COMMUNITY
BREASTFEEDING: OUR DUTY AS HCPS TO GIVE THE BALANCED PICTURE In the UK, breastfeeding rates are lower than most of Europe. Whilst almost three quarters of women started breastfeeding at birth,1 only a third were still breastfeeding at six months.2 Breastfeeding can be a highly emotive topic. Mums want to give their babies the best start in life and nutritionally speaking we know that breastmilk is the best option. “Breast is best”, not only for the infant but for the mother too: breastmilk provides the infant with protective factors that resist gastrointestinal, respiratory and ear infections.3 Breastfeeding is also associated with higher scores on intelligence tests in later life3 and it is also shown to protect the mother from breast cancer, improve birth spacing and it may even reduce ovarian cancer and Type 2 diabetes.3 Not only does breast milk supply nutrients, but the act of breastfeeding is calming for the baby and supports their mouth and jaw development.4 RECOMMENDATIONS
It is recommended that infants should be exclusively breastfed for the first six months of life, as breastmilk supplies all the nutrients the infant requires to develop and grow.4 Colostrum, the milk produced in the first few days after giving birth, is a concentrated source of nutrients for those early days when baby cannot take much in their tummy. Beyond six months, solids should be introduced to support the infant’s additional requirements and breastfeeding should be continued up to two years or beyond.4 It is tricky to make recommendations at this stage, as each mother and baby are variable in when and how much they wean, so some intuition and adjustment is required.
Mothers need to be in positive energy balance whilst breastfeeding, to account for meeting her own needs, plus the needs of the infant, as well as taking into consideration the extra energy that the body needs to produce breastmilk, and how efficient mum is at converting what she eats into breastmilk.
Priya Tew Freelance Dietitian, Dietitian UK Priya runs Dietitian UK, a freelance dietetic service that specialises in social media and media work, consultancy for food companies and private patient work.
NUTRIENT DEFICIENCIES
It is understandable that a mother may be concerned about providing enough nutrition for her baby. However, it should be reassuring that milk composition is very resistant to marginal deficiencies in maternal diet and micronutrient deficiencies are rare in breastfed infants, except if the mother is severely depleted pre/postnatally. Table 1 overleaf provides more detail on specific recommendations for maternal diets to ensure breastmilk volume and composition is adequate. Every baby is unique and whilst breastfeeding may come quite naturally to some mums and babies, to others it can bring its own set of complications and problems. There is the potential to over-simplify breastfeeding, leaving mums who find breastfeeding difficult, feeling that they are failing their baby. As healthcare professionals, we have a role to encourage and support breastfeeding, but also need to be aware of when to allow mums to know it is ok to stop.
Naomi Leppitt Dietitian Naomi is newly qualified, working as a Community Dietitian in Windsor.
REFERENCES Please visit the Subscriber zone at NHDmag.com
BREASTFEEDING SUPPORT
Breastfeeding support groups and counsellors can play a key role in www.NHDmag.com October 2019 - Issue 148
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THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS USE ONLY
BREAST MILK IS BEST FOR PRETERM INFANTS When breast milk isn’t available, nutriprem is nutritionally closer than any other preterm formula* Preterm infants have very high nutrient requirements and face a significant risk of growth failure, developmental delay, necrotising enterocolitis (NEC) and late-onset sepsis.1 Breast milk is best for preterm infants and offers an array of benefits including decreased rates of these conditions and improved neurodevelopmental outcomes.1 However, when breast milk is not available or in limited supply, a preterm formula that is nutritionally closer to breast milk offers the best alternative.2
Whey and casein proteins are important for supporting optimum development in preterm infants Breast milk contains a mixture of whey and casein proteins in varying proportions, from around 20% casein at birth, rapidly increasing to over 40%.3 Whey and casein proteins have individual specific functions, including digestion, immune function and mineral absorption.3 While the unique benefits of breast milk proteins can not be replicated in a formula, only nutriprem provides a protein composition which mirrors that of breast milk by including both whey and casein proteins in appropriate ratios.
Intact proteins in breast milk support gastrointestinal development Over 99% of proteins in breast milk are intact.4 Experts believe that intact protein may have a role in gut maturation, as the intact proteins in breast milk are digested into bioactive peptides which support the development of the gut.5,6 Hydrolysed
and partially hydrolysed formulas are available and have a role in supporting some preterm infants who fail to tolerate an intact protein formula. However, these formulas may prevent the formation of bioactive peptides that occurs during the digestion of intact proteins.6,7
Lactose is a key energy source for breastfed infants Lactose, the main carbohydrate and key energy source for breastfed preterm infants, enhances calcium absorption and may provide a prebiotic effect.8-10 Lactose therefore is the predominant carbohydrate in nutriprem. Maltodextrin is an alternative polysaccharide carbohydrate source often used in preterm formula, but has been linked to reduced stool frequency and increased stool hardness and therefore may not be appropriate for use as the main carbohydrate source for preterm infants.11
Phospholipid-bound LCPs help create a fat profile closer to breast milk Fatty acids are typically bound to triglycerides, but in breast milk up to 20% of the long-chain polyunsaturated fatty acids (LCPs) are instead bound to phospholipids, which improves their absorption in preterm infants.12–14 Only nutriprem preterm formulas contain 15% of the LCPs in phospholipid bound form. Together with betapalmitate sourced from natural milk fat and 10%* of fat from medium chain triglycerides (MCT), the fat composition of nutriprem preterm formulas are closer to breast milk than any other preterm formula in the UK.15–20
Prebiotic oligosaccharides (OS) significantly impact gut microbiota and GI health Breast milk is incredibly rich in prebiotic OS with approximately 200 prebiotic OS identified to date,21 which encourage the growth of beneficial bacteria (such as bifidobacteria) and inhibits growth of potentially harmful bacteria in the gut.21 Nutriprem preterm formulas* contain a blend of 9:1 short-chain GOS:long chain FOS, which mimics the prebiotic effect of the oligosaccharides found in breast milk. Nutricia’s GOS/FOS blend has been proven to help promote a microbiota composition, stool frequency and stool consistency closer to breastfed infants.11,22,23
The only nutritionally complete post discharge formula with a composition closest to breast milk Experts recommend that infants at risk of long-term growth failure require a specialist post discharge formula with increased protein, minerals and trace elements.24 Only nutriprem post discharge formula offers a nutritionally closer to breast milk composition, prebiotic oligosaccharides and sufficient iron to meet their daily requirements up to 6 months corrected age.2,25**
NUTRIPREM IS NUTRITIONALLY CLOSER TO BREAST MILK THAN ANY OTHER PRETERM FORMULA IN THE UK.*
Composition
Preterm breast milk
nutriprem 1
Gold Prem 128
nutriprem 2
Protein ratio
60:40 whey:casein3
60:40 whey:casein
100% whey
60:40 whey:casein
100% whey
Protein type
Over 99.9% intact protein4
100% intact protein
100% partially hydrolysed protein
100% intact protein
100% partially hydrolysed protein
Lactose
Lactose
Maltodextrin
Lactose
Lactose
7.3g/100ml26
5g/100ml
3.7g/100ml
5.9g/100ml
5.3g/100ml
Main Carbohydrate Lactose level Medium chain triglycerides (MCT) Phospholipid bound LCPs Betapalmitate source Prebiotic Oligosaccharides Iron
7-17%
15–18
10%
39.5%
Gold Prem 228
10%
~6%
Up to 20% of LCPs12,14
15% of LCPs
0% of LCPs
15% of LCPs
0% of LCPs
Naturally occurring
Natural milk fat
Structured vegetable fat
Natural milk fat
Structured vegetable fat
0.5-1.1g per 100ml27
0.8g per 100ml
No prebiotic OS
0.8g per 100ml
No prebiotic OS
1.2mg/100ml
0.8mg/100ml (will not meet 2-3mg/kg in typically consumed volumes)
Guidelines recommend 2-3mg/kg up to six months corrected age2,25
Correct as of May 2019. *nutriprem 1 and nutriprem 2 only **SMA Gold Prem 2 contains 0.8mg/100ml iron which will not meet the recommended daily iron requirements of preterm and low birth weight infants up to 6 months corrected age
NOT nutritionally complete**
IMPORTANT NOTICE: Breast milk is best for babies. Nutriprem human milk fortifier, nutriprem protein supplement, hydrolysed nutriprem, nutriprem 1 and 2 are foods for special medical purposes for the dietary management of preterm and low birthweight infants. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed nutriprem, nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low birthweight infants.
References: 1. Underwood MA. Pediatr Clin North Am. 2013;60(1):189–207. 2. Agostoni C et al. J Pediatr Gastroenterol Nutr. 2010;50(1):85–91. 3. Lönnerdal B. Am J Clin Nutr. 2003;77(6):1537S–1543S. 4. Lönnerdal B. Protein in Neonatal and Infant Nutrition: Recent Updates. 2016;86:97–107. 5. Senterre T., Rigo J. Nestle Nutri Inst Workshop Serv. 2016;86:39–49. 6. Vandenplas Y et al. J Pediatr Gastroenterol Nutr. 2016;62(1):22–35. 7. Wada Y and Lönnerdal B. Peptides. 2015;73:101–105. 8. Abrams SA, Griffin IJ, Devila PM. Am J Clin Nutr. 2002;76:442–6. 9. Schaafsma G. Inter Dairy J. 2008;18(5):458–465. 10. Ziegler E et al. J Pediatr Gastroenterol Nutri. 1983;2(2):288–94. 11. Mihatsch W et al. Acta Paediatr. 2006;95(7):843–8. 12. Bitman J et al. Am J Clin Nutr. 1984;40(5):1103–19. 13. Carnielli V et al. Am J Clin Nutr. 1998;67(1):97–103. 14. Harzer G et al. AM J Clin Nutr. 1983;37(4):612–21. 15. Genzel-Boroviczény O et al. Eur J Pediatr. 1997;156(2):142–7. 16. Boker S et al. Ann Nutr Metab. 2007;51(6):550–6. 17. Ehrenkranz R et al. J Pediatr Gastroenterol Nutr. 1984;3(5):755–8. 18. Bitman J et al. Am J Clin Nutri. 1983;38(2):300–12. 19. Innis S et al. Lipids. 1994;29(8):541–5. 20. Ballard O et al. Pediatr Clin North Am. 2013;60(1):49–74. 21. Marcobal A., Sonnenburg J. Clin Microbiol Infect. 2012;18, Suppl 4:12–5. 22. Boehm G et al. Arch Dis Child Fetal Neonatal Ed. 2002;86(3):F178–F181. 23. Knol J et al. Acta Paediatr. 2005;94(449):31–3. 24. Aggett P et al. J Pediatr Gastroenterol Nutr. 2006;42(5):596–603. 25. Domellöf M. World Rev Nutr Diet. 2014;110:121–39. 26. Koletzko B et al. Nutritional Care of Preterm Infants. Karger. 2014. 27. Kunz C et al. J Pediatr Gastroenterol Nutr. 2017;64(5):789–798. 28. SMA Gold Prem 1 and Gold Prem 2 datacards. Accessed May 2019. https://www.smahcp.co.uk/sites/site.prod1.smahcp.co.uk/files/2018-12/ZTC3149%20SMA%20Preterm%20Datacard%20FINAL_0.pdf
Healthcare professional helpline 0800 996 1234 eln.nutricia.co.uk
@NutriciaELNHCP
19-035. August 2019
COMMUNITY Table 1: Breastfeeding estimated nutrient requirements Energy Protein Fat
Vitamins
Minerals
+1.38 MJ/day 325-425kcal/day +11g/d +200mg/d DHA 2 portions fish week, 1 of which should be oily Vitamin C: +30mg/d Vitamin A: +350µg RE/d Thiamin: +0.2mg/d Vitamin D: 10µg/d Riboflavin: +0.5mg/d Vitamin E: >3mg/d Niacin: +2mg/d folate: +60µg/d Vitamin B12: +0.5µg/d Iron: 14.8mg/d Calcium: 1250mg/d Iodine: 250µg/d
supporting women to continue breastfeeding and to normalise any problems that arise. Our breasts are not a body part we talk about and show each other on a regular basis, which can mean some mums will find the act of talking about nipple shapes, or breastfeeding in public, intimidating. Having a supportive environment where this is normalised can make the transition to motherhood easier. So, do advise mums to look for local groups, such as the NCT breastfeeding cafes and La Leche League groups. COMMON ISSUES
Baby’s weight gain Whilst it can be normal for a baby to lose a little weight in the first few days post-birth, it can also be a sign that breastfeeding is not being well initiated. Colostrum is produced from midpregnancy and can actually be harvested by hand in the last few weeks of pregnancy, then stored in the freezer for use in those first few weeks post-birth. Milk production starts to be seen two to three days post-birth for most mums. Mastitis/blocked ducts This is when a milk duct becomes blocked. A lump can be felt and the breast may be swollen, hot, red and tender to touch. The mum may have a temperature and flu-like symptoms. Having this on top of a newborn baby to look after is, therefore, exhausting and it is important that the mum gets some help. Feeding is usually painful. However, it is also important to carry on feeding. Pumping or hand expressing milk can help to clear the duct along with breast massage. Refer mums to their GP/health visitor as antibiotics may also be needed.
Nipple pain, soreness and bleeding Using nipple cream and nipple shields can help with this. These issues are not well talked about and some mums may feel they need to stop breastfeeding as it is uncomfortable. Normalising the fact that breastfeeding is a new skill for baby, for mum (and for breasts!), can help mums understand that it can take time to master. Cluster feeding On some days, it can feel as though baby is constantly feeding. This can be due to a developmental leap, teething, sickness, for comfort, or due to a growth spurt. Feeding baby on demand can be hard work, but babies really do know best! If a mum is really struggling with breastfeeding, then it is part of a healthcare professional’s role to help counsel them into seeing what is right for baby and themselves at that point. Combination feeding is an option, where baby takes some milk via the breast and some formula too. Pumping milk to store for a bottle feed is another option. Of course, there is also the option of fully formula feeding babies and some babies may have to be formula fed from birth. It is key that mums feel supported to make their decisions and are educated about all the options.
Useful resources
NCT: www.nct.org.uk Kelly mom: www.kellymom.com La Leche League: www.llli.org www.NHDmag.com October 2019 - Issue 148
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Supporting Mums to Breastfeed Lansinoh® – a company founded by a mother with a passion to support & encourage breastfeeding – have a range of breastfeeding products to assist new mums in providing their babies with the best start in life. Here are three Lansinoh products that can help overcome common breastfeeding challenges you may be asked about by mothers in your care.
HPA® Lanolin Lanolin creates a temporary barrier to promote a moist wound healing environment*. Lansinoh’s HPA® Lanolin soothes and protect sore and cracked nipples, helping to replenish skin back to its natural state. 100% natural so there’s no need to remove before breastfeeding. It’s is also the only lanolin product to have received the British Allergy Foundation Seal of Approval.
Thera°Pearl® 3-in-1 Breast Therapy The Lansinoh Thera°Pearl® Breast Therapy Pack can be used hot or cold to help relieve mastitis, engorged breasts and encourage let down. Flexible and reusable, Thera°Pearl® 3-in-1 Breast Therapy pack has soft covers that can be slipped comfortably inside the bra to relieve any discomfort caused by some conditions associated with breastfeeding. This product can also be used with a breast pump.
Contact Nipple Shields Lansinoh Contact Nipple Shields can be used as an effective, short term tool to support mums to breastfeed, under the encouragement, guidance and appropriate advice of a healthcare professional. The shields can be used to help with flat or inverted nipples, tongue and/or lip tie, and over-active let-down. They can also be used for feeding a premature, small or ill baby.
You can discover more about helping mums to breastfeed at: www.lansinoh.co.uk/professional *Field CK, Kerstein MD. Overview of wound healing in a moist environment Am J Surg. 1994; 167 (1):S2-S6