Breast feeding and lactation management

1. Breast feeding and Lactation
management

2. “Breast fed infants, are Healthy Infants.”

3. Anatomy and Physiology of Lactation

4. • Modified sweat glands
• Contains adipose tissue
and fibrous connective
tissue.

5. • Each breast contains about 20
lobes, each lobes contains
several lobules which at the end
have alveolar in which milk is
produced.
• After production of milk in the
alveolus, the milk moves through
the ducts and are stored in the
lactiferous sinus.
• When the infant latches on the
breast, milk is expressed from the
sinuses.

6. • Hormonal positive feedback
mechanism.
Suckling Hormonal Reflex Arc

7. Suckling Hormonal Reflex Arc
Source: Lactation Education Program Nutrition Policy and Education
• The sucking stimulates the nipple; this
sends messages to the spinal cord and
subsequently to the brain.
• Prolactin is released from the anterior
pituitary for milk production and oxytocin
from the posterior pituitary for the milk
let down.
• Prolactin receptors are established
within the first eight days of delivery.
• Suckling at breast increases prolactin
levels, so at each feeding, levels rise,
hence more milk production.

8. Reflexes that help in breast feeding
• Rooting reflex
• Sucking reflex
• Swallowing reflex
• Sucking and swallowing is coordinated by
34 weeks of gestation
• Prolactin refelx: milk production
• Let down reflex( Oxytocin reflex)

9. Advantages of breast feed
1. Optimum fluidity and warmth
2. Economical
3. Convenient: no need to carry utensils
4. Physiological: sweetest milk with high
lactose and digestible protein, lipids rich
in EFA, long chain PUFA

10. 5. Biochemically: superior
• Protein is mostly whey (80%) rich in lactalbumin and
lactoferrin and the rest is casein(20%).
• Lactoferrin is bacteriosataic and ensures iron and
zinc absorption.
• Alpha casein and lactglobulin which are allergens are
absent in human milk.
• Rich in binding proteins of thyroxin, B12, vitamin D etc.
• Calcium to phosphorous ratio is more than 2 and
ensures calcium absorption.

11. 6. Microbiologically:
Sterile and less chance of contamination
Lactoferrin bacteriostatic and inhibits E coli; binds iron and
makes it unavailable to Ecoli
Peroxidases and lipases kill bacteria
Bile salt stimulated lipase (BSSL) kills amoeba and giardia
PABA is important in protection against malaria
Transfer maternal antibodies
Bifidus bacteria and acidic ph associated with human milk
lead to colonization by Lacto bacilli

12. 7. Immunological:
• Supplies passive immunity
• Macrophages, lysozymes and complement offer
immunity to baby
• Supplies acute phase reactants
• Contains immunoglobulin, secretory IgA(SIgA)
• SIgA are produced mamary gland by plasma cell that
originate from immunocompetent lymphoid tissue ( gut
associated lymphoid tissue, bronchus associated
lymphoid tissue by virtue of enteromamary and
bronchomamary axes)
• Bioactive factors: milk are proteins like lactoferrin,
enzymes, hormones, growth factors, mucins, probiotic
substances and polyamines

13. 8. Psychologically: Emotional stabilty, mother infant
feeding
9. Mental growth: Breast fed have higher IQ than those
with other milks
10. Maternal benefits:
• decreases post partum bleed,
• involution of uterus,
• burn off extra fat that has accumulated during pregnancy
decreases breast and ovarian carcinoma
• Natural birth spacing
11. Epidemiologically: breast feed baby is 14 times less
likely to die from diarrhea, 4 times less likely to die from
respiratory disease, 2.5 times less likely from other
infections.

14. Preparing mother for breast feed
• Antenatal:
• Motivation and care
• Last trimester: examine breast and nipples for
retracted and cracked nipples-oiling, massaging and
suction: “inverted syringe technique
• Nutrition to pregnant: 300kcal and 15 gm protein extra
• Nutrition to lactating mother: 400-500kcal/ 25gm protein

15. Identify high risk mother
1. Primipara mother
2. Breast feeding problem in previous pregnancy
3. Breast problems: retracted nipple
4. Mother who has not been motivated

16. Initiation of breast feed
• Put to breast within half an hour after normal delivery
• Prelacteal feeds( eg water honey etc) should not be
given
• Soon after birth, baby is awake, alert and biologically
ready to breast feed -initiation of breast feed is very
easy. Later on baby goes to sleep
• Breast feed can be initiated when mother is sedated or
on IV fluids
• In 2-4 days small quantity of colostrum(10-40ml) is
secreted that is what baby needs

17. Ensure mother infant bonding
• Rooming in: keeping mother and baby in same room
• Bedding in: keeping mother and baby in same bed
• Mothering in: keeping baby on abdomen of the mother
• Skin to skin contact helps to maintain the body
temperatures, reduce risk of hypoglycemia, enhance
oxytocin release and beneficial nutrition with intake of
colostrum
• Skin to skin contact should occur for about 1-2 hours
after delivery.
• Procedures after delivery like weighing, administration
of vitamin K, eye prophylaxis and other procedures
should be delayed

18. Technique of Breast-Feeding:
1. Breast should be cleansed every day when the mother
takes a shower, otherwise breast is washed with plain
water and dries thoroughly.
2. Mother’s clothes should not be tight over the breast
and clean.
3. The mother should wash hand thoroughly before
nursing her infant.
4. The infant should be hungry, dry and warm.
5. The mother should be in comfortable position either in
sitting or lying position (support feet in sitting position).

19. 6. Positioning of infant:
• Baby’s head and body straight
• Baby’s body turned towards mother, nose opposite the
nipple
• Baby’s body touching mother’s abdomen
• Baby’s whole body well supported, not just neck or
shoulder’s

20. • The mother should support her breast; she can cup her
breast with her hand from underneath using four fingers
underneath and well behind the areola. Her thumb should
be resting on the top of her breast ”C-hold”.
correct breast support Incorrect breast support

21. 8. Rub the nipple or a finger gently against the infant’s cheek or
lips to stimulate “rooting reflex”.
• Touch the infant’s lip with the nipple to evoke oral searching
reflex where the infant opens his mouth widely and thrusts the
tongue forward and hold the nipple and apart of the areola
(depending on the size of the areola, if it is small it will
disappear, if it is large, a large part will be visible). This is what
is called “latch on”. Remember that the infant who should come
to the breast, not the breast to the infant.
Fig “Latch on”

22. 10. Proper attachment:
• Baby’s chin touching breast
• Mouth is wide open and tongue is under lactiferous
sinus and nipple against palate
• Lower lip turned outwards
• More areola is visible above baby’s mouth than below it
• No pain while breastfeeding
Effective suckling
• Cheeks are full, not hollow
• Regular slow, deeps suck

23. 11. No need to press the breast away from the infant’s
nostrils with finger. If the infant is well positioned and
well attached, he will be able to breathe through the
sides of the nostrils.
12. The common used “scissor” position (V-hold) of the
fingers may pull the breast out of his mouth. Mother
can cup her breast with her hand from underneath (C-
hold)
No position can be labeled “ideal”, the important thing is
that the mother is relaxed and can hold her infant close
to her breast comfortably for the time it takes.

24. 13. How often and for how long:
• Self-demand method is the key
• It also means letting the infant finish a feed and come
off the breast spontaneously.
• All newborn infants need some night feeds, the breast
feeding hormones help mothers go back to sleep
quickly after a feed, therefore, rooming in is very
important.
• Infants have different feeding patterns where:
A. Some infants feed fast, others slowly. Some
infants feed in spurt with rests in between, others
feed more steadily.
B. Some may need to feed as many as 10-15 times
or as few as 6-8 times within 24 hours.
C. Some infants feed on both breasts, others on
one breast only.

25. – Hold infant close to his mother’s body, tummy against
tummy and the infant facing the breast, so that he doesn’t
have to turn the head to feed.
– The infant’s nose should be level with nipple and he will tilt
his head back a little.
– In some positions, the infant’s bottom is supported with
mother’s hand (sitting, vertical and horizontal position). In
other position, she can support the head gently with her
hand.
– The classical feeding positions
1. Cradle position.
2. Cross cradle position.
3. Foot-ball hold.
4. Horizontal position.
5. Back wards position.
6. Position for two babies.

26. D- Horizontal position

27. 14. Burping after feed
• Babies tend to take a lot of air during feeding which may lead to
abdominal distention, colic, regurgitation.
• Baby is put on shoulder head supported & gently pat on back
• Eructate the infant 1-2 times during and once at the end of the
feed.
• Regurgitation of 5-15 cc of milk when eructated or after feeding
is normal.

28. 15. When nursing is completed, the infant should be placed
in a crib on his right side or in prone position to facilitate
emptying if the stomach.

29. How often to breast feed
• Exclusive demand feeding
• Practice frequent breast feed initially and allow self regulation
by baby
• Exclusive breast-feeding: It means that no food or drink other
than breast-feeding is offered to breast-feeding baby up to 6
months and he/she is fed on demand, day and night, with no
restriction on the length or frequency of breast feeding.
• There is no need to give water or fruit juice in between while
baby is on exclusive demand feed

30. How to know whether breast milk is
sufficient or not?
• Is the baby resting or sleeping for 1-2 hours after
feeding?
• Passing urine frequently?
• Stool 1-6 episode stool per day?
• Baby gaining weight?

31. Signs of Effective Breastfeeding
• Frequent feedings 8-12 times daily.
• Intermittent episodes of rhythmic sucking with audible
swallows should be heard while the infant is nursing.
• Infant should have about 6-8 wet diapers in a 24 hour period
once breast feeding is established.
• Infant should have minimum of 3-4 bowel movements every
24 hours.
• Stools should be about one tablespoon or larger and should
be soft and yellow after day 3.
• Average daily weight gain of 15 -30g.
• Infant has regained birth weight by day 10 of life.

32. How long to breast feed
Should be continued well into second year of life; the period
of maximum brain growth and myelination
After 4-6 months weaning food should be offered in
addition to breast feed

33. “nipple confusion”
• Feeding bottle causes

34. Contraindications to breast feed
• Rare
• Congenital lactose intolerance
• Galactosemia
• Drugs: antimalignant drugs, antithyroid,
antipsychotic (lithium)
• Temporary contraindication: secondary
lactose intolerance, breast milk jaundice

35. Composition of breast milk
• Varies at different stages after birth to suit
needs of the baby

36. Types and Composition of Human Breast
Milk
• Types of Breast Milk:
• Colostrum or Early Milk
• Transitional Milk
• Mature Milk

37. Colostrum
• Colostrum or Early Milk is produced in the late stage of
pregnancy till 4 days after delivery; and is rich in antibodies.
• Yellow and thick
• Contains more antibodies and high amount of vitamins( A D E
K)
• Volume: 10 to 40ml
The perfect match: quantity of colostrum per feed and the newborn
stomach capacity

38. • Transitional milk:
Produced from day 4 – 10 is lower in protein in comparison to
Colostrum.
Following two weeks of delivery
Immunoglobulin and protein content decreases
Fat and sugar content increases
• Mature milk:
Mature milk is produced from approximately ten days after
delivery up until the termination of the breastfeeding.
It is thinner watery
But contains all nutrient essential for optimal growth

39. • Preterm milk:
Contains more proteins, sodium, iron, immunoglobulin
More calories
• Fore milk:
Secreted at start of milk
Watery and rich in proteins, sugar, vitamins, mineral
Water satisfy thirst
• Hind milk:
Richer in fat content
Provides more energy and satisfies hunger

40. Protein composition of human colostrum
and mature breast milk (per litre)
Constituent Measure Colostrum
(1-5 days)
Mature Milk
(>30 days)
Total protein G 23 9-10.5
Casein mg 1400 1870
α-Lactalbumin mg 2180 1610
Lactoferrin mg 3300 1670
IgA mg 3640 1420
From: Worthington-Roberts B, Williams SR. Nutrition in Pregnancy and Lactation, 5th ed. St. Louis,
MO, Times Mirror/Mosby College Publishing, p. 350, 1993.

41. Decreased frequency or effectiveness of suckling
Decreased amount of milk removed from breasts
Delayed milk production or reduced milk supply
Some infants have difficulty attaching to breast if formula
given by bottle
Impact of routine formula supplementation
Slide 4.6.4

42. Reason for Supplementation
• Birth weight < 1500 g or GA < 32 weeks
• Severe hypoglycemia
• Acute water loss
• Hyperbilirubinemia related to poor intake
• Delayed bowel movement or dark stools at day 5
• Delayed milk production
• Weight loss >8% of birth weight.

43. Problems encountered in breast-
feeding:
1. Breast engorgement
2. Nipple trauma
3. Inverted nipple
4. soreness of the nipple
5. Mastitis
6. Breast abscess
7. Prematurity of infants.
8. Cleft lip & Cleft palate
9. Cardiac diseases.
10. Jaundice.

44. Slide 4g

45. Slide 4h

46. Slide 4i

47. Slide 4j