Infant feeding Ayda khader - PowerPoint Presentation

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Infant feeding

Ayda khader

may

. 2018

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The chapter aim s to:

explain the structure and function of the female breast

describe the properties and components of breast milk

emphasize the role of the midwife in ensuring breastfeeding success for both mother and baby

discuss the role of breast milk expression and human milk banking

describe the different causes of difficulty with breastfeeding

discuss the use of formula feeding and the various products available

outline the requirements and recommendations of the International Code of Marketing of Breast milk Substitutes and the Baby Friendly Hospital Initiative

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Introduction

Breastfeeding for the first 6 months of life is the ideal start for babies.

Breastfeeding improves infant and maternal health and cognitive development

it is the single most important preventive approach for saving children's lives

Low breastfeeding rates have led to a progressive increase in the incidence of illness that has a significant cost to the National Health Service

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Anatomy and physiology of the breast

The breasts are compound secreting glands, composed of varying proportions of fat, glandular and connective tissue, and arranged in lobes.

Each lobe is divided into lobules consisting of alveoli and ducts.

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Breast Anatomy

The breast is internally composed of the following parts:Lobes and LobulesInternally, the mammary gland is composed of 15-25 lobes that radiates around the nipple. Each lobe consists of about 20-40 lobules, a smaller milk duct that contains 10-100 supporting alveoli.Glandular tissueGlandular tissues are responsible for milk production and transportation which is composed of:Alveoli – epithelial grape-like cluster of cells where milk is produced.

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Ductules – branch-like tubules extending from the clusters of alveoli and empties to larger ducts called lactiferous ducts.Lactiferous ducts – widen underneath the areola and nipple to become lactiferous sinuses.Lactiferous sinuses – collect milk from lactiferous ducts and narrows to an opening in the nipple (nipple pore).

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Connective tissueConnective tissue supports the breast. Cooper’s ligaments are fibrous bands that attach the breast to the chest wall and keep the breast from sagging.Blood supply nourishes breast tissue and supplies the nutrients to the breast needed for milk production.Internal and external mammary arteries & upper intercostals arteriesVenous drainage through corresponding vessels into internal mammary and axillary veins

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Nerves make the breast sensitive to touch, hence allowing the baby’s suck to stimulate the release of hormones that trigger the let-down or milk ejection reflex (oxytocin) and the production of milk (prolactin).Largely controlled by hormone activityThe skin is supplied by thoracic nervesSome sympathetic nerves supply the nipple and areola

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Lymph nodes:removes waste productsLymphatic drainage largely into axillary glandSome into liver and mediastinal glandThe lymphatic vessels of each breast communicate with one another Adipose tissue (fat) – protects the breast from injury.

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The breast is externally composed of the following parts:Axillary tail Is breast tissues extending toward the axilla Areola – circular pigmented area 2.5 cm in diameter at the center of each breast.In the areola are small glands called Montgomery's glands which secrete an oily fluid to keep the skin healthy

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Nipple  protruding area at the center of each breast areola at level of 4th ribA protuberance of 6mm in length, composed of pigmented erectile tissuesThe surface of nipple is perforated by small orifice of lactiferous ductsIt is covered with epithelium

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Nipple  protruding area at the center of each breast areola at level of 4th ribA protuberance of 6mm in length, composed of pigmented erectile tissuesThe surface of nipple is perforated by small orifice of lactiferous ductsIt is covered with epithelium

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Anatomy and Physiology

Breast enlargementDuring pregnancy and lactation indicates the mammary glands are becoming functionalBreast size before pregnancy does not determine the amount of milk a woman will produce

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Hormones during pregnancyEstrogen stimulates the ductile systems to grow, then estrogen levels drop after birthProgesterone increases the size of alveoli and lobesProlactin contributes to increasing the breast tissue during pregnancy.

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Hormones during breastfeedingProlactin levels rise with nipple stimulationAlveolar cells make milk in response to prolactin when the baby sucksOxytocin causes the alveoli to squeeze the newly produced milk into the duct system

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Enhancing factors

Hindering

factors

Emptying of breast

Good attachment & effective suckling

Early initiation of breastfeeds

Frequent feeds including night feeds

Sensory impulse from nipple

Prolactin

in blood

Prolactin

“milk secretion” reflex

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Delay in initiation of breastfeeds,

Pre-lacteal feeds,

Bottle feeding,

Incorrect positioning,

Painful breast

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Lactation

Lactogenesis I : production start Initiation of milk production which occurs in second trimester of pregnancy Lactogenesis II : full productionPostpartum initiation of high volume milk production which occurs as transition from low volume colostrum

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Lactogenesis II initiated by falling progesterone levels in the presence of high prolactin levels. Progesterone levels fall 10 fold in first 4 days postpartum.Breast milk changes in constituents with decreased concentration of secretory IgA and lactoferrin.

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Alveoli secrete milk and contract when stimulated Oxytocin stimulates milk secretion and is released during the ‘let down’ or milk ejection reflex After let down, milk travels into the ductules, then to the larger – lactiferous or mammary ducts

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Baby sucking

Sensory impulse from nipple to brain

Oxytocin

contracts

myoepithelial

cells

Oxytocin

“milk ejection” reflex

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Thinks lovingly of baby

Sound of the babySight of the babyConfidence

WorryStressPainDoubt

Stimulated by

Inhibited by

Oxytocin reflex

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Lactation

Latch On and suckingOxytocin ReleaseReleases MilkInfant Empties BreastProduction IncreasesMilk Production OccursInterference with this cycle decreases the milk supply.

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Evidence-based early care

Latch

Moving

Milk

Let

Down

Breastfeeding Success

Start out right: establish

normal physiology

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Breast milk composition difference( dynamics):Gestational age at birth ( preterm and full term)Stage of lactation ( colostrum and mature milk)During a feed ( foremilk and hind milk)

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Colostrum : Is the breast milk that women produce in the first few days after delivery. It is thick and yellowish or clear in colour. It contains more protein than mature milk. Small amounts but close to stomach capacity

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Colostrum

Property Antibody-richMany white cellsPurgativeGrowth factorsVitamin-A rich

Importanceprotects against infection and allergyprotects against infectionclears meconium; helps prevent jaundicehelps intestine mature; prevents allergy, intolerancereduces severity of some infection (such as measles and diarrhoea); prevents vitamin A-related eye diseases

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Mature milk Is the breast milk that is produced after a few days. The quantity becomes larger, and the breasts feel full, hard and heavy. Some people call this the breast milk ‘coming in’. Foremilk is the milk that is produced early in a feed. Hindmilk is the milk that is produced later in a feed.Volume produced: 1st 24 hrs: 7 ml / feed2nd 24 hrs: 14 ml / feedAt six month: 800 ml / day

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Foremilk looks thinner than hind milk. It is produced in larger amounts, and it provides plenty of protein, lactose, and other nutrients. Because a baby gets large amounts of foremilk, he gets all the water that he needs from it. Babies do not need other drinks of water before they are six months old, even in a hot climate. If they satisfy their thirst on water, they may take less breast milk.

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Hind milk Is the milk that is produced later in a feed. Hind milk looks whiter than foremilk, because it contains more fat. This fat provides much of the energy of a breastfeed. This is an important reason not to take a baby off a breast too quickly. The baby should be allowed to continue until he has had all that he wants.

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Breast milk composition

Mature milk in 10 daysAll necessary nutrient and fluid in 6 month88% water4.5% fatMakes up 1/2 of calories in breast milkSupplied the energy or rapid growth, more produced at nightCholesterol is optimal for brain development

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Breast milk composition cont..

Secretory IGA => Most important immunoglobulin, breast milk is only source for first 6 weeks100 amino acid , mineral and vitaminsIron supplement at 4 – 6 monthsConsider vitamin D

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Properties of breast milk

Biologic specificity => Long-chain omega-3 Fatty Acids Important for brain and retinal development Higher IQs

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Immunologic specificity

Protection against pathogens & allergensKills pathogenic organisms or modifies their growth.Stimulates epithelial maturation for future defence.First immunizationProtection against common respiratory and intestinal diseases.

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Immunologic specificity cont..

Colostrum = Baby’s first vaccinationLess risk of illness such as: Ear infections, pneumonia, crohn’s disease and other bowel illnesses, stomach flu and other intestinal illnesses, ear infections, childhood cancers, diabetes, arthritis, allergies, asthma and eczema .

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Breastfeeding

Best for baby Reduces incidence of allergies Economical - no waste. Antibodies - greater immunity to infections Stool inoffensive - never constipated. Temperature always correct and constant.

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Breastfeeding

Fresh milk - never goes sour in the breast Emotionally bonding Easy once established Digested easily within two to three hours Immediately available Nutritionally balanced Gastroenteritis greatly reduced

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Exclusive breastfeeding:The feeding of an infant or young child with breast milk directly from female human breasts rather than from a baby bottle or other container"an infant's consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk, and no foods) except for vitamins, minerals, and medications."

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Predominant breastfeedingMeans breastfeeding the baby but also giving the baby small amount of water or water based drink such as teaFull breastfeedingMeans breast feeding either exclusively or predominantly

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Bottle feeding

Means feeding the baby from the bottle, whatever in the bottle including expressed milk Artificial feedingMeans feeding a baby on artificial feed, not breastfeeding at all.

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Human milk varies in its composition:

with the time of day (e.g. fat content is lowest in the morning and highest in the afternoon)

with the stage of lactation (e.g. the fat and protein content of colostrum is higher than in mature milk)

in response to maternal nutrition (e.g. although the

total amount

of fat is not influenced by diet, the

type

of fat that appears in the milk will be influenced by what the mother eats)

because of individual variations.

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Antenatal preparation

 

Breasts and nipples are altered by pregnancy

Increased sebum secretion obviates the need for cream to lubricate the nipple.

Women who have inverted and non- protractile (

flat

) nipples often

find

that they improve spontaneously during pregnancy

Neither the wearing of Woolwich shells nor

Hoffmann's

exercises are of any value and should not be recommended

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Effective positioning for the mother

A comfortable position is a prerequisite of comfortable breastfeeding. A woman who has recently given birth, especially one new to breastfeeding, may need some help with this.

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lying on her side

After a caesarean section, or where the perineum is very painful,

lying on her side

may be the only position a woman can tolerate in the first few days

aftr

birth,

It is likely that she will need assistance in placing the baby at the breast in this position, because she has only one free hand.

When feeding from the lower breast it may be helpful to raise her body slightly by tucking the end of a pillow under her ribs.

Once the woman can do this unaided, she may

find

this a comfortable and convenient position for night feeds, enabling her to get more sleep

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Mother lying on her side

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Sitting position

mother may prefer to

sit up

to feed her baby,

In the early days following the birth, it is particularly important that the mother's back is upright at a right-angle to her lap.

This is not possible if she is sitting in bed with her legs stretched out in front of her, or sitting in a chair with a deep backward-sloping seat and a sloping back.

Both lying on her side and sitting correctly in a chair with her back and feet supported enhance the shape of the breast and allow ample room in which to

manoeuvre

the baby.

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Mother feeding sitting up

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Effective positioning for the baby

The baby's body should be turned towards the mother's body so that the baby is coming up to her breast at the same angle as her breast is coming down to the baby.

The more the mother's breast points down, the more the baby needs to be on his back.

The advice to have the baby

tummy to tummy

may be mistakenly taken to imply that the baby should always be lying on his side.

However, taking account of the

angle of the dangle

might be more useful.

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Baby's body in relation to the mother's body, depending on the angle of the breast

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Attaching the baby to the breast

The baby should be supported across the shoulders, so that slight extension of the neck can be maintained.

The baby's head may be supported by the extended

fingers

of the mother's supporting hand or on the mother's forearm

It may be helpful to wrap the baby in a small sheet (Vancouver wrap), so that his hands are by his side.

 

 

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Baby’s mouth is wide openBaby’s chin touches the breastBaby’s lower lip is curled outwardUsually the lower portion of the areola is not visible

Key points of good attachment

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Healthy term babies are equipped with a number of primitive

reflexes

that enable them to obtain the nourishment they require.

At birth, all

reflexes

are of brainstem origin, with minimal cortical control.

As the baby matures, higher, cortical pathways develop and the

reflexes

disappear sequentially: rooting at about 4 months of age and tongue protrusion by about 6 months of age

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If the newborn baby's mouth is moved gently against the mother's nipple, the baby will open his mouth wide

As the baby drops his lower jaw and darts his tongue down and forward, he should be moved quickly to the breast.

the mother should be to aim the baby's bottom lip as far away from the base of the nipple as is possible. This allows the baby to draw breast tissue as well as the nipple into his mouth with his tongue.

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A wide gape.

The baby has formed a ‘teat’ from the breast and the nipple, which causes the nipple to extend back as far as the junction of the hard and soft palates

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The role of the midwife

The midwife's role during the

first

few feeds is twofold. First, she must ensure that the baby is adequately fed at the breast.

Secondly her role is to support the mother in developing the necessary practical positioning and

afachment

skills so that she is able to feed her baby independently. Whilst the baby is

reflexly

equipped for breastfeeding, mothers are not.

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Some mothers will need more help and support than others. Reasons for this include:

Previous unsuccessful breastfeeding.

Breastfeeding may have gone well last time by chance rather than knowledge.

The new baby may behave very differently, or have different needs, from the mother's previous baby/babies.

The mother may have recently fed (or still be feeding) a toddler and has forgotten quite how much help a new baby requires to breastfeed.

Their previous baby may have been born at a time when underpinning information now known to be outdated was thought to be correct.

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reasons for babies withdrawing from the breast are:

incorrect attachment

the milk flow is very fast and the baby needs to let go and pause

the baby has swallowed air with the generous flow of milk that occurs at the beginning of a feed and requires an opportunity to expel wind.

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Causes of colic in breast feeding :

Baby poorly attach

Reduce fat intake

Baby soon hungry again ,gastric empty time more rapid(low fat feed)

More

freguent

feed, more lactose

More undigested lactose creates an osmotic

gradiant

Bacteriain

the baby gut are provided with more substrate than

usuall

Dissention of the gut by both fluid and gas producing pain

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Expression

is appropriate in the following situations, if:there is concern about the interval between feeds in the early perinatal period (expressed colostrum should always be given in preference to formula milk to healthy term babies)there are difficulties in attaching the baby to the breastthe baby is separated from the mother, due to prematurity or illnessthere is concern about the baby's rate of growth, or the mother's milk supply (expressing to top up with the mother's own milk may be necessary in the short term while the cause of the problem is resolved)the mother needs to be separated from her baby for periods (occasionally or regularly), as the baby gets older. 

Expressing

breastmilk

 

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Manual expression of milk

Manual expression has several advantages over mechanical pumping and should be taught to all mothers. It is usually the most

efficient

method of obtaining

colostrum

. Some mothers will find hand expressing superior to any breast pump.

Expressing with a breast pump

If it is possible and practical, the mother should be able to experiment with a variety of breast pumps to discover what will suit her best as not all pumps work well for every woman

.

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Manually operated pumps

Most manually operated pumps are not

efficient

enough to allow initiation of full lactation but they can be useful when expressing is required once lactation is established. It is helpful for midwives to explain to mothers that these pumps function most efficiently if the vacuum phase is considerably longer than the release phase. 

Electrically controlled pumps

Some electrically controlled pumps provide a regular vacuum and release cycle, with variability in the strength of the suction and others also vary the frequency of the cycle.

Double pumping

is possible with most models, and this has repeatedly been shown to be

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Storage of

breastmilk

advises that expressed milk can be stored for up to:

5 days in the main part of a fridge, at 4 °C or lower

2 weeks in the freezer compartment of a refrigerator

6 months in a domestic freezer, at −18 °C or lower.

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Care of the breasts

 

Daily washing is all that is necessary for breast hygiene.

Brassieres may be worn in order to provide comfortable support

are useful if the breasts leak and breast pads (or breast shells) are used.

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  Breast problems

Sore and damaged nipples

The cause is almost always trauma from the baby's mouth and tongue, which results from incorrect attachment of the baby to the breast.

Correcting this will provide immediate relief from pain and allow rapid healing to take place.

Epithelial growth factor, contained in fresh human milk and saliva, may aid this process.

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Resting

the nipple enables healing to take place but makes the continuation of lactation much more complicated because it is necessary to express the milk and to use some other means of feeding it to the baby.

Nipple shields should be used with caution, and never before the mother has begun to lactate

They may make feeding less painful, but often they do not. Their use does not enable the mother to learn how to feed her baby correctly, and their longer-term use may result in reduced milk transfer from mother to baby.

This in turn may result in mastitis in the mother (reduced milk removal), slow weight gain or prolonged feeds in the baby (reduced milk transfer), or both.

If mothers choose to use them, they should be advised to seek help with learning to attach the baby comfortably without a nipple shield as soon as practicable

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Other causes of soreness

Infection with

Candida

albicans

(thrush) can occur, although it is not common during the

first

week after birth.

Sudden development of pain after a period of trouble-free feeding is suggestive of thrush.

The nipple and areola are

inflamed

and shiny, and pain typically persists throughout the feed.

The baby may show signs of oral or anal thrush.

Both mother and baby should receive concurrent fungicidal treatment, such as

miconazole

, and it may take several days for the pain in the nipple to disappear

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Dermatitis

Sensitivity may develop to topical applications such as creams, ointments or sprays, including those used to treat thrush.

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\ Anatomical variations

Short nipples

Short nipples should not cause problems as the baby is able to form a teat from both the breast and nipple. 

Long nipples

Long nipples can lead to poor feeding because although the baby is able to latch on to the nipple, he is unable to draw any breast tissue into his mouth, due to the length of the nipple.

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Abnormally large nipples

If the baby is small, his mouth may not be able to get beyond the nipple and onto the breast. Lactation can be initiated by expressing, by hand or by pump, provided the nipple

fits

into the breast shield.

As the baby grows and the breast and nipple become more protractile, breastfeeding may become possible. 

Inverted and flat nipples

If the nipple is deeply inverted it may be necessary to initiate lactation by expressing and delay attempting to attach the baby to the breast until lactation is established and the breasts have become soft and the breast tissue more elastic.

 

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diffculties with breastfeeding

Engorgement

This condition occurs around the 3rd or 4th day following the baby's birth.

The breasts become hard, often

oedematous

, painful and sometimes appear

flushed

.

The mother may be

pyrexial

.

Engorgement is usually an indication that the baby is not keeping pace with the stage of lactation.

Engorgement may occur if feeds are delayed or restricted or if the baby is unable to feed efficiently because he is not correctly attached to the breast

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Deep breast pain

deep breast pain responds to improvement in breastfeeding technique and is likely to be due to raised

intraductal

pressure caused by

inefficient

milk removal.

Although it may occur during the feed, it typically occurs afterwards.

This distinguishes it from the sensation of the

let-down

reflex

, which some mothers experience as a fleeting pain.

Very rarely, deep breast pain may be the result of

ductal

thrush infection

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Mastitis

an

inflammation

of the breast, is the result of milk stasis, not infection, although infection may supervene

one or more adjacent segments of breast tissue are

inflamed

through milk being forced into the connective tissue of the breast, and appear as wedge-shaped areas of redness and swelling.

If milk is forced back into the bloodstream, the woman's pulse and temperature may rise and in some cases

flu

-like symptoms, including shivering attacks or rigors, may occur.

The presence or absence of systemic symptoms does not help to distinguish infectious from non-infectious mastitis

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Infective mastitis

The main cause of

superficial

breast infection is damage to the epithelium, allowing bacteria to enter the underlying tissues.

The damage usually results from incorrect attachment of the baby to the breast, which has caused trauma to the nipple.

The mother therefore requires urgent assistance to improve her feeding technique, as well as appropriate antibiotics.

Multiplication of bacteria may be enhanced by the use of breast pads or shells.

In spite of antibiotic therapy, abscess formation may occur. Infection may also enter the breast via the milk ducts if milk stasis remains unresolved

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Breast abscess

A

fluctuant

swelling develops in a previously

inflamed

area: namely a

breast abscess

. Pus may be discharged from the nipple.

Simple needle aspiration may be

effective

, or incision and drainage may be necessary

It may not be possible for the baby to feed from the

affected

breast for a few days,

milk removal should continue by expression would reduce the chances of further abscess formation

A sinus that drains milk may form, but it is likely to heal in time.

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Blocked ducts

Lumpy areas in the breast are not uncommon, due to distended glandular tissue. If such lumps become very

firm

and tender and sometimes

flushed

, they are often described as

blocked ducts

.

a physical obstruction within the lumen of the duct.

this is very rarely the cause of the symptoms. It is much more likely that milk drainage has been somewhat uneven due to less than optimal attachment and that secreted milk is trying to occupy more space than is actually available, causing the alveoli to distend.

Milk may subsequently be forced out into the connective tissue of the breast where it causes

inflammation

.

The

inflammatory

process narrows the lumen of the duct by exerting pressure on it from the outside as the tissue swells, resulting in

mastitis

or

incipient mastitis

.

the solution is to improve milk drainage by improved

afachment

, with possibly milk expression, and to treat the accompanying pain and

inflammation

.

Slide78

White spots/epithelial overgrowth

Very occasionally, a

ductal

opening in the tip of the nipple may become obstructed by epithelial overgrowth.

A white blister is evident on the surface of the nipple,

effectively

causing a physical obstruction closing

off

the exit points from one or more milk- producing sections of the breast.

This may sometimes be resolved by the baby feeding. Alternatively, after the baby has fed and the skin is softened, the blister may be removed with a clean

fingernail

, a rough

flannel

, or a sterile needle.

True blockages of this sort tend to recur, but once the woman understands how to deal with them, the progression to mastitis can be avoided.

Slide79

Feeding difficulties due to the baby

Colic in the breastfed baby

Cleft lip

Cleft palate

Tongue tie (

Ankyloglossia

)

Blocked nose

Down syndrome

Prematurity

Illness or surgery

Slide80

Contraindication to breastfeeding

Breastfeeding may have to be suspended temporarily following the administration of certain drug ,

eg,chloramphenicol

.

Most region have drug

centres

pharmacy information services where advice may be sought about the

saftey

of drug for lactating women

carcinoma

Breast

suergery

Breast injury

One breast only

Human immunodeficiency virus infection

Slide81

Weaning from the breast

When the mother or the baby decides to stop breastfeeding,

feeds should be tailed

off

gradually.

Breastfeeds may be omitted, one at a time, and spaced further apart.

Adding supplementary foods should not begin until about 6 months of age.

If the mother uses solid food to give the baby

tasters

and the experience of

different

textures before weaning, these should be given

after

the breastfeed.

Solid foods given to the baby before the breastfeed (weaning) will result in them taking less milk from the breast and less milk being produced.

Allowing the baby to lead the process of weaning may make the transition much easier.

Slide82

The baby friendly hospital initiative

The Baby Friendly Hospital Initiative (BFI) was an initiative launched worldwide in 1991 (and in the UK in 1994) by WHO and UNICEF to encourage hospitals to promote practices supportive of breastfeeding.

It was focused around the 10 steps to successful breastfeeding with which all hospitals who wish to achieve

Baby Friendly

status must comply

Evidence for the 10 steps is contained in the WHO/UNICEF document of the same name

This has subsequently been extended to community-based facilities, neonatal units and university training

programmes

for midwifery and health visiting, all of which can be BFI- accredited in their own right.

In addition, all accredited Baby Friendly facilities must fully implement the International Code on the Marketing of

Breastmilk

Substitutes

Slide83

The 1 0 steps t o successful breast feeding

 

Have a written breastfeeding policy that is routinely communicated to all healthcare staff.

Train all healthcare staff in skills necessary to implement this policy.

Inform all pregnant women about the benefits and management of breastfeeding.

Help mothers initiate breastfeeding soon after birth.

Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.

Slide84

6)

Give newborn infants no food or drink other than

breastmilk

, unless medically indicated.

7)

Practice rooming-in: allow mothers and infants to remain together 24 hours a day.

8)

Encourage breastfeeding on demand.

Give no artificial teats or dummies to breastfeeding infants.

Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital or clinic.

Slide85

Thanks