BREASTFEEDING

LECTURE

DR. JANESA VALERIE REYES

PEDIATRICIAN
 TOPICS

1. Composition of breast milk

2. Anatomy and physiology of breastfeeding
3. Strategies for successful breastfeeding
4. Common problems in breastfeeding
COMPOSITION OF
BREAST MILK
 BREASTMILK

Best food for optimal growth and development of infants

 EXCLUSIVE BREASTFEEDING

WHO defines exclusive breastfeeding as feeding breast milk only

(including expressed breast milk and milk from a wet nurse), not
allowing the infant to receive any other food or drink, even water, for
6 months.
BENEFITS OF BREASTFEEDING

INFANTS
1. Boosts immunity and host defense
2. Prevents atopic disease
3. Prevents visual problems
4. Promotes dental and jaw
development
5. Protects premature and LBW babies
6. Improves mood and sleep
7. Appropriate weight gain
8. Less picky eating
9. Decreased risk in diabetes, CVD and
cancer
10. Promotes cognitive development
BENEFITS OF BREASTFEEDING

MOTHER AND FAMILY

1. Improves postpartum health: prevents
prolonged uterine bleeding
2. Hastens postpartum weight loss
3. Helps optimum child spacing
4. Affordable and convenient
5. Protects mother from cancer: ovarian
and breast
BENEFITS OF BREASTFEEDING

SOCIETY AND THE

ENVIRONMENT

1. Reduces child abuse

2. Improves overall quality of life
3. Safe and does not harm the
environment
 COMPOSITION OF BREAST MILK

1. CARBOHYDRATES: Lactose and oligosaccharides

2. FATS: triglycerides, cholesterol, phospholipids and steroid hormones
3. PROTEINS: including several caseins, and whey (alpha-lactalbumin,
lactoferrin, secretory IgA, and lysozyme)
4. MINERALS: including sodium, potassium, chloride, calcium,
magnesium and phosphate
5. VITAMINS (depend on the maternal vitamin status)
 FATS

Major energy source of infants

Approximately 50% of the calories in human milk
3.5 grams of fat per 100ml of breast milk
Long chain PUFA 👉
arachidonic acid (ARA) and
docosahexaeoic acid (DHA),
derivatives of the essential
fatty acids, linoleic and
linolenic acids.
have been associated with
improved cognition, growth
and vision.
DISADVANTAGE OF FORMULA MILK

Formula milk has a greater quantity of medium

chain-length fatty acids (MCFA) than human milk
which decreases the overall content of LCFA
 FATS
Hindmilk is 1.5 to 3x more fats than the foremilk.
 FATS
Hindmilk is 1.5 to 3x more fats than the foremilk.

Satiety
Weight gain
 CARBOHYDRATES

LACTOSE is the principal carbohydrate, with small proportion of

oligosacchides.
7 grams per 100ml of breast milk
Contributes to softer stool consistency, nonpathogenic bacterial fecal flora,
and improved absorption of minerals.
Oligosaccharides 👉 important in the host defense of the infant as their
structures mimic specific bacterial antigen receptors.
 PROTEIN

0.9grams per 100ml of breastmilk

👉 lower than in animal milk
The higher protein in animal milk can overload the infant’s immature
kidneys with waste nitrogen products
Whey casein ratio 70:30
Bovine milk contains 18% whey and 82% casein
 VITAMINS

Maternal vitamin status affects the content of vitamins in human milk

Potential vitamin deficiencies:
Vitamin B12 in mothers who are vegan
Vitamin K deficiency in newborns:
 VITAMINS

Reasons for vitamin k defieincy in newborns

low vitamin K in breast milk
inadequate production of vitamin K by an immature liver
absence of bacterial flora that produces vitamin K
poor placental transfer of vitamin K
maternal intake of warfarin
 VITAMINS

Vitamin D in human milk is low

Sunlight exposure is readily available in the Philippines, endogenous
vitamin D production is presumed to be adequate.
MINERALS AND TRACE ELEMENTS

Concentrations of calcium and phosphorus are relatively constant through

lactation but are significantly lower than in formula
Despite lower mineral concentration and intake, bone mineral accretion and
status of breastfed infants is similar to that of infants fed formula due to
enhanced absorption (bioavailability) during the first year of life
MINERALS AND TRACE ELEMENTS

Zinc, iron and copper decline during

lactation but the needs for these
nutrients are usually adequately met
through the first six months of life.
The timely introduction of
complementary feeding would
supplement the increased in need
for these minerals.
COLOSTRUM

earliest breast milk produced during pregnancy

secreted in the first 2-3 days after delivery
👉
thick in consistency does not drip nor flow easily
COLOSTRUM

Mothers thus mistakenly think that

no milk is being produced. In fact, it
is produced in small amounts, 40-
50ml on the first day, the amount
normally needed at this time.
COLOSTRUM
Secretory IgA is at its highest level
Rich in white cells, larger proportion of protein,
minerals and fat soluble vitamins (A,E, and K)
compared with later milk.
It is yellowish and sometimes greenish, due to a high
level of carotenoid.
It is not dirty or stale and should not be discarded.
COLOSTRUM
Secretory IgA is at its highest level
Rich in white cells, larger proportion of protein,
minerals and fat soluble vitamins (A,E, and K)
compared with later milk.
It is yellowish and sometimes greenish, due to a high
level of carotenoid.
It is not dirty or stale and should not be discarded.
WHEN DOES MILK PRODUCTION
BEGIN TO INCREASE?
Provided that the newborn is able to
breastfeed per demand, milk production
starts to increase between 2 and 4 days
after delivery.
The mother starts to feel breast fullness, a
sensation described as the milk having
“come in”. On the third day, the infant
normally takes about 300-400ml per 24
hours and on the 5th day 500-800ml.
TRANSITIONAL MILK

From days 7-14, “transitional milk” is present as

translucent milk with a slightly more bluish hue.
MATURE MILK

after 2 weeks, the mature milk flows which is thicker

and creamier.
ANATOMY AND PHYSIOLOGY
OF LACTATION
ANATOMY OF THE BREAST
 HORMONAL CONTROL OF MILK
PRODUCTION

Suckling of the baby at the breast triggers

PROLACTIN secretion by the anterior lobe of pituitary gland
OXYTOCIN secretion of posterior lobe of pituitary gland
Estrogen is involved indirectly in lactation
PROLACTIN
OXYTOCIN
PROMOTES LET-DOWN REFLEX

Suckling at the breast

Mother’s anticipation of BF: image, smell or cry of her baby
Keep the mother and baby together to sustain let down reflex
especially in the early days of BF
INHIBITS LET-DOWN REFLEX

Emotional stress
Severe pain
Anxiety
Self-imposed expectations
REGULATION OF MILK PRODUCTION
WHAT IS THE MOST IMPORTANT REGULATORY
MECHANISM OF MILK PRODUCTION?

Emptying of the breast of by the infant’s suckling is the most

important.
FEEDBACK INHIBITOR OF LACTATION (FIL)
BREAST EMPYTING
STRATEGIES FOR SUCCESSFUL
BREASTFEEDING
 STRATEGIES FOR SUCCESSFUL
BREASTFEEDING
The success of breastfeeding initiation and continuation depends on
multiple factors, such as:
1. Education about breastfeeding
2. Hospital breastfeeding practices and policies
3. Routine and timely follow-up care
4. Family and societal support
 MOTHER BABY FRIENDLY
HOSPITAL INITIATIVE

a global program launched by WHO and UNICEF in 1991 to help

motivate facilities providing maternity and newborn services
worldwide to implement the 10 STEPS TO SUCCESSFUL
BREASTFEEDING.
 LAWS IN THE PHILIPPINES

REPUBLIC ACT 10028: EXPANDED BREASTFEEDING

PROMOTION ACT OF 2009
EXECUTIVE ORDER 51: THE PHILIPPINE MILK CODE
 REPUBLIC ACT 10028: EXPANDED
BREASTFEEDING PROMOTION ACT OF 2009

an act providing incentives to all government and private health

institutions with rooming-in and breastfeeding practices and for
other purposes
adopts rooming-in as a national policy to encourage, protect and
support the practice of BF
 REPUBLIC ACT 10028: EXPANDED
BREASTFEEDING PROMOTION ACT OF 2009

Mandated that all health and non-health facilities, establishments

or institutions shall establish lactation stations.
Lactation periods: nursing employees shall be granted break
interval in addition to the regular time-off for meals to breastfeed
or express milk
 EXECUTIVE ORDER 51: THE
PHILIPPINE MILK CODE

Restricts advertising and marketing artificial breast milk

substitutes, feeding bottles, and pacifiers to protect and promote
breastfeeding for safe and adequate nutrition of infants
Bans the use of health care system for the promotion of the
covered products: donations, samples, other giveaways by milk
companies to health workers and general public
 COMMON PROBLEMS IN
BREASTFEEDING

Breastfeeding difficulties can lead to early termination of

breastfeeding.
 BREASTFEEDING TECHNIQUES

1. CORRECT POSITION OF THE MOTHER

2. CORRECT POSITION OF THE INFANT
3. CORRECT ATTACHMENT OF THE BABY TO THE BREAST
CORRECT POSITION OF THE MOTHER
1. Have the mother and the baby in a comfortable
position
2. Support the baby throughout the feeding, with
the head, back and hips in alignment
3. Hold the baby and the mother's arm with the
head at or below so the mouth is aligned with
the nipple
4. Use the hand of the opposite the arm to cup the
breast and present the nipple to the baby
5. Support the breast using a C-hold. with the 4
fingers below and the thumb above
CORRECT POSITION OF THE INFANT
1. The baby’s body should be straight, not bent or twisted
2. The baby’s head can be slightly extended at the neck,
which helps the chin to be close to the breast
3. The baby should face the breast. Because the nipples
usually point downwards, the baby should not be held
horizontally against the mother’s chest or abdomen, but
turned slightly to see the mother’s face.
4. The baby’s body should be close to the mother
5. The entire body, not just the head and neck, should be
supported
CORRECT ATTACHMENT OF THE BABY TO
THE BREAST

1. Stroke lightly the corner of the baby's lips with

breast nipple to stimulate infant to open mouth
wide to grasp the breast to suck
2. Allow baby to grasp the entire nipple plus one
inch of the surrounding areola, grasping a larger
portion of the lower than the upper part of the
areola
3. Insert a clean finger into the corner of the baby's
mouth to release the grasp at the end of feeding
4. Allow the baby to suck on each breast for 15-30
minutes
5. Empty regularly the breast every 2-3 hours to
ensure adequate milk supply
SIGNS OF GOOD ATTACHMENT
👉
1. Mouth wide open wide
enough to take in “plenty” of
breast tissue and that the baby
is close to the breast
2. The lower lip turned outward
against the breast
3. The chin is touching the breast
and the nose is close to the
breast
4. The cheeks are full
5. More of the areola visible above
the baby’s top lip than below the
lower lip
SIGNS OF POOR ATTACHMENT

1. Mouth not wide open

2. Lower lip pointing forward or
turned inwards
3. Chin not close to the breast
4. More areola visible below the
baby’s bottom lip than above the
top lip
 POOR ATTACHMENT

POOR ATTACHMENT is the most common and most important cause of

sore nipples and may result in inefficient removal of milk and apparent low
supply.
BREASTFEEDING POSITIONS
COMMON PROBLEMS IN
BREASTFEEDING

Inadequate milk supply

INADEQUATE MILK SUPPLY

IS IT ACTUAL OR PERCEIVED?
INADEQUATE MILK SUPPLY

IS IT ACTUAL OR PERCEIVED?
 INADEQUATE MILK SUPPLY

How to diagnose:
1. Nursing history
2. Infant urine and stool output
3. Weight
 INADEQUATE MILK SUPPLY

NURSING HISTORY
INFANT feeds
First week: 8 to 12 times per day
By 4 weeks: 7-9x per day
 INADEQUATE MILK SUPPLY

URINE OUTPUT
Once on day 1, twice on day 2 and so on..
By 5th day of life: urinates 6-8x per day
 INADEQUATE MILK SUPPLY

first 3-4 days of life 4th to 5th day of life

5th day of life

 INADEQUATE MILK SUPPLY

STOOL OUTPUT
By 5th day of life: 3 or more yellow stools per day
 INADEQUATE MILK SUPPLY

WEIGHT
weight loss should not be more than 10% of birthweight and
should be regained by 10th day of life.
 NIPPLE OR BREAST PAIN

Second most common reason for premature discontinuation of

breastfeeding
CAUSES OF NIPPLE PAIN OR BREAST PAIN

Nipple injury
Nipple vasoconstriction
Breast engorgement
Plugged ducts
Nipple and breast infections
Excessive milk supply
Nipple dermatitis/psoriasis
 NIPPLE PAIN

NIPPLE PAIN DUE TO SENSITIVITY NIPPLE PAIN DUE TO TRAUMA

Subsides 30 seconds to 1 minute Pain persists at the same or an
after suckling begins increasing level throughout the nursing
Diminishes after 4th postpartum episode
day and completely resolves Severe pain that extends beyond first
beyond first postpartum week postpartum week
Can be given acetaminophen May be due to poor position or latch-on
before feeding if needed Nipple abrasion, bruising, cracking,
and/or blistering
CARE FOR TRAUMATIZED NIPPLE
Correcting technique. BF on unaffected side first. — lactation consultation, expressed
BM
Nipple cracked or abraded — antibiotic such as bacitracin or mupircon is applied then
cover with nonstick pad — help prevent nipple infection
Cool or warm compress, apply BM to the nipple, give mild analgesic like
acetaminophen or ibuprofen
Infants with mechanical feeding problems
👉
ankyloglossia - lingual frenotomy has been shown to decrease nipple pain and
facilitate breastfeeding
this is because effective BF requires coordinated anterior and vertical motion of
the tongue
 PREVENTION

proper position and latch of the infant — most effective

Anticipatory guidance prior to hospital discharge regarding prevention of engorgement
Avoidance of excessive moisture of the nipples and irritating cleansers. Allow the
nipple to air dry gently after BF
➡️
Detect nipple abnormalities during prenatal period possible feeding difficulties
Evaluate abnormalities of infant’s oral cavity
 PREVENTION

proper position and latch of the infant — most effective

Anticipatory guidance prior to hospital discharge regarding prevention of engorgement
Avoidance of excessive moisture of the nipples and irritating cleansers. Allow the
nipple to air dry gently after BF
➡️
Detect nipple abnormalities during prenatal period possible feeding difficulties
Evaluate abnormalities of infant’s oral cavity
BREAST FULLNESS VERSUS ENGORGEMENT

FULL ENGORGEMENT

Hot Painful

Heavy Edematous

Tight, especially at the nipple

Hard Shiny
May look red

Milk flowing Milk not flowing

No fever May have fever for 24 hours

 ENGORGED
FULL BREAST
BREAST
 BREAST FULLNESS

few days after delivery

breasts are filled with milk
milk is flowing well
needs to breastfeed frequently to remove milk
in a few days, her breasts will adjust to the baby’s needs, and they will feel less full
 BREAST ENGORGEMENT

Swollen breasts due partly to milk and partly to increased tissue fluid and blood
👉
Milk does not flow milk stasis
Painful breasts
Fever for less than 24 hours
 TREATMENT OF BREAST ENGORGEMENT
ASSESSMENT TREATMENT

Hold baby skin to skin, help with attachment and allow to

If baby is able to suckle
suckle frequently. Stimulates oxytocin

If baby is unable to suckle Express breastmilk by hand or with a pump

Warm compress or warm shower

Massage to neck and back
Before feed to stimulate
Light massage of breast
oxytocin reflex
Stimulate nipple skin
Help mother to relax

After feed to reduce edema Cold compress

 BREAST ENGORGEMENT
CAUSES PREVENTION

Frequent removal of milk, early

Plenty of milk
initiation

Delayed start to breastfeed Start breastfeeding soon after delivery

Poor attachment to breast Ensure good attachment

Infrequent removal of milk Encouarge unrestricted BF

Restriction of length of feeds Encourage unrestricted BF

 MASTITIS

Severe pain, often feels ill, nausea and headache

Part of breast is swollen and hard, with redness overlying the skin
Other parts of the breast look normal
Usually only one breast
 MASTITIS

Severe symptoms:
fever for more than 24 hours
possible infection (infected cracked nipple)
does not improve in 24 hours of frequent and effective feeding and/or expression
worsening condition of mother
TREATMENT OF BLOCKED DUCTS AND
MASTITIS
Advise
frequent breastfeeds
gentle massage towards nipple
warm compress
analgesics (ibuprofen)
Suggest, if helpful
vary position
TREATMENT OF BLOCKED DUCTS AND
MASTITIS
Advise
frequent breastfeeds
gentle massage towards nipple
warm compress
analgesics (ibuprofen)
Suggest, if helpful
vary position
TREATMENT OF BLOCKED DUCTS AND
MASTITIS
If any of these symptoms continue
symptoms severe (high fever, large affected area)
fissure
no improvement in 24 hours
Advanced treatment required
complete rest
Refer to an appropriate medical provider for antibiotic treatment
CONTRAINDICATIONS TO BREASTFEEDING
CONTRAINDICATIONS TO BREASTFEEDING