March242015Dr.ElskeHildes-Ripstein-ChildHealthandPediatrics

Outline1.  Toreviewthephysiologyofbreastmilkproductionand

lactation2.  Tounderstandthenutritionalbenefitsofbreastfeeding

andthehealthbenefitsforbothinfantandmother3.  Tobecomeawareofcommonbarrierstosuccessful

breastfeeding4.  Tounderstandhowthe10stepsofBFI“BabyFriendly

Initiative”supportsbreastfeedinginhospitalsettings5.  Toacknowledgewhatcanbedoneinanindividual

practice

Mammogenesis� Duringpubertyalveolarbuddingstartswithinmammarygland/tissue

�  Itcontinuesundertheinfluenceofmenstrualcycleestrogenandprogesteroneuntiltype1,2and3lobulesarepresent.

� Type4lobulesdeveloponlyundertheinfluenceofHumanChorionicGonadatropinduringpregnancy

HormonalinfluencesonMammogenesis,LactogenesisI,IIand

Galactogenesis

LactogenesisI(Secretoryini;a;on;latepregnancy>20weeks)�  HCGfromplacentacausesterminalbudding(type4lobulesofbreastwithsecretoryacini)

�  HighProgesteronefromplacentainfluencesfurtherdifferentiationandbeginningofsecretoryactivity(colostrumsecretionbeginsandcolostrumaccumulateswithinaveoli).Insulin,cortisol,humanPlacentalLactogenalsonecessary.

�  Colostrumisthe“firstmilk”ayellowishwaterysubstancecontainingcaseinandlactoseandsecretoryIgA;

�  ThehighpregnancylevelsofProgesteroneandEstrogeninhibitprolactinstimulatedmilksecretionuntildelivery

Lactogenesis-;melineandhormonalinfluences

LactogenesisII�  DuringLabouranddeliverythereisapeakofcortisolandprolactinwhichresultsinaburstofmitoticactivityinmammaryglandandmilksecretion/production.

�  Therapiddeclineofprogesteroneandestrogenaftertheplacentaisdeliveredallowtheprolactinstimulationofmilksupplyandsecretion.

�  Thetransitionbetweencolostrumand“breastmilk”isusualbetweenday2-3butmaybeaslateas7days.

�  Thisphasecanbedelayedwithdiabetes,C-section,placentalretention,stressfulvaginalbirthetcastheyaffecthormonalfeedbackloop

GalactogenesisorLactogenesisIII�  Thisphaseisthemaintenancephaseoflactationextendingfromtheproductionofmaturemilkuntilweaning.

�  Localmechanismsforhormonalreleaseandfeedbacksuchasinfantsuckling-mechanicalstimulation;infantcry-neuroendocrinereceptorsbrain;removalofmilk-pressurereceptorsinbreastdownregulateprolactinreceptorsetc

�  Prolactinisreleasedfromanteriorpituitaryinburstsinresponsetoinfantsuckling(stimulationofmilksupplyandproduction)whileoxytocinisreleasedfrompostpituitary(ejectionreflex-myoepithelialcellcontraction)

HumanBrMilkComposi;on� Nutritionalqualityishighlyconservedacrossindividualsandpopulations

� Mainlylactose,proteinandfat� 3sourcesofmajorcomponentsofBreastMilk;eithersynthesizedinlactocyteviareceptormediatedtransportacrossmammaryepitheliumfrommaternalstoresoccinfluencedbymaternaldiet-egfattyacids,producedbycellsinBrmilk

Bioac;veFactorsinHumanMilkFactors Examples RoleImmunoglobulins IgG,IgM,sIgA Antibacterial

Cytokines TGF-Beta,IF6-10,TNF-alpha

Immuneactivationandanti-inflammatory

Cellularcomponents Macrophages,stemcells Antibacterial

GrowthFactors- IntestinalGF(EpidermalGFandneuronalGF,tissueGF,vascularendothGF,Erythropoetin)

PromotesIntestinalmaturationandhealing,vascularanderythrocytegrowth/production

CytokineInhibitors Anti-inflammatory

Antimicrobialproteins lactoferrin,lactadherin Anti-bacterialproperties

Oligosaccharides, glycans;mucins,HumanMilkOligosaccharide

Anti-infectivepropertiesNon-nutritive,promotesprobioticorganisms

Hormones, ghrelin,adiponectin,leptin,calcitoninandsomaostatin

Anti-infantobesity,energycontrol,appetitecontrol,antinflammation

GoodForInfant� DecreaseInfectiousMorbidity(innateimmunefactors) OM3.6foldincreaseFormulavsBrfedinfants GIinfections2.8xriskFormulavsBrfed NECinprematureinfants2.4xriskFormulavsBrfed

� Decreasesasthma,atopicdermatitis1.4-1.7xriskFormulavsBr

� Decreasesriskofobesity?inconclusivestudiesbutBreastmilkcontainsadipokinesandmayregulateenergyintake.

� DecreasesSIDS1.6-2.1xriskFormulavsBrfed.

GoodForMom� DecreasesRiskBreastCancer(NeverBrfed2.4xriskpremenopausalBrCa)

� DecreasesOvarianCa(NeverBrfed1.3xrisk)� Metaboliccost=500kcal/dayforbreastfeeding.promotesweightlossandfavorableglulevel,lipidmetabolismandBP.

� Differencesinmetabolismpersist-(Neverbrfedmetabolicsyndrome1.3xrisk,Myocardialinfarction1.3xriskandType2DM1.7xrisk)

CanadianPediatricSocietyGuidelines

Recommend:� ExclusiveBreastfeedingforthefirst6months(plusVitDsupplement)

“howeverintroductionofcomplementaryfoodsshouldalsobeledbyinfant’ssignsofreadinessandmayoccurfewweeksbeforeorafter6months.Beyond6months-delayincreasesriskofirondeficiency”

� EncourageBreastfeedingfor2yearsandbeyond(whileprovidingappropriatenutritionalguidance)

www.cps.ca-positionstatementsPaediatrChildHealth2013;18(4)

Factorsinfluencingsuccessoflacta;on(ini;a;onanddura;on)�  Skintoskincontactatdeliveryforfirsthour.(increasesprolactin)

� Nolimittoinfantsuckling;frequentfeeds� RoominginandFeedingondemand�  SupportExclusiveBrFeeding-noformulamarketingpacks(volumeinterfereswithfreqsuckling)

� Noartificialnipplesuntillactationestablished(bottleorpacifiers-differenttongueactionandflow)

� Resources(Peersupport;lactationconsultantsinhospandcommunity-lalecheleague-midwife)

WHO1981Interna;onalCodeofMarke;ngBreastMilksubs;tutes�  TheMemberStatesvotedtoapprove118-yeswith1abstention:

“Consciousthatbreast-feedingisanunequalledwayofprovidingidealfoodforthehealthygrowthanddevelopmentofinfants;...........protectsinfantsagainst

disease;andthatthereisanimportantrelationshipbetweenbreast-feedingandchild-spacing;

Recognizingthattheencouragementandprotectionofbreast-feedingisanimportantpartofthehealth,nutrition.....andthatbreastfeedingisanimportantaspectofprimaryhealthcare;Consideringthat,whenmothersdonotbreast-feed,oronlydosopartially,thereisalegitimatemarketforinfantformula......butthat(it)shouldnotbemarketedordistributedinwaysthatmayinterferewiththeprotectionandpromotionofbreast-feeding;”

BabyFriendlyIni;a;ve� Bornfromthe“InnocentiDeclaration1990”-promotingandhelpingtoestablishexclusiveBreastFeedingasthenorm

�  In1991theBabyFriendlyHospitalInitiativewasestablishedbyWHOandUNICEF;andupdated2009basedonrecentevidence

� Canada’sProgramisknownastheBabyFriendlyInitiativeandiscomposedof10stepsthatareknowntoimproveBreastfeedingoutcomes.ForBFIaccreditationhospitalorcommunityprogramhastocomplywithall10steps

10Components/StepsofBFI“BabyFriendlyIni;a;ve”

1.WrittenBrFeedingPolicyinplace2.TrainallHealthCareProvidersinBrFeedingSupport3.InformallpregnantwomenofthebenefitsBrfeeding4.Placeinfantskintoskinforatleast1hourimmediatelyafterbirth5.ShowhowtoBrfeedandmaintainlactation(handexpression)6.NofoodordrinkotherthanbreastmilktoBrfeedinginfant(unless

medicalindication)7.Practiceinfantandmotherrooming-in8.EncourageBrfeedingondemand-mothersalerttofeedingcues9.Supportmotherstocareforandfeedwithnoartificialnipples/

pacifiers10.EstablishBrfeedingsupportgroupsfordischargedmothers�  BFIsupportsinitiationanddurationofBreastfeeding

RecentdatafromManitobaHospitaldischargeabstractsbyregionNorecentManitobaDataonDurationofBreastfeeding

BreasTeedingatdischargefrombirthhospitaliza;on(MB2012/13)*

Wpg ThePasn=339

Thompsonn=806

Brandonn=1666

BoundryTrailsn=944

HSCn=5400

StBn=57oo

AnyBreastfeeding

83% 70% 65% 84% 93%79%

87%

ExclusiveBreastFeeding

43% 51% 20% 49% 74%41% 44%

*SourceExcelsheetfromLindaRomphf(LactationConsultantandBFIadvisor

2009/10CanadianCommunityHealthSurvey-dura;onExclBreastFeeding

2009/10CanadianCommunityHealthSurvey-MatReasonsdiscon;nua;onExclBreastFeeding

Opportuni;esforPromo;ng/Suppor;ngBreasTeeding–aPhysician’srole1.   DuringPregnancyoratdelivery

2.   DuringBirthHospitalisation

3.   DuringHealthVisitswithin1styr

4.   CommunityAdvocacy

1.DuringPregnancyordelivery�  exploremother’sknowledgelevelaboutBrfeedingandDispelmyths,

�  Ensureskintoskintimeandfirstfeedwithin1hour.�  Supportcolostrumtransportasnecessaryforprems/IDM

� Ensurenophysical/medicalbarrierstobrfeeding-hypotonia,cleftpalateetc

2.DuringBirthHospitalisa7on�  Impartknowledgeandcorrectmisconceptions;(notenoughmilk,wantotherstobeabletofeedbaby,)

�  Supportandreassure-goovernormalweightpatterns(10-15%lossnotuncommon)

�  Ensuresafefeedingplanforinfant.Adequatecaloriesprovidedtoeachinfantforgrowth(canusecuporsupplementalsystemforEBMorformula.)Avoidhypoglycemia-butcantrialglucosegelratherthanformula

�  Ensureaccesstocommunitysupports/resources(PublicHealth,Breastfeedinghotlineandclinics,lalecheleague)

3.HealthVisitswithin1styr� AskaboutandSupportSustainedBrFeedingeveryvisit.Answerquestionsandtroubleshootorgivemotheradequateresourcesforinfo/help.

�  SupportExclusiveBreastfeedinguntil6monthsage� Remindanyamountofbreastisbeneficial!;(preventsinfection;manybenefitsandconveniences-alwayswarm,neverrunout,noneedtosterilizeitems

� Discusstheamazingcapacityandflexibilityofmilkproduction(rightamountattherighttimefortherightage)

4.CommunityAdvocacyAsidefromindividualpatientadvocacy:

� SupportyourhospitaltobecomeBFIcertified�  Beawareofandavoidformulacompanymarketing�  AdvocateforHumanMilkBanking;� ProvidePublicandSocietywithcurrentknowledgetosupportnormalizationofbreastfeedingfor2yrsandbeyond(workplaceaccommodationsforBrfeedingmoms;rootsofempathyprograminschoolsetc,publichealthbenefitseducationetc).

WorkingwithHealthcareteam,NursingLacta;onconsultants,Publichealth

� Proudandgratefulfortheteamapproach!� Dependonnurses/midwivesskintoskin;firstcolostrumandfeedat30minutesage;teachhowtopositionandlatchanewborn.

� GratefulfortheLCteammedicationsinbreastmilk,helpingprematureinfants,oruniqueordifficultcases

� PublicHealthearlyhomevisit,weigh,monitorjaundiceandtroubleshootfeedingissues

Lactogenesis-hormonalinfluences

HumanMilkComposi;on(PedClinicsNAmericaFeb2013)Macronutrient(g/dL)andenergy(kcal/dL)

Proteing/dl(Casein)

Fatg/dl Lactoseg/dl Energymeankcal/dl

TerminfantsMaturemilkn=581(1991)

1.2(0.9-1.5) 3.6(2.2-5.0) 7.4(7.2-7.7) 70(57-83)

DonormilkN=415(2009)

1.2(0.7-1.70) 3.2(1.2-5.2) 7.8(6.0-9.6) 65(43-87)

MaturemilkRefStdn=2553(1990)

0.9(0.6-1.4) 3.6(1.8-8.9) 7.2(6.4-7.6) 67(50-115)

Preminfant<29weeksN=52(2011)

2.2(1.3-3.3) 4.4(2.6-6.2) 7.6(6.4-8.8 78(61-94)

32-34weeksN=20

1.9(1.3-2.5) 4.8(2.8-6.5) 7.5(6.5-8.5) 77(64-89)

Donorpremn=47(2012)

1.4(0.8-1.9) 4.2(2.4-5.9) 6.7(5.5-7.9) 70(53-87)

%ExclusiveBreastFed %AnyBreastFed

01020304050607080

birthhospd/c

~3.5mthage

non-Aboriginal

Aboriginal*p=0.004

01020304050607080

birthhospd/c

~3.5mthage

non-Aboriginal

Aborigianl

combined

BreastfeedingatBirthand4months1996

*p=0.018

%Motherscon;nuedBreasTeedingofthoseini;a;ng

0

10

20

30

40

50

60

~3.5mthsage

non-Aboriginal

Aboriginal

P=0.22NS

2009/10CanadianCommunityHealthSurvey-dura;onBreastFeeding6months-ethnicity

2009/10CanadianCommunityHealthSurvey-dura;onBreastFeeding6monthsbymatage

WHO1981Interna;onalCodeofMarke;ngBreastMilksubs;tutes� WHOandUNICEF(UnitedNationsChildren’sFund)emphasizedtheimportanceofmaintainingthepracticeofbreast-feeding—andofrevivingthepracticewhereitisindecline—asawaytoimprovethehealthandnutritionofinfantsandyoungchildren

�  noteddeclineofbreastfeedingforavarietyofreasons:“includingthepromotionofmanufacturedbreast-milksubstitutes,andurged"Membercountriestoreviewsalespromotionactivitiesonbabyfoodstointroduceappropriateremedialmeasures,includingadvertisementcodesandlegislationwherenecessary”

Creden;als:� PediatricianatChildren’sHospitalofWpg-DeptofPediatricsandChildHealth-(inpatientwardsandoutpatientclinic)

�  ServiceChieffortheHealthyNewbornWardsatWomen’sHospital(2008-present)

�  FacultyatUniversityofManitoba-teachmedstudents,internsandpediatricresidentsaboutwellinfantandchildcare

� MScthesison“infantcarepractices”‘95/96(asrelatedtoSIDS;includedsomebreastfeedingsurveydata)

� Proudmotherof4breastfedchildren!