Breastfeeding Education for Physicians: - PowerPoint Presentation

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Breastfeeding Educationfor Physicians: The Road to Baby Friendly Designation

Jennifer Amrol, MDAssistant Professor of Clinical PediatricsUniversity of South Carolina School of Medicine

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Review the anatomy and physiology of breastfeeding.Examine the composition of human milk and the significance of individual components.Objectives

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Breast Anatomy

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Mammary tissueAlveoliDuctsNipple and Areola

Supporting connective tissue and fat, blood and lymphatic vessels, nerves Adipose tissue distribution greatly differs among women and is not related to milk productionBreast

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Mammary tissueAlveoliSmall sacs of milk secreting and storing cells clustered into lobulesSurrounded by myoepithelial cells which contract in response to oxytocin for milk ejection

DuctsConnect lobules to form distinct mammary lobeThen connect lobes to end at the galactophoreDucts beneath areola become fuller due to oxytocin during a feed

Number is not related to milk production

Breast Anatomy

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Nipple Has an average of 9 milk ducts passing to outside Has smooth muscle fibers and sensory nervesShape and size vary between women

Breast Anatomy

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Women with inverted nipples can breastfed but they many need more help postpartum.She should request assistance with breastfeeding as soon as possible after her baby is born.After delivery, a breast pump might be useful to help evert the nipples. If a pump is not available, a 20ml syringe with the adaptor end cut off and the plunger inserted backwards is used to help draw out a nipple.

Avoid bottle and pacifier use so the baby does not become accustomed to the longer artificial nipple which feels and flows differently.When all else fails, an ultra-think silicone nipple shield can be tried temporarily.Nipple preparation during pregnancy is not recommended.Inverted Nipples

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Areola Circular and pigmented Contains Montgomery glands Secrete a bacteriostatic, oily fluid to protect the areola and nipple during lactation Produces the mother’s scent that attracts the baby

Shape and size vary between womenBreast Anatomy

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MammogenesisGrowth of the breastsIn utero, prepubertal, pubertalLactogenesis

Functional change of the breasts so that they can secrete milkOccurs during pregnancy and initial postpartum periodGalactopoiesisMaintaining the production of milkBegins 9 days postpartumInvolution

Termination of milk production

With weaning

Stages of Lactation

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In uteroMammary bulb is seen at 18-19 weeks gestationFat pad precursor developsRudimentary ductal system is present at birth

After birth/before pubertySmall set of branching ducts grows with childRemains inactiveMammogenesis

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Puberty -ThelarcheTakes 3 to 3 ½ yearsOccurs 2 ½ to 3 years prior to menarcheInitial stagesIncrease in size and pigmentation of areola

Development of breast budMammogenesis

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Puberty -ThelarcheEstrogenBreast tissue enlarges

Stimulates growth of mammary ducts into preexisting fat padProgesteroneEffect begins with onset of menses and ovulationSecreted by ovary during luteal phase (second half of menstrual cycle)Stimulates

lobulo

-alveolar development

Alveolar clusters grow with each luteal phase and regress with onset of menses and loss of hormones

Mammogenesis

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Mammary gland develops capacity to secrete milkIncludes all steps needed to transform undifferentiated breast tissue in early pregnancy to fully differentiated state after pregnancyTwo stages

Beginning at the twelfth week of pregnancy Beginning shortly after deliveryLactogenesis

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Occurs by mid pregnancyPregnancy hormonesProgesterone

Lactogenic hormonesProlactin and Human placental hormoneStimulate nipple and areolar growthBreast changes

Double in weight

Increased blood flow

Growth in lobules and alveoli (progesterone effect)

Increased secretory activity

Mammary gland becomes competent to secrete milk

Alveoli accumulate colostrum

Colostrum is secreted immediately postpartum when the newborn feeds

Milk secretion is prevented by elevated levels of estrogen and progesterone

Lactogenesis Stage 1

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Occurs whether or not the newborn breastfeedsDay 2 or 3 to day 8 after birthAverage of 40 hours postpartumEarlier in

multiparous womenTight junction in alveolar cell closesOnset of copious milk secretionDrop in levels of estrogen and progesteroneRelative increase in prolactin levels

Breasts are full and warm

Switch from endocrine to autocrine control

Continued milk production depends on regular milk removal

Lactogenesis Stage 2

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Blood flow, oxygen, and glucose uptake increaseProgesteroneRemoval of placenta with its progesterone is required for milk secretion

Progesterone receptors appear to be lost in lactating tissues so that the inhibitory effect of circulating progesterone is decreased once lactation is establishedSo progesterone only birth control can be used once lactation is going wellInsulin, GH, cortisol, and PTH

Maternal secretion allows for mobilization of nutrients and minerals required for lactation

Lactogenesis Stage 2

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Begins 9 days after birth and continues until weaningEstablished milk secretion/production is maintainedContinued autocrine system of controlProlactin

Required to maintain milk secretionOxytocinRequired to produce let-down to allow milk extractionGalactopoesis

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Begins at weaningRegular milk extraction ceasesProlactin is withdrawnIs completed ~40 days after last breastfeeding

Milk secretion decreases due to the buildup of inhibitory peptidesMammary gland returns nearly to pre-pregnancy stateInvolution

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The cyclical process of milk synthesis and secretionOccurs with the help of prolactin and oxytocin

Regulation of milk synthesisQuite efficientAverage of ~800 ml/day but volume secreted may vary depending on infant’s requirement

Milk production

Improves with relaxation

Decreases with maternal stress and fatigue

Increased dopamine and/or norepinephrine inhibit prolactin synthesis

Stress and fatigue inhibit oxytocin release

Effect of Alcohol

Lower levels may enhance milk letdown due to decreased stress but higher doses inhibit oxytocin release thereby inhibiting letdown

Lactation

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Physiology of Lactation

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ProlactinPolypeptide hormone synthesized in the anterior pituitaryPositive regulation of secretion

Released from anterior pituitary with the peak determined by the intensity of suckling by the infantNegative regulation of secretion Main control is from hypothalamic inhibitory factors (dopamine acts through the D2 receptors in lactotrophs)Stimulates mammary gland ductal growth and epithelial cell proliferation

Stimulates milk synthesis in mammary gland epithelial cells

Suppresses ovulation

Physiology of Lactation

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ProlactinLevels increase from 10 ng/ml in prepregnant state to ~200

ng/ml at termSecretion occurs 7 to 20 times per day with peaks of up to 75 minutesPeak is superimposed on continuous background level of secretion

Levels quickly rise with suckling

and peak

~30 minutes after start of a feed

Effect on milk production is most pronounced in first few weeks after birth

Levels are not proportional to milk secretion and do not directly regulate milk synthesis or secretion

More is produced at night so nocturnal feeds are helpful in keeping up supply

Makes mother feels relaxed and sleepy

Physiology of Lactation

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Physiology of Lactation

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OxytocinSynthesized in hypothalamus and stored in the posterior pituitary

Release is stimulated by sucklingNeuroendocrine reflex has a significant psychological componentOxytocin release may be stimulated by thought, sight, or sound of infantStimulates myoepithelial cells in alveoli to contract and expel milkForcible milk removal is called milk ejection or let-down

Variation in perception of let-down

Aids in uterine involution after delivery

Uterine contractions may be associated with “after pains” that indicate oxytocin release

Physiology of Lactation

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Signs of Oxytocin ReleaseTingling sensation in breast before or during a feedMilk flowing when mother thinks of baby or hears crying baby

Milk flowing from other breast during feedingMilk streaming from breast if latch is interruptedSlow deep sucks and swallows by the baby during feedUterine pain during feedThirst during a feed

Physiology of Lactation

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Milk productionPositive local regulation by demand

Increased suckling Increased emptyingIncreased milk secretion/productionSkin to Skin (SSC) supports successful breastfeeding

Partial milk removal sets a new, lower rate of milk production

Negative local regulation of milk production

Feedback Inhibitor of Lactation

Accumulates in milk between feeds so without removal of milk, secretion/production is inhibited

Explains why an empty breast makes milk faster than a fuller one

Distention or stretch of the alveoli

Local effect to inhibit milk secretion/production

Once milk removal stops, involution begins

Physiology of Lactation

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Feedback Inhibitor of LactationInhibitory whey protein present in breast milkBuilds up as milk accumulates in the mammary gland

Without milk removal, the inhibitor stops epithelial cells from secreting/producing more milkProtects breast from harmful effects of overfillingOnce milk is removed, secretion restartsAllows production of milk to be determined by infant’s needs

Especially important regulatory mechanism once lactation is established since prolactin does not control milk volume produced

Physiology of Lactation

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Mothers make nourishing milk for their infants from all kinds of food. There are no foods that must be avoided, unless mother or baby develops an allergic reaction. Breastfeeding mothers have an increased thirst that usually maintains an adequate fluid intake; no data support the assumption that increasing fluid intake will increase milk volume. Mothers do not need to drink milk to make milk; thirst can be satisfied from a variety of nourishing beverages, including water.

Calcium is available not only in milk and milk products but in many other foods, such as broccoli, spinach, kale, bok choy, collards, mustard and turnip greens, almonds, and canned fish. Poor maternal nutrition is not a contraindication to breastfeeding. Mothers following a vegan diet should take a B12 supplement

Maternal Diet and Milk Supply

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Metoclopramide — most commonly usedDomperidone — not approved in USA. Similar to metoclopramide but less side effects as little crosses blood brain barrier

Fenugreek and other herbal medicines — no scientific data except anecdotal reportsGoat’s rue, milk thistle, anise, basil, blessed thistle, fennel seeds and marshmallow

Galactagogues

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Effect is to increase prolactin levelBenefit shown in small placebo controlled crossover study with increase of 50 cc per feed with dose of at least 30 mg per daySide effects

gastrointestinal, anxiety, sedation, and rare dystonic reactionsNo documented neonatal reactionsShort term: 1–3 weeks is common. No evidence supporting long-term use. Usually wean after 10–14 days

Common dosing regimen

10 mg

po

qd

first day

Then 10 mg

po

bid

Then 10 mg

po

TID

Metoclopramide

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Most commonly recommended herbal galactogogueUsual dose is 1-4 capsules (580-610mg) tid

to qidNo standard dosingMay also be taken as one cup of strained tea tid¼

tsp

seeds steeped in 8oz water for 10 minutes

Increases supply within 24 to 72 hours

Side effects in mother

Maple like odor to sweat, milk, and urine

Diarrhea

Increased asthmatic symptoms

Lower blood sugar

Contraindicated during pregnancy due to uterine stimulant effects

Fenugreek

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Human Milk Composition

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ColostrumDenser milk provided for the first 2-3 days after birth

Facilitates the passage of meconium to decrease enterohepatic circulation and thus encourage elimination of bilirubin Aids in establishment of Lactobacillus bifidus flora in infant’s gutMilk Volumes

Day 1 40-50 ml

(range of 7-123ml)

Day 3 300-400 ml

Day 5 500-800 ml

Low volumes encourage frequent feeds to stimulate milk synthesis

Colostrum Energy Value

67 kcal/100ml

Colostrum components

Higher concentrations of Na, K, and

Cl

than mature milk

Higher percentage of protein, minerals and fat soluble vitamins than mature milk

Human Milk Composition

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ColostrumDenser milk with higher concentration of proteins

White cells and antibodies (especially sIgA)Important immune protection from exposures to environmental micro-organisms40-60% of cells are macrophagesEpidermal growth factor

Prepares gut lining to receive nutrients in milk

Lactose

Prevents hypoglycemia and facilitates

meconium

passage and therefore bilirubin excretion

Vitamin A

Protects the eyes and epithelial surfaces

Beta carotene, its precursor, provides yellowish color of colostrum

Human Milk Composition

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Immunoglobulins in Human Milk(levels decrease over time)

Output - mg/24 hours Day Postpartum

IgG

IgM

IgA

1 80 120 11,000

3 50 40 2,000

7 25 10 1,000

8 – 50 10 10 1,000

Human Milk Composition

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Human Milk Composition

Note the increases in calories, lactose, and fat

while the protein decreases

from colostrum to mature milk

.

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Transitional MilkMilk produced from days 5-12Intermediate composition between colostrum and mature milk

Volume continues to increaseMacrophage as percentage of WBCs increases to 80-90%Concentration is 104 to 105 per ml of milk

Human Milk Composition

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Mature MilkMilk produced after ~14 daysContains all the nutrients an infant needs for the first 6 months of life and is uniquely specific for humans

Fat (3.8%), protein (0.9%), carbohydrates (7.2%), vitamins, minerals, and water (87%)Is easily digested and efficiently usedComposition varies through lactation: over a day, within a feed, and between women

Calories

20 calories per ounce (65-

75

kcal/100ml)

Human Milk Composition

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Formula Breast Milk Milk

Note the substantial structure of human milk under a microscope; this is due to the compartmentation of the various components such as the nutrients and bioactive substances. This image demonstrates that milk is a living tissue containing about 4000 cells/cubic mm including neutrophils, macrophages, and lymphocytes.

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WaterHuman milk is 87% waterProvides sufficient fluid to maintain hydration even in hot climates

Human Milk Composition

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Fat content3.5-3.8g/100ml provides 50% of energy/calories in milk

Most variable component of human milkSeparates on standingContains cholesterol, triglycerides, short-chain fatty acids, and long-chain polyunsaturated fatty acidsForemilk

Milk that accumulates in breast since previous feed

Lower fat content (1.5 to 2%) and looks bluish-gray

Hindmilk

Milk that is secreted during a feed

Higher fat content (2-3x more

than foremilk-

5 to 6%) and looks creamy white

Human Milk Composition

Fat

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Fat content increases from the start of a feed (~1.7%)to the end of a feed (~5.5%). Protein content decreases from the start (0.9%) of a feed to the end (0.7%).

Foremilk has less fat but more protein than hindmilk

.

Human Milk Composition

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Lipid ComponentMilk fat globuleForms with lipid secretion from apical mammary epithelial cell and envelopment in its plasma membraneAlso contains proteins, growth factors, and vitamins

Mucins on the globule membrane adhere to viruses and bacteria to aid in elimination from bodyHuman Milk CompositionFat

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Lipid ComponentBile salt-stimulated lipaseActs on triglycerides to produce free fatty acids and 2-monoglycerides

Prevents fatty acids from forming soaps with mineralsResults in superior absorption of fat and mineralsNot present in formula

Human Milk Composition

Fat

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Lipid ComponentAbundance of essential fatty acids (linoleic and linolenic acids)

Most exist as triacylglycerols and phospholipids167 fatty acids have been identified in human milkUnique long chain polyunsaturated fatty acids (including omega-3 fatty acids DHA and ARA)

Term infants are able to convert long chain polyunsaturated fatty acids to DHA and ARA so the addition of these to term formulas may be unnecessary but is likely useful for preterm infants who cannot convert them.

Cholesterol is also present in significant quantities

Human Milk Composition

Fat

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Human milk contains 9g protein/L (whey and casein)Less than in other animal milksWhey proteins consist primarily of α-

lactalbumin without β-lactalbuminCow milk whey contains β-lactalbumin to which infants can become intolerantContains less casein than other milks

Provides 80% of milk’s nitrogen

Protein content declines over 2-4 weeks but then is constant until weaning

Human Milk Composition

Protein

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Colostrum90/10 ratio of whey/caseinMature Milk70/30 ratio of whey/caseinLate Lactation

50/50 ratio of whey/caseinCow Milk18/82 ratio of whey/caseinHuman Milk Composition

Protein

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Whey (70%)Contains water, electrolytes, and proteins

α-lactalbumin, albumin, lactoferrin, immunoglobulins, enzymes (e.g., lysozyme), growth factors, and hormonesRemains in solution after acidificationLactoferrin, lysozyme, and sIgA resist proteolytic digestion and line the GI tract to provide host defense

Present only in human milk

Generally more easily digested and associated with more rapid gastric emptying

Human Milk Composition

Protein

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Lactoferrin Transports and promotes the absorption of ironInhibits the growth of iron-dependent bacteria in the gastrointestinal tract such as coliforms and yeastLysozyme

Enzyme that protects the infant against E. Coli and SalmonellaPromotes the growth of healthy intestinal flora and has anti-inflammatory functionsSecretory IgAPrimary Ig in breastmilk Protects the infant from viruses and bacteria, specifically those to which the baby, mom, and family are exposed Helps protect against E. Coli

Human Milk Composition

Protein- Whey

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Casein (30%)β-casein forms a soft curd in the infant’s stomach if pH<5

Curd is an insoluble calcium caseinate-calcium phosphate complexLow solubility in acid

Human milk casein curds are more easily digested than those in other milks

Human Milk Composition

Protein

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Non-protein nitrogen containing compoundsProvide 20% of nitrogen in milkEpidermal growth factor

Contributes to the development and function of intestinal mucosaTaurineFree amino acid associated with bile acid conjugation and neurotransmissionNucleotides

Have metabolic and immune functions

Carnitine

Used for

lipolysis

of long-chain fatty acids

Somatomedin

-C, Insulin and other peptides

Human Milk Composition

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When is lactase present in the infant gut? Present in maximal amounts in the intestinal brush border of full term infantsDeficient before 34

wgaHuman Milk Composition Carbohydrates

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Lactose (90%) 7.2g/LDisaccharide of galactose and glucose synthesized in the breast

Important source of glucoseImportant source of galactose for galactolipids used in infant brain developmentMonosaccharides, oligosaccharides, and glycoproteins (10%)

Oligosaccharides prevent bacteria from adhering to mucosal surface

Oligosaccharides plus glycoproteins = “bifidus factor”

Stimulate growth and colonization of newborn’s gut with

Lactobacillus bifidus

(beneficial bacteria that creates an acidic gut where harmful bacteria cannot survive)

Human Milk Composition Carbohydrates

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MineralsContent is similar between mammal milks but concentrations, ratios, and bioavailability are species specific

Lower quantities results in lower solute load for immature renal systemIron, sodium, potassium, calcium, magnesium, zinc, and small amounts of copper, selenium, chromium, manganese, molybdenum, and nickelZinc and IronWell absorbed from human milk

Zinc deficiency is rare in breastfed infants whose mothers have adequate Zn intake

Human Milk Composition

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Iron100mcg/L versus formula with 12mg/L50-100% of human milk iron is absorbed

4% of iron fortified formula iron is absorbedAbsorption is enhanced by high lactose and vitamin C concentrations in human milkLactoferrin in whey binds iron Increasing digestion and absorption of ironAlso makes iron unavailable to iron dependent bacteria in gut

Normal full-term infants can be exclusively breastfed for 6 months without becoming iron deficient

Human Milk Composition

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VitaminsVitamin A, beta carotene, and vitamin EPlentiful in colostrum and early transitional milk

Vitamin A protects against infection and aids early retinal developmentVitamin E protects red cells against hemolysisVitamin DSufficient only with adequate maternal diet and maternal and infant sun exposure

AAP recommends 400 IU/d for all breastfed infants until they are ingesting or exposed to sufficient Vitamin D from other sources

Vitamin K

Poorly transported prenatally and also limited in human milk

All newborns must receive Vitamin K at birth

Vitamin B12

Mothers on vegan diets may produce B12 deficient milk so supplements are recommended

Human Milk Composition

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Examples of the Non-nutritional Components of Human milk

Antimicrobial factors secretory IgA, IgM, IgG lactoferrinlysozymecomplement C3leukocytes

bifidus factor

lipids and fatty acids

antiviral

mucins

, GAGs

oligosaccharides

Cytokines and anti-inflammatory factors

tumour

necrosis factor

interleukins

interferon-g

prostaglandins

a1-antichymotrypsin

a1-antitrypsin

platelet-activating factor: acetyl hydrolase

Transporters

lactoferrin

(Fe)

folate

binder

cobalamin

binder

IgF

binder

thyroxine

binder

corticosteroid binder

Others

casomorphins

d -sleep peptides

nucleotides

DNA, RNA

Growth factors

epidermal (EGF)

nerve (NGF)

insulin-like (IGF)

transforming (TGF)

taurine

polyamines

Digestive enzymes

amylase

bile acid-stimulating esterase

bile acid-stimulating lipases

lipoprotein lipase

Hormones

feedback inhibitor of lactation (FIL)

insulin

prolactin

thyroid hormones

corticosteroids, ACTH

oxytocin

calcitonin

parathyroid hormone

erythropoietin

Potentially harmful substances

viruses (e.g., HIV)

aflatoxins

trans

-fatty acids

nicotine, caffeine

food allergens

PCBs, DDT, dioxins

radioisotopes

drugs

http://www.unu.edu/unupress/food/8F174e/8F174E04.htm

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Passive Immunization via the Enteromammary Pathway

Human Milk Composition

Maternal exposure

Maternal gut

Antigens

Lymphoblasts

Mesenteric node

Thoracic duct

Blood stream

Other mucosal surfaces

Breast tissue and breastmilk

Infant gut

Lymphoblasts mature into lymphocytes that produce immunoglobulins that move into the bloodstream

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Milk Composition Differences

Human Milk

Commercial

Substitutes

Protein

Appropriate (species specific) quality/quantity

, easier to digest

Corrected

in quantity but not in quality (not species specific)

Fat

Appropriate quality/quantity of essential fatty acids, lipase present

Lipase absent

Vitamins

Adequate

except for vitamins D and K in some situations

Vitamins

added

Minerals

Correct amount

Partly corrected

Anti-Infective properties

Present

Absent

Growth Factors

Present

Absent

Digestive enzymes

Present

Absent

Hormones

Present

Absent

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Thank you for completing Section 2 of Breastfeeding Education for Physicians. To obtain CME credit, please click on the link below, provide your information and complete the post-test https://www.surveymonkey.com/s/BreastfeedingSection2