Breastfeeding

AMERICAN ACADEMY OF PEDIATRICS Section on breastfeeding

(Pediatrics 2012)

AMERICAN ACADEMY OF PEDIATRICS Section on breastfeeding

(Pediatrics 2012)

UNICEF and WHO (1991)

10 STEPS TO SUCCESSFUL BREASTFEEDING

10 STEPS TO SUCCESSFUL BREASTFEEDING

https://www.who.int/teams/nutritionand-food-safety/food-and-nutritionactions-in-health-systems/ten-stepsto-successful-breastfeeding

RECOMMENDATIONS WHO, AAP

SIP, SIN, SICuPP, SIGENP, Ministry of Health

(Position Statement 2015)

Definitions recommended by the WHO and internationally recognized

Breastfeeding is an interactive process

“Mother” system

1. Hormonal control (PRL/OSS)

2. Peripheral control (FIL)

“Baby” system

1. Ability to suck

2. Correct position and latch (effective drainage)

Global distribution of breastfeeding at 12 months

Data are from 153 countries between 1995 and 2013

In low-income countries, most infants are still breastfed at 1 year compared with less than 20% in many high-income countries and less than 1% in the UK

C. G Victora, MD,. The Lancet. January, 2016

Global distribution of breastfeeding at 12 months

Data are from 153 countries between 1995 and 2013

C. G Victora, MD,. The Lancet. January, 2016

Child-friendly communities for breastfeeding (2007)

Breastfeeding in Italy

• Low educational and socio-economic status

• Lack of support from partners or other family members

• Not feeling up to it, fear of not having enough milk (exhaustion, post-partum stress)

• Desire

• Health status

• Return to work

but also orientation, culture and advice in prenatal classes, birth centers, NICUs, local health authorities, and pediatrician offices

Breastfeeding in public

• Breastfeeding produces neither noise nor smell, and it does not require too much space; the breast is not visible, but rather “sensed”

• Mainly a cultural issue

• Breast is considered as an object related to sexual pleasure

• “Principle of good manners”: it is not very elegant

• In Italy there are no laws for or against breastfeeding

Anatomy

1. Cooper’s ligament

2. retromammary fat

3. gland tissue

4. intramammary fat

5. subcutaneous fat

6. main lactiferous duct

7. lactiferous duct

Anatomy

The alveolus is the basic functional unit (0.12 mm in diameter), consisting of small bags of about 100 lactocytes that synthesize milk. The alveoli are surrounded by myoepithelial cells which have a contractile capability. Groups of 10-100 alveoli form the lobules, which are grouped into lobes. Small ducts drain the alveoli and converge, thus forming larger ducts, until they create a single duct with a diameter of about 2 mm (nevertheless, the diameter is variable, as shown by the US study) that reaches the surface of the nipple. Each lobe drains independently into the nipple. The lobes are 9, but the holes on the nipple are approximately 15 (some holes have a blind end).

Milk secretion phases

lactogenesis III

Lactogenesis

Lactogenesis: PROLACTIN

Enters the bloodstream

AFTER the feed to stimulate the production of milk for the NEXT feed

Prolactin is secreted in greater quantities during the night

It suppresses ovulation Breastfeeding

1. The baby sucks

2. Sensory impulses from the nipple

3. Prolactin in the bloodstream

Lactogenesis: OXYTOCIN

Acts

BEFORE and DURING the feed, allowing the milk to flow (milk ejection or oxytocin reflex)

Oxytocin stimulates the uterus to contract

1. The baby sucks

2. Sensory impulses from the nipple

3. Circulating oxytocin

Oxytocin reflex

Oxytocin reflex

• Thinking about the baby

• Listening to their sounds

• Looking at them

• Feeling comfortable

STIMULATE the oxytocin reflex

• Concern

• Stress

• Pain

• Feeling insecure

HINDER the oxytocin reflex

Peripheral regulation of milk synthesis

On demand breastfeeding

 Through suction, the baby regulates the production of prolactin, the oxytocin reflex, and the removal of FIL

 Suction must be frequent and correct

 8-12 feeds a day

 > > during the “growth spurts” (usually at 3 and 6 weeks, and at 3 months)

On demand breastfeeding

• Lactation onset is anticipated by 12-24 hours

• Prevention of breast engorgement

• Higher milk production

• Reduction of neonatal jaundice

On demand breastfeeding

• Whenever the baby looks hungry

• Both day and night

• At intervals managed by the baby

• Feeds without a fixed duration

Calibration and maintenance

Duration of breast feeds

Woolridge MW. Early Human Dev 7:269, 1982

506 babies

Number of feeds

With exclusive breastfeeding, the number of feeds in 24 hours remains almost constant throughout the first 6 months of life

Breast milk

• Colostrum

7th month of pregnancy –

• Transition milk

Until the 14th day

• Mature milk

3rd/4th day

Colostrum

Breast milk: composition

Breast milk

Breast milk in preterm infants

(<37 weeks)

Breast milk

• The taste depends on the diet of the mother

• Variations in flavour can help the baby to get used to the flavours of the foods eaten by the family, and to the transition to such foods after 6 months

• Formula milk always tastes the same

Breast milk: composition

Breast milk: composition

Breast milk: composition

Breast milk: composition

Breast milk: composition

• Higher quantity in breast milk as compared to other animals’ milks

• The quantity is related to the dimensions of the encephalon Riordan J, 2016

Breast milk: composition

Lactose

glucose

galactose

Function

Riordan J, 2016

G.M. Hendricks, M. Guo, in Manufacturing Technology, 2014

Breast milk: composition

Assunzione di latte e di grassi da parte di un bambino allattato da un solo seno

The lipid concentration is lower at the beginning of the feed (foremilk) and higher at the end of it (hindmilk)

Breast milk: composition

Breast milk: composition

Entero-Mammary pathway

1. Ingestion of pathogens

How the breastfed baby benefits from the maternal immunological experience

2.

Mesenteric activation of the B cells in the Peyer′s patches

3. Migration of plasma cells to the breast

4. IgA secretion in breast milk

Breast milk: composition

Main constituents of breast milk (g/L)

Oligosaccharides (HMOs)

Nicholas J. Andreas. Early Human Development, 2015

Jantscher-Krenn E, Bode L, Minerva Pediatrica, 2012

Oligosaccharides (HMOs)

Macronutrients and HMOs in mature human and bovine milk

(approximate values)

Lars Bode. Human milk oligosaccharides: Every baby needs a sugar mama. Glycobiology, 2012

Oligosaccharides (HMOs)

• Over 200 molecules identified

• Resistant to low pH and intestinal enzymes

• Can be found in faeces

• A minimum part is absorbed and excreted in urine (approximately 1%)

Lawrence RA, 2016

Bode L. Hearly Human Developmeent, 2015

Oligosaccharides (HMOs)

• Prebiotic

• Anti-adhesive/anti-infective

• Immune modulator

• Anti-inflammatory

• Fiber

Lawrence RA, 2016

Bode L. Hearly Human Developmeent, 2015

Oligosaccharides (HMOs)

They promote the growth of potentially beneficial bacteria, such as Bifidobacterium infantis, thus protecting against the colonization by pathogens

Jantscher-Krenn E, Bode L, Minerva Pediatr, 2012

Bode L. Early Human Development, 2015

Breastfeeding

Oligosaccharides (HMOs)

• HMOs reach the colon unaltered

• Metabolic substrate for bifidobacteria

• Bifidobacteria are selected, whose genome allows for the synthesis of glycosidases, which metabolize them

• The metabolism of HMOs produces SCFAs and reduces the faecal pH, thus promoting their growth

 HMOs induce the selective growth and development of bifidobacteria

Jantscher-Krenn E, Bode L, Minerva Pediatr, 2012 Bode L. Early Human Development, 2015

Oligosaccharides (HMOs)

• Many pathogenic bacteria bind to the glycocalyx on the surface of the enterocyte through "lectins" (Glycan binding proteins)

• Structurally, HMOs are similar to the surface receptors of the glycocalyx

• They bind to lectins and block bacterial adhesion

• HMOs also modify the glycosylation mechanisms of intestinal epithelial cells by modifying the expression of the glycocalyx, with an impact on bacterial adhesion, proliferation and colonization

Jantscher-Krenn E, Bode L, Minerva Pediatr, 2012 Bode L. Early Human Development, 2015

Oligosaccharides (HMOs)

Bode L. Hearly Human Developmeent, 2015

Anna Kulinich, Li Liu, Carbohydrate Research, 2016

Bode, Kunz, et al., 2004

T. Eiwegger, B. et al. Pediatr. Allergy Immunol, 2010

Oligosaccharides (HMOs)

Bode L. Hearly Human Developmeent, 2015

Anna Kulinich, Li Liu, Carbohydrate Research, 2016

Bode, Kunz, et al., 2004

Oligosaccharides (HMOs)

• They reach the colon undigested

• They behave like soluble fibers

• They make the stool softer, and increase the frequency of evacuations

Oligosaccharides (HMOs)

HMOs are a potential source of nutrients (sialic acid) for brain development, as they are contained in gangliosides and glycoproteins

Jantscher-Krenn E, Bode L, Minerva Pediatr, 2012

Oligosaccharides (HMOs)

Jantscher-Krenn E, Zherebtsov M, Nissan C, et al. The human milk

oligosaccharides disialyllacto-N-tetraose prevents Necrotizing

Enterocolitis in neonatal rats. Gut 2012

Gut, 2018

HMO composition in breast milk from 200 mothers with VLBW infants was analyzed for the first 28 days postpartum

Breast milk: composition

Breast milk: composition

Breast milk: composition

Benefits

Breast milk: benefits

Breast milk: benefits

Breast milk: benefits

SM., Fewtrell, Current Pediatrics, 2004

Section on breastfeeding. Peediatrics, 2012

Spiegler J, J Pediatr, 2016

J. Zhou, Pediatrics, 2015

Tham R, Bowatte G, Dharmage SC, et al. Breastfeeding and the risk of dental caries: a systematic review and meta-analysis. Acta Paediatr Suppl 2015

Horta BL, de Mola CL, Victora CG. Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure, and type-2 diabetes: systematic review and meta-analysis. Acta Paediatr Suppl 2015

Horta BL, de Mola CL, Victora CG. Breastfeeding and intelligence: systematic review and meta-analysis. Acta Paediatr Suppl, 2015

PEDIATRICS, 2012

2013

Journal of Pediatric Gastroenterology and Nutrition

1.

Benefits for the mother and the baby

Benefits for the mother and the baby

• Stabilize the glucose level, reduce crying periods, facilitate cardiorespiratory stability and gastrointestinal adaptation, and promote growth

• Stay close to reduce anxiety and stress

 Depression and stress (salivary cortisol) are lower in the first month in the case of skin-to-skin contact

• Encourage mother-child bonding

Lori Feldman-Winter, MD, et al. Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns. Pediatrics, 2016

Benefits for the mother

Benefits for the mother

Breast milk: OTHER BENEFITS

Breastfeeding in the Neonatal

Intensive Care Unit (NICU)

Breastfeeding in the NICU Influencing factors

Breastfeeding in the NICU Knowledge

Breastfeeding in the NICU Methods and techniques promoting breastfeeding

Kangaroo Mother Care

Kangaroo Mother Care

Kangaroo Mother Care

Kangaroo Mother Care

Kangaroo Mother Care

Kangaroo Mother Care

(Bogota, Colombia, 1978)

Kangaroo Mother Care

Contraindications to breastfeeding

Contraindications to breastfeeding

Breastfeeding and medications

Breastfeeding and medications: References

Breastfeeding and medications: References

Breastfeeding and medications: References

Breastfeeding and medications: References

Breastfeeding and SARS-CoV-2

Close contact between mother and baby

A woman with COVID-19 should be encouraged to breastfeed safely, make skin-to-skin contact with her baby, and keep him/her in her room.

Covid-19 positive women can breastfeed if they wish. They should: Wear a surgical mask covering both nose and mouth Wash their hands before touching the baby

Frequently clean and disinfect surfaces

Breastfeeding and SARS-CoV-2

If a woman with COVID-19 is too sick to breastfeed, she can be supported in finding an alternative that allows her to feed her baby with breast milk

Milk pumping Resume breastfeeding

Donated human milk

Protecting breastfeeding

Human Milk Banks (HMBs)

Human Milk Banks (HMBs)

Human Milk Banks (HMBs)

Human Milk Banks (HMBs)

Human Milk Banks (HMBs)

Breastfeeding in emergencies

Breastfeeding and nutrition in children: what to do in humanitarian emergency situations

Bambino Gesù Children’s Hospital summarizes the WHO and IFE recommendations in 10 points

Breastfeeding and nutrition in children: what to do in humanitarian emergency situations

Bambino Gesù Children’s Hospital summarizes the WHO and IFE recommendations in 10 points

Breastfeeding is an interactive process

Quality

Quantity Duration

mouth wide open

“Mother” system

1. Hormonal control (PRL/OSS)

2. Peripheral control (FIL)

everted

lips asymmetric latch (a larger portion of the areola is visible over the mouth) the chin touches the breast

“Baby” system

1. Ability to suck

2. Correct position and latch (effective drainage)

Assessment of the feed

Challenges to breastfeeding

Overcoming breastfeeding difficulties

Assessment scheme

POSITION LATCH SUCKING

Baby lying on his side (ear/shoulder/hip)

Facing the mother and close to her body (embracing him)

Mouth wide open Slow and deep rhythm

Chin touching her breast

Swallowing is audible

Nose facing the nipple Lower lip turned outward

The baby is supported; head slightly backwards

A larger portion of the areola is visible above the baby’s upper lip than below the lower lip

Round and full cheeks (not sucked or dimpled)

No click

Breastfeeding positions

Breastfeeding positions

Baby lying on his side (ear/shoulder/hip)

Facing the mother and close to her body (she embraces him)

Nose facing the nipple

The baby is supported; head slightly backwards

Breastfeeding positions

Baby lying on his side (ear/shoulder/hip)

Facing the mother and close to her body (she embraces him)

Nose facing the nipple

The baby is supported; head slightly backwards

Breastfeeding positions

Baby lying on his side, aligned (ear/shoulder/hip)

Facing the mother and close to her body (she embraces him)

Nose facing the nipple

The baby is supported; head slightly backwards

Breastfeeding positions

Baby lying on his side, aligned (ear/shoulder/hip)

Facing the mother and close to her body (she embraces him)

Nose facing the nipple

The baby is supported; head slightly backwards

Breastfeeding positions

Classic

Football hold

Cross-cradle hold

Biological nurturing

Side-lying hold

Sitting baby

Twins

What differences can you see?

WHO/CDR/93.6 3/9

What differences can you see?

WHO/CDR/93.6 3/8

Breastfeeding positions

Area inside the baby’s mouth

Place the base of the hand on the baby’s shoulders. The latching starts with the chin

IRCCS-OPBG

Breastfeeding positions

Area inside the baby’s mouth

The baby’s head is inclined slightly backwards

• rapidly draw the baby close to the breast

• Push the shoulder blades with the base of the hand

• his chin touches the breast first

• the baby’s body embraces his mother’s IRCCS-OPBG

Breastfeeding positions

• The baby’s head is inclined slightly backwards

• His chin rests on the breast

• Hold the baby firmly on the shoulders, not crouched, and keep him close to your body

IRCCS-OPBG

Breastfeeding positions

THE POSITION OF THE TONGUE IS IMPORTANT

Mother competent in feeding (“beyond the technique”)

Breastfeeding positions

Mouth wide open

Breastfeeding positions

Slow and deep rhythm

Swallowing is audible

Round and full cheeks (not sucked or dimpled)

No click

Breastfeeding

Pain during breastfeeding can be a red flag

Say no to easy feeding bottles

Feed Assessment

FACTORS

Factors influencing maternal supply

Breastfeeding

Even a few drops of milk can be valuable to a premature baby, as well as encouraging for the mother

Manual Pumping

Manual Pumping

Manual Pumping

Types of breast pumps

Types of breast pumps

Breast milk collection for “special” babies

Breast milk collection for “special” babies

Breast milk storage

Storage of pumped breast milk

( + 4 °C) 48/72 HOURS

SEPARATE FROM OTHER FOODS (- 18°C)

SEPARATE FROM THE FRIDGE 3/6 MONTHS

( - 20/25 °C) 9/12 MONTHS

Breast milk storage

Storage of frozen breast milk