) 6.8 8.0 – 8.6 (lactose, corn syrup, maltodextrin) Minerals ↑ Vitamins ↑esp. Vit. D SOY PROTEIN FORMULAS SOY PROTEIN FORMULAS Based on vegetable proteins (soya) Lactose free, “milk free” For children with allergy to cow’s milk proteins or those with lactose or galactose intolerance COMPOSITION OF HUMAN MILK VS. SOY PROTEIN FORMULA COMPOSITION FACTORS HUMAN MILK SOY PROTEIN FORMULA Energy (kcal/dl) 69 67 Protein (gm/dl) 1.1 1.9 – 2.1 (soy prot.) Casein 40% 100% Whey 60% Fat (gm/dl) 4.5 3.3 – 3.6 (milk fat) (24-100% veg. oil) Carbohydrate (gm/dl) 6.8 6.9 – 7.4 (sucrose, (lactose) maltodextrin) Carnitine + + Linoleic Acid (mg/L) + 250-500 GOAT’S MILK FORMULA GOAT’S MILK FORMULA Intended for those allergic to cow’s milk and/or soy products ↓ energy yield Lactose predominant Whey predominant → ↓ β-lactoglobulin → less allergies ↑ Ca+2, proteins & ash Expensive Currently not acceptable in many places because there are no robust randomized clinical trials HYPOALLERGENIC FORMULA HYPOALLERGENIC FORMULAS Intended for babies born to parents with strong family history of allergy or those with allergy to proteins Reduces the risk of allergies in infants and children COMPOSITION OF HUMAN MILK VS. HYPOALLERGENIC FORMULA COMPOSITION FACTORS HUMAN MILK HYPOALLERGENIC FORMULA Energy (kcal/dl) 69 67 Protein (gm/dl) 1.1 1.13 Casein 40% 40% Whey 60% 60% Fat (gm/dl) 4.5 3.21 (milk fat) (veg. oil) CHO (gm/dl) 6.8 7.74 (lactose) Minerals (gm/dl) 0.2 0.31 SUMMARY OF MODIFICATIONS AND ENRICHMENTS OF COMMERCIAL MILK FORMULAS Modification/Enrichment Comments Use of vegetable oil Increased level of saturated fatty acids Addition of sucrose (in condensed milk) Nutritionally out of balance formula Use of vegetable protein (soya) Lower biologic value Lactose-free formula (soy protein No benefits obtained from lactose as the dominant formulas) carbohydrate Addition of probiotics and prebiotics To support growth of healthy GIT flora for stronger natural defenses SUMMARY OF MODIFICATIONS AND ENRICHMENTS OF COMMERCIAL MILK FORMULAS Modification/Enrichment Comments Docosahexaenoic acid/Arachidonic acid For adequate visual and brain development  (DHA/ARA) & taurine efficient brain synapses  babies grow smarter  gifted children Addition of nucleotides For brain growth and development; for strengthening the baby’s immune system Essential Fas (Linolenic acid [ω- Essential for physical and mental development 6]/Linoleic acid [ω-3]) Hypoallergenic formulas Protein blend for those at risk of developing allergy Use of MCTs, CHO blend of lactose, For adequate development of visual and brain corn syrup & maltodextrin function; high energy content for rapid growth in premature infants ADVANTAGES OF BREASTFEEDING ADVANTAGES OF BREASTFEEDING 1. Never be approximated 2. A Living Biologic Fluid Has antimicrobial properties Immunoglobulins IgA and IgG Promote gastrointestinal growth, motility and function  enhanced maturity of the GIT Proteases Cortisol, somatomedin-C, insulin-like growth factor Hormones (IGF), insulin and thyroid hormones Epidermal Growth Factor (EGF), Nerve Growth Growth Factors Factor (NGF), Intestinal mediators (neurotensin, motilin) Enzymes Platelet-activating factor (PAF) acetylhydrolase Anti-inflammatory Agents Interleukin-10 Free Amino Acids Taurine, Glutamine Polyunsaturated fatty acids (PUFA) ADVANTAGES OF BREASTFEEDING 3. It contains the major nutrients (CHOs, fats & CHONs), vitamins & minerals in the right forms and proportions. 4. The composition of breast milk is not subject to human error; this property is more than enough reason why breast milk is far superior to cow’s milk. 5. It contains living cells like white blood cells, macrophages and lymphocytes that lower rates of gastroenteritis, respiratory tract illnesses, recurrent otitis media, urinary tract infections, and sepsis in premature babies. ADVANTAGES OF BREASTFEEDING Short Term Benefits to the Infant Neurobehavioral Benefits Early skin-to-skin contact between mothers Reduce infant crying and newborns Increase blood glucose levels Promote greater cardiorespiratory stability in late preterm infants Enhanced maternal-infant bonding Has analgesic effect Radiant warmth from the skin-to-skin contact. Higher salivary cortisol levels in breastfed infants Gastrointestinal Functions Reduce the risk of gastroenteritis and diarrheal disease Increase the rate of gastric emptying Increase intestinal lactase activity in premature infants Decrease the intestinal permeability early in life in premature infants Reduce the risk of developing NEC in preterm infants ADVANTAGES OF BREASTFEEDING Short Term Benefits to the Infant Prevention of acute illnesses during breastfeeding Gastroenteritis and diarrhea Respiratory diseases Coronavirus disease 2019 (COVID-19) Otitis media Urinary tract infection Neonatal sepsis or infection in the newborn Sudden Infant Death Syndrome (SIDS) Decreased risk of childhood mortality, lower rates of hospitalizations and outpatient visits ADVANTAGES OF BREASTFEEDING RECAP: Anti-infective Properties: Colostrum sIgA, lactoferrin Mild laxative effect Antibodies to E. coli Lysozyme Anti-staphylococcal factor Lactoperoxidase Bile salt-stimulated lipase Productive lipid byproducts Free FAs & monoglycerides WBCs Neutrophils, lymphocytes Human milk oligosaccharides (Glu, Gal, Glu-Nac, Fuc, SA, & Lactose ADVANTAGES OF BREASTFEEDING Long Term Benefits to the Infant Reduced risk of acute illnesses even after breastfeeding is discontinued Reduced risk of certain chronic illnesses related to duration of breastfeeding: Moderate evidence of benefit Type I DM - longer breastfeeding duration was more protective than shorter durations Inflammatory bowel disease (IBD) (eg. Crohn’ s disease and ulcerative colitis) - lower rates with longer duration of breastfeeding Wheezing - lower incidence in early childhood due to reduction in the number of upper respiratory infections that cause wheezing in infants and young children. Dental health Malocclusion Dental caries ADVANTAGES OF BREASTFEEDING Long Term Benefits to the Infant Reduced risk of certain chronic illnesses related to duration of breastfeeding: Limited evidence of benefit Leukemia and lymphoma Allergic conditions like atopic asthma in older children (after six years of age) or on eczema or allergic rhinitis (in all age groups) Childhood obesity (appetite control mechanism) Type 2 DM Cardiovascular risk factors – like slightly lower blood pressure (reduction of approximately 1 mm Hg) during childhood, which may not be clinically significant Celiac disease ADVANTAGES OF BREASTFEEDING Long Term Benefits to the Infant Reduced risk of certain chronic illnesses related to duration of breastfeeding: Limited evidence of benefit Neurodevelopmental Slightly improved performance in intelligence tests; lower outcomes severity and incidence of retinopathy of prematurity Auditory function Auditory-evoked responses mature faster in breastfed premature infants Attention Deficit Hyperactivity Reduced incidence among exclusively breastfed infants Disorder (ADHD) Autism Spectrum Disorder Unclear association between breastfeeding and ASD (ASD) Child behavior Lower risk of behavior problems in children at 5 yrs. of age and breastfed for 4 months compared with a shorter duration of breastfeeding Abuse and neglect: reduced odds in adolescents of neglect and sexual abuse who were breastfed for 9 months or longer ADVANTAGES OF BREASTFEEDING Short Term Benefits to the Mother Contraceptive effect/”lactation amenorrhea” secondary to prolonged postpartum anovulation or delayed resumption of ovulation → spacing of pregnancy Enhancement of uterine involution Improved maternal response to stress Insufficient evidence to determine the association of breastfeeding with postpartum depression or weight change ADVANTAGES OF BREASTFEEDING Long Term Benefits to the Mother Decreased incidence of breast, epithelial ovarian and endometrial CA in breastfeeding women Modest reduction in CVD (e.g. hypertension) but may wane as a woman ages Reduced risk for Type 2 DM during the yrs. after delivery Remains uncertain in reduction of risk for osteoporosis ADVANTAGES OF BREASTFEEDING Economic benefits of breastfeeding Breastfeeding is inexpensive; does not cost a penny → lot of savings No need for vitamins Costs nothing for food Fewer medical bills Decrease in parental work absences Societal benefits of breastfeeding Reduced infant mortality Reduced incidence of chronic childhood diseases Lower carbon footprint SUMMARY & REFERENCES  SUMMARY B R E A S T F E E D I N G Best for baby’s and mother’s health and well-being. Reduces incidence of anemia, allergies and related disorders. Economical, no waste, no expense. Antibodies for greater immunity to infections. Spacing of pregnancy due to lactation amenorrhea and anovulation. Temperature is always correct and constant. Fresh milk, never gets contaminated nor spoiled nor composition duplicated. Emotional development and maternal-infant bonding are heightened. Excessive obesity, fatness and sweet tooth are avoided. Digested and absorbed easily, and utilized efficiently. Immediately available, anywhere and anytime. Nutritionally balanced. Gastroenteritis, respiratory, urinary and other infections are greatly reduced. FURTHER READING & RESOURCES RA 10028: Expanded Breastfeeding Promotion Act of 2009. Drugs and Lactation Database (LactMed®) REFERENCES Academy of Breastfeeding Medicine. ABM Clinical Protocol #9: use of galactogogues in initiating or augmenting maternal milk production, Second Revision. 2018 Escamila-Perez R, Segura-Perez. Maternal and economic benefits of breastfeeding. UpToDate. Apr 22, 2024. Lawrence, R. Breastfeeding, A guide for the medical profession. 9th Ed. Elsevier. 2022. Martin CR, Ling PR, Blackburn GL. Review of infant feeding: key features of breast milk and infant formula. Nutrients. 2016 May 11;8(5):279. doi: 10.3390/nu8050279. PMID: 27187450. Spencer J. Common problems of breastfeeding and weaning. UpToDate. May 27, 2024.