Breastfeeding & Infant Nutrition - Azerbaijan Medical University

AZERBAIJAN MEDICAL UNIVERSITY FAMILY MEDICINE DEPARTMENT Breastfeeding & Infant Nutrition Ph.D. Dr. Aygun Guliyeva  Breastfeeding Technique  Preparation for breastfeeding should begin in the preconception period or at the first contac...

AZERBAIJAN MEDICAL UNIVERSITY FAMILY MEDICINE DEPARTMENT Breastfeeding & Infant Nutrition Ph.D. Dr. Aygun Guliyeva  Breastfeeding Technique  Preparation for breastfeeding should begin in the preconception period or at the first contact with the patient. Most women choose their method of feeding prior to conception. Psychosocial support and education may encourage breastfeeding among women who might not otherwise have considered it. Evidence for this strategy, however, is anecdotal and requires further investigation.  Breastfeeding Technique  One commonly perceived physical barrier is nipple inversion. Women who have inverted nipples will have difficulty with the latch-on process. Nipple shields are relatively inexpensive devices that can draw the nipple out. Manual or electric breast pumps may also be used to draw out inverted nipples, typically beginning after delivery. Breastfeeding should begin immediately in the postpartum period, ideally in the first 30-40 minutes after delivery. This is easier to accomplish if the infant is left in the room with the mother before being bathed and before the newborn examination is performed. It is also safe to allow breastfeeding before administration of vitamin K and erythromycin ophthalmic ointment.  Breastfeeding Technique  Clinical situations arise that preclude initiation of breastfeeding in the immediate postpartum period (eg, cesarean delivery, maternal perineal repair, maternal or fetal distress). In such cases, breastfeeding should be initiated at the earliest time possible. Only when medically necessary should a supplemental feeding be initiated. If mothers have expressed a desire to breastfeed, the practitioner should coordinate an interim feeding plan, emphasizing that bottle feeding not be started. Acceptable alternatives include spoon, cup, or syringe feeding.  Breastfeeding Technique  Breastfed children commonly feed at least every 2-3 hours during the first several weeks postpartum. Infants should not be allowed to sleep through feedings; however, if necessary, feeding intervals may be increased to every 3-4 hours over night. The production of breast milk is on a supply-demand cycle. Breast stimulation through suckling and the mechanism of breastfeeding signals the body to make more milk. When feedings are missed or breasts are not emptied effectively, the feedback loop decreases the milk supply. As the infant grows, feedings every 3-4 hours are acceptable. During growth spurts, the amount of milk needed for the rate of growth often exceeds milk production. Feeding intervals often must be adjusted to growth periods until the milk supply catches up.  Breastfeeding Technique  Although feeding intervals may be increased during nighttime periods, a common question becomes when to stop waking the infant for night feedings. Anecdotal evidence suggests that after the first 2 weeks postpartum, in the absence of specific nutritional concerns, the infant can determine its own overnight feeding schedule. Typically, most infants will begin to sleep through the night once they have reached approximately 10 lb.  (The international weight pound, officially defined as exactly 0,45359237 kilos, is the most used nowadays.) (10 lb x 0,453592 kg = 4,53592)  Breastfeeding Technique  Positioning of the infant is critical for effective feeding in the neonatal period, allowing for optimal latch-on. In general, infant and mother should face each other in one of the following three positions: the cradle, the most common; the football; or the lay/side. The cradle hold allows the mother to hold the infant horizontally across the front of the chest. The infant's head can be on the left or right side of the mother depending on which side he or she is feeding. The infant's head should be supported with the crook of the mother's arm. The football hold is performed with the mother sitting on a bed or chair, the infant's bottom against the bed or chair and the infant's body lying next to the mother's side, and the infant's head cradled in her hand. The side position allows the mother to lay on her left or right side with the infant lying parallel to her. Again, the infant's head is cradled in the crook of the mother's elbow. This position is ideally suited for women after cesarean delivery because it reduces the pain associated with pressure from the infant on their incisions. It must be stressed that choice of position is based on mother and infant comfort. It is not unusual to experiment with any or all positions prior to determining the most desirable. It is likewise not uncommon to find previously undesirable positions more effective and comfortable as the infant grows and the breast feeding experience progresses. All breastfeeding positions should allow for cradling of the infant's head with the mother's hand or elbow, allowing for better head control in the latch-on stage. The infant should be placed at a height (often achieved with a pillow) appropriate for preventing awkward positioning, maximizing comfort, and encouraging latch-on.  Breastfeeding Technique  Many of the difficulties with breastfeeding result from improper latch-on. Latch-on problems are often the source of multiple breastfeeding complaints among mothers, ranging from engorgement to sore cracked nipples. Many women discontinue breastfeeding secondary to these issues. The latch-on process is governed by primitive reflexes. Stroking the infant's cheek will cause the infant to turn toward the side on which the cheek was stroked. This reflex is useful if the infant is not looking toward the breast Tickling the infant's bottom lip will cause his or her mouth to open wide in order to latch on to the breast. The mother should hold her breast to help position the areola to ease latch-on. It is important that the mother's fingers be behind the areola so as not to provide a physical barrier to latch-on. Once the infant's mouth is opened wide, the head should be pulled quickly to the breast. The infant's mouth should encompass the entire areola to compress the milk ducts. If this is done improperly, the infant will compress the nipple, leading to pain and eventually cracking, with minimal or no milk expression. The mother should not experience pain with breastfeeding. If this occurs, the mother should break the suction by inserting a finger into the side of the infant's mouth and then latch the infant on again. This process should be repeated as many times as necessary until proper latch-on is achieved.  Breastfeeding Technique  One issue that continually concerns parents is whether the infant is receiving adequate amounts of breast milk. Several clinical measures can be used to determine if infants are receiving enough milk. Weight is an excellent method of assessment. Pre- and postfeed measurement of an infant with a scale that is of high quality and measures to the ounce is a very accurate means of determining weight. The problem is that this type of scale is not available to most families. Weight can also be evaluated on a longer-term basis. Infants should not lose more than about 8% of their birth weight after delivery and should gain this weight back in 2 weeks. Most infants with difficulties, however, will decompensate before this 2-week period. Breastfed infants should be evaluated 2-3 days after discharge, especially if discharged prior to 48 hours after delivery. A more convenient way to determine the adequacy of the infant's intake of milk is through clinical signs such as infant satisfaction after feeding and bowel and bladder amounts. In most cases, infants who are satisfied after feeding will fall asleep. Infants who do not receive enough milk will usually be fussy or irritable or continuously want to suck at the breast, their finger, and so on. Breastfed infants usually will stool after most feeds but at a minimum 5-6 times a day. After the first couple of days, the stool should turn from meconium-like to a mustard-colored seedy type. If breastfed infants are still passing meconium or do not have an adequate amount of stool, parents and the healthcare team should evaluate whether they are taking in enough milk. Infants should also urinate approximately 3 or 4 times a day. This may be hard to assess with the current era's superabsorbent diapers; therefore, careful examination of the diaper should be made.  Problems Associated with Breastfeeding  An inadequate milk supply can lead to disastrous outcomes if not identified and treated. There are two types of milk inadequacies: the inability to make milk and the inability to keep the supply adequate. The first type of milk inadequacy is quite rare, but examples include surgeries in which the milk ducts are severed or Sheehan syndrome. There is no specific treatment to initiate milk production in affected women. The inability to maintain an adequate milk supply has numerous etiologies, ranging from dietary deficiencies to engorgement The key in preventing adverse events is early recognition and effective treatment. One of the mainstays of treatment is working with the body's own feedback loop of supply and demand to increase the supply. As more milk is needed, more milk will be produced. This is effectively done by using a breast pump. Pumping should be performed after the infant has fed.  Problems Associated with Breastfeeding  Engorgement is caused by inadequate or ineffective emptying of the breasts. As milk builds up in the breasts, they become swollen. If the condition is not relieved, the breasts can become tender and warm. Mastitis can also develop. The mainstay of treatment is emptying the breasts of milk, either by the infant or, if that is not possible, by mechanical means. Usually when the breast is engorged, the areola and nipple are affected, and proper latch-on becomes difficult if not impossible. A warm compress may be used to help with letdown, and the breast can be manually expressed enough to allow the infant to latch on. If this is not possible or is too painful, the milk can be removed with an electrical breast pump. Between feedings, a cold pack can be used to decrease the amount of swelling. There have been reports that chilled cabbage leaves used to line the bra can act as a cold pack that conforms to the shape of the breast and can reduce the pain and swelling. However, there is no evidence of any medicinal properties in the cabbage that affect engorgement. Mastitis, if occurring, is treated with antibiotics. Mothers can continue to breastfeed with the affected breast, so care should be taken to choose an antibiotic that is safe for the infant.  Problems Associated with Breastfeeding  Sore nipples are a common problem for breastfeeding mothers. In the first few weeks, there may be some soreness associated with breastfeeding as the skin gets used to the constant moisture. There should not be pain with breastfeeding; if there is pain, it is usually secondary to improper latch-on, which resolves with correction. With severe cracking, there will occasionally be bleeding. Breastfeeding can be continued with mild bleeding, but if severe bleeding occurs, the breast should be pumped and the milk discarded to prevent gastrointestinal upset in the infant. There are some remedies that can be used in the event of cracking. Keeping the nipples clean and dry between feedings can help prevent and heal cracking. The mother's own milk or a pure lanolin ointment can also be used as a salve. Mothers should be warned not to use herbal rubs or vitamin E because of the risk of absorption by the infant. Another cause of sore nipples is candidal infection. This usually occurs when an infant has thrush. Sometimes treating the infant will resolve the problem, but occasionally, the mother will need to be treated as well. Taking the same nystatin liquid dose that the infant is using twice a day will resolve the infection. Again, keeping the nipples clean and dry can help.  Problems Associated with Breastfeeding  Blebs, a small pimple or blister-like lesion on the nipple, can also be a cause of sore nipples. This occurs secondary to the opening of the milk duct being covered by new epithelial cells. Treatment includes moisturizing the nipples with lanolin and gentle exfoliation. This can be exacerbated by a candidal infection as well and would require the same treatment stated previously. If these lesions do not heal, they may require surgical debridement.  Another controversial issue in breastfeeding is silicone implants. Although only little research has been done on effects of silicone implants on lactation, there are a few areas of concern, including implants leaking material in breast milk, baby absorbing the silicone from the milk if it is spilled, and additional risks of infant exposure to the silicone. Due to its presence in the environment, it is difficult to distinguish between normal and abnormal maternal levels. It has been found that silicon is present in higher concentrations in cow's milk and formula than in milk of humans with implants. An additional study directly assayed the silicone polymer and found that levels in the milk of women with implants were not significantly different from those in other human milk samples.  Maternal Nutrition & Breastfeeding  Often some maternal foods that are strong in flavor, such as garlic, broccoli, and onions, can provide a flavor to breast milk that is displeasing to the infant or can create increased flatulence. These food types should be avoided if they interfere with feeding. There are also women who are concerned about creating allergies based on food that is consumed while breastfeeding. Currently, there is lack of evidence that maternal dietary restrictions (eg, avoiding peanuts) during pregnancy or lactation play a significant role in prevention of atopic disease in infants. Antigen avoidance during lactation does not prevent atopic disease, with the possible exception of eczema, although more data are needed to substantiate conclusions.  Vegetarian Diet& Breastfeeding  The number of humans choosing a vegetarian diet has increased dramatically over the past decade. With these increasing numbers, more research has been done in an effort to evaluate the feasibility of a vegetarian diet in infancy. A vegetarian diet is defined as a diet consisting of no meat. This definition does not encompass the variety of vegetarian diets that are consumed. A pure vegetarian or vegan consumes only plant food. In general, most pure vegetarians also do not use products that result from animal cruelty such as wool, silk, and leather. Lacto-ovo vegetarians consume dairy products and eggs in addition to plants, and lacto vegetarians consume only dairy products with their plant diet.  Vegetarian Diet& Breastfeeding  There is great variety in each of these diets and, therefore, great variety in the type and amount of food necessary for adequate nutrition. Milk from breastfeeding mothers who are vegetarians is adequate in all nutrients necessary for proper growth and development. Although all required nutrients can be found in any vegetarian diet, in infancy, the amount necessary may be difficult to provide without supplementation. The American Dietetic Association stated that a lacto-ovo vegetarian diet is recommended in infancy. If this diet is not desired by parents or is not tolerated by children, then supplementation may be necessary. Vitamin B12 , iron, and vitamin D are nutrients that may need to be supplemented, depending on environmental factors.  Contraindications to Breastfeeding  Although considered the optimal method of providing infant nutrition during the first year of life, breastfeeding may be contraindicated in some mothers. Scenarios that may preclude breastfeeding include mothers who actively use illicit drugs such as heroin, cocaine, alcohol and phencyclidine (PCP); mothers with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS); and mothers receiving pharmacotherapy with agents transmitted in breast milk and contraindicated in children, particularly potent cancer agents. Some immunizations for foreign travelers and military personnel may also be contraindicated in breastfeeding mothers. Infants with galactosemia should also not breastfeed.  Infant Formulas  Formulas exist as concentrates and powders that require dilution with water and as ready-to-feed preparations. Commonly, formula preparations provide 20 cal/oz with standard dilutions of 1 oz concentrate to 1 oz water and 1 scoop powder formula to 2 oz water for liquid concentrates and powders, respectively. Formulas exist as cow's milk based, soy-based, and casein-based preparations.  A. Cow's Milk-Based Formula Preparations  This is the preferred, standard non-breast milk preparation for otherwise healthy term infants who do not breastfeed or for whom breastfeeding has been terminated prior to 1 year of age. Cow's milk-based formula closely resembles human breast milk and is composed of 20% whey and 80% casein, with 50% more protein/dL than breast milk as well as iron, linoleic acid, carnitine, taurine, and nucleotides. Formulas containing docosahexaenoic acid and arachidonic acid have been recently marketed to promote eye and brain development. So far, no randomized trials have shown any benefit, although no harm has been established.  Approximately 32 oz will meet 100% of the recommended daily allowance (RDA) for calories, vitamins, and minerals. These formula preparations are diluted to a standard 20 cal/oz and are typically whey-dominant protein preparations with vegetable oils and lactose. There are also multiple lactose free preparations. Most standard formula preparations do not meet the RDA for fluoride, and exclusively formula-fed infants may require 0.25 mgld of supplemental fluoride.  B. Soy-Based Formula Preparations  Indicated primarily for vegetarian mothers and lactose intolerant, galactosemic, and cow's milk-allergic infants, soy-based formulas provide a protein-rich formula that contains more protein per deciliter than both breast milk and cow's milk formula preparations. Because the proteins are plant based, vitamin and mineral composition is increased to compensate for plant-based mineral antagonists while supplementing protein composition with the addition of methionine. Soy-based formulas tend to have a sweeter taste owing to a carbohydrate composition that includes sucrose and corn syrup. There is no proven benefit of soy-based formulas for milk protein allergy. Soy- based formulas should not be used for preterm infants because they cause less weight gain and increase the risk of osteopenia of prematurity. ProSobee, IsomiL and 1- Soyalac are common soy-based preparations.  C. Casein Hydrolysate-Based Formula Preparations  This poor-tasting, expensive formula preparation is indicated principally for infants with either milk and soy protein allergies or intolerance. Other indications include complex gastrointestinal pathologies. This formula, which contains casein-based protein and glucose, is not recommended for prolonged use in preterm infants owing to inadequate vitamin and mineral composition and proteins that may be difficult to metabolize. Standard preparations provide 20-24 cal/oz.  D. Premature Infant Formula Preparations  Indicated for use in preterm infants of < 1800 g birth weight and with 3 times the vitamin and mineral content of standard formula preparations, these formulations provide 20-24 cal/oz. Premature infant preparations are approximately 60% casein and 40% whey, with 1:1 concentrations of lactose and glucose as well as 1:1 concentrations of long- and medium-chain fatty acids. Commercially available preparations include Enfamil Premature with Iron, Similac Natural Care Breast Mille Fortifier, and Similac Special Care with Iron. Similac Neo-Care, designed for preterm infants weighing >1800 g at birth, provides 22 cal/oz in standard dilution.  Human Milk Fortifiers for Preterm Infants  Human milk fortifiers (HMFs) are indicated for preterm infants