Breastfeeding

Breastfeeding is a natural way for infants (predominantly term) to receive nutrition and it is recommended up to 2 years of age, with almost exclusive breastfeeding during the first 6 months (WHO = World Health Organization). In order to reduce allergy and celiac disease (especially in families with allergies), complementary nutrition should be introduced between 4-6 months (17-26 weeks of life) (ESPGHAN = European Society for Pediatric Gastroenterology, Hepatology and Nutrition). Complementary nutrition (non-milk) can be introduced also in scenarios where an infant fails to thrive (suboptimal weight gains).

Breastfeeding – advantages

• optimal nutrition for healthy growth (quantity) and development (quality)
• immunology factors
• prevention of metabolic disorders (atherosclerosis, diabetes mellitus)
• mother – child bond (psychosocial link)
• neurodevelopment
• economical

Breastfeeding – physiology

• breast development during pregnancy (estrogens)
• postnatal lactation (prolactin)
• during infant suckling (oxytocin), smooth muscle layer cells (myoepithelium) surrounding the alveoli contract to squeeze the breast milk into the duct system = milk ejection reflex / let-down (note: oxytocin as a muscle contractor also responsible for uterus contractions)
• breast milk flow: alveoli (lobules) => ducts (milk canals) => sacs (milk pools) => infant

Breast milk

Breast milk composition changes depending on the infant’s needs

• Colostrum = a thick yellowish fluid produced for the first few days after birth (rich for immunoglobulins)
• Saccharides (40% of caloric value) represented mainly by lactose (amount increasing as the milk matures), then galactose and fructose
• Lipid (50% of caloric value) represented by linoleic and alfa linolenic acids that are substrates for long chain PUFA (polyunsaturated fatty acids; docosahexaenoic and arachidonic acids) required for CNS and retina development; several times more lipids in the hindmilk (milk at the end of a feed) than in the foremilk (milk at the beginning of a feed)
• Protein (10% of caloric value) is the most stable part of breast milk with 70% of whey proteins (mainly lactalbumin) and 30% of casein protein (compared to animal (sheep, buffalo, cow) milk, where casein can constitute up to 80% of total protein content); additional important proteins:
  • lysozyme = antimicrobial agent that dissolves peptidoglycan component of bacterial cell walls
  • lactoferrin = globular glycoprotein in secretory fluids (milk, saliva, tears, nasal secretions) with antimicrobial activity (inhibits microbial growth)
  • secretory IgA (sIgA) = the most prevalent IgA form; main immunoglobulin found in mucous secretions (tears, saliva, sweat, colostrum, secretions from the genitourinary tract, GIT, prostate and respiratory epithelium)
• Minerals – low sodium; calcium/phosphate ratio 2:1
• Vitamins – water soluble vitamins generally in sufficient amounts, fat soluble can be insufficient (especially vitamin K and D) => requires additional substitution

Vitamin D

• group of substances (fat-soluble steroids)
• prohormones rather then vitamins
• vitamin D₂ (ergocalciferol)
• vitamin D₃ (cholecalciferol)

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COMPOSITION	COLOSTRUM	MATURE MILK
Energy (kcal/100ml)	54	67
Protein (g/100 ml)	2	1
Lipids (g/100 ml)	1.8	3.4
Lactose (g/100 ml)	5.6	6.5
Calcium (mg/100 ml)	21	25
Phosphate (mg/100 ml)	11	14
Sodium (mg/100 ml)	33	20
Potassium (mg/100 ml)	62	46
Zinc (mg/100 ml)	0.9	0.15
Iron (mg/100 ml)	0.12	0.09

Breastfeeding

Proper technique and mother-child cooperation are essential for successful breastfeeding – there are several things to be aware about:

• Infant positioning during breastfeeding
• Neonatal reflexes to facilitate breastfeeding (root, suck, swallowing reflex)
• On demand breastfeeding (but usually every 2-3 hours)
• Frequent breastfeeding stimulates lactation
• Weight loss up to 10% (regained by 2 weeks of life)
• Urine during the first 12-24 hours (then 6-8 wet nappies/day)
• Stool during the first 24-48 hours (then variable, can be once per week!)
• Twins can be breastfed simultaneously

Preterm newborns can be also breastfed – there are several maturation aspects that should be reached in order to successfully breastfeed preterm infants:

• Thermostability
• Stable ventilation and circulation status
• Strong reflexes (including their coordination)

Mothers who breastfeed should have optimal nutrition and try to prevent complications:

• Sufficient hydration, calcium, vitamin (B₁₂) intake
• Iodine intake (up to 300 µg/day)
• Sore/cracked nipples (usually result of suboptimal breastfeeding technique, risk of Candida infection = thrush)
• Breast engorgement/blocked milk duct (painful swelling treated with cold poultice, massage, antipyretics and resuming breastfeeding) => can progress to =>
• Mastitis (inflammation of the breast) => same local treatment as above + antibiotics (Oxacillin – Staphylococcus aureus as the usual pathogen) => can progress to =>
• Abscess that may require surgical treatment

Contraindications to Breastfeeding

• Inherited metabolic disorders
  • galactosemia
  • phenylketonuria
  • maple syrup disease
• Maternal disease
  • heart failure
  • liver disease
  • psychiatric disorders (postpartum (puerperal, lactation) psychosis)
  • infection (tuberculosis; HIV – in Europe)
• Maternal medication
  • cytostatic agents
  • lithium
  • psychostimulats
  • radioisotopes
  • drugs – heroine/cocaine
  • relative contraindications (alcohol, nicotine, caffeine)

Baby friendly initiative

Baby Friendly Hospital Initiative (BFHI) is a worldwide programme of the World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) to promote and encourage breastfeeding across the globe

There are 10 steps for successful breastfeeding according to BFHI, however, several critical reports pointed out the potential drawbacks of the programme, including rigid enforcement of the practices, increased risk for Sudden Unexpected Postnatal Collapse, unnecessary pacifier ban and maternal exhaustion

10 steps /criteria for BFHI accreditation (2018)

Critical management procedures

• 1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions
• 1b. Have a written infant feeding policy that is routinely communicated to staff and parents
• 1c. Establish ongoing monitoring and data-management systems
• 2. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding

Key clinical practices

• 3. Discuss the importance and management of breastfeeding with pregnant women and their families
• 4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth
• 5. Support mothers to initiate and maintain breastfeeding and manage common difficulties
• 6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated
• 7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day
• 8. Support mothers to recognize and respond to their infants’ cues for feeding
• 9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers
• 10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care

References

① Bass JL, Gartley T, Kleinman R. Unintended Consequences of Current Breastfeeding Initiatives [published correction appears in JAMA Pediatr. 2017 Apr 1;171(4):399]. JAMA Pediatr. 2016;170(10):923-924. doi:10.1001/jamapediatrics.2016.1529

② Gidrewicz DA, Fenton TR. A systematic review and meta-analysis of the nutrient content of preterm and term breast milk. BMC Pediatr. 2014;14:216. Published 2014 Aug 30. doi:10.1186/1471-2431-14-216

③ Mastroeni SS, Okada IA, Rondó PH, Duran MC, Paiva AA, Neto JM. Concentrations of Fe, K, Na, Ca, P, Zn and Mg in maternal colostrum and mature milk. J Trop Pediatr. 2006;52(4):272-275. doi:10.1093/tropej/fmk004