FSHN 3620 • Exam 2 SG: Ch. 6/7

Lactation Nutrition

Benefits of breastfeeding for baby

• lower risk of:

  • Diarrhea

  • Vomiting

  • Preterm necrotizing enterocolitis

  • Pneumonia, RSV, whooping cough

  • Ear infections

  • Bacterial meningitis 

  • Type 2 diabetes & obesity

  • Teeth problems

  • Autoimmune diseases

  • Dermatitis & wheezing

  • Food allergies

  • Mortality

• Childhood weight → leaner at 1 yr

• Cognitive → increased cognitive ability & higher IQ

• Analgesic effects: reduced pain, calmness

• Has right amt of macros, micros, & waters

  • changes composition over time

• Sleeping & soothing

Benefits of breastfeeding for mother

• lower risk of:

  • Breast cancer

  • Ovarian cancer

  • Endometrial cancer

• Quick recovery from childbirth → oxytocin

• Increases physical & emotional bonding - strong attachment

• Self confidence

• Convenient

• Helps lose weight

• Delays ovulation

Immune system benefits of breastfeeding

• Only in breastmilk, not formula

• Lactic acid bacteria/bifidobacterium

• Mother’s antibodies passed over

• decreased risk of:

  • Respiratory & ear infections

  • Allergies

  • ADD

  • Autism 

  • Asthma

  • Type 1 diabetes

• Increased T-cells

• Macrophages, neutrophils, epithelial cells

• Immunoglobin A

• Better mucosal lining (buterate)

• Diverse microbiome

• ++ Interferon: interferes with viral reproduction.

• Lysosome protections against gram-positive bacteria

Lactation physiology – how is milk produced?

Prolactin: hormone that stimulates milk production.

• Stimulated by suckling

Oxytocin: hormone responsible for ejection of milk from milk gland.

• Stimulated by suckling or nipple stimulation

• Acts on uterus during & after delivery

Hormones involved in lactation – how are they stimulated and what do they do?

SoL = Stage of Lactation

Estrogen

• Role: ductal growth

• SoL: mammary gland differentiation with menstruation

Progesterone

• Role: alveolar development

• SoL: after onset of menses & during pregnancy

Human growth hormone

• Role: development of terminal end buds

• SoL: mammary gland development

Human placental lactogen

• Role: alveolar development

• SoL: Pregnancy

Prolactin

• Role: alveolar development & milk secretion

• SoL: pregnancy & breastfeeding (from 3rd trimester → weaning)

Oxytocin

• Role: Letdown: ejection of milk from myoepithelial cells

• SoL: from onset of milk secretion → weaning

Nutritional composition of breastmilk

• Lipids (3-5% mature milk)

  • Lowest in foremilk, doubled in hindmilk

  • 20.9–26.2 kcal/oz or 65–75 kcal/dL

  • DHA: retinal development, high IQ scores

    • Essential for retinal development

    • Higher concentration in preterm milk

    • Levels influenced by maternal diet

• Protein

  • Antiviral & antimicrobial effects

  • Lower content

  • Classes

    • Casein

    • Whey

    • Mucins 

• CHOs

  • Monosaccharides (glucose)

  • Polysaccharides

  • Oligosaccharides

    • 200+ 

    • Promote growth of beneficial bacteria

    • Innate immune protection

• Lactose: enhances calcium absorption

  • Dominant CHO 

  • Enhances calcium absorption

• Protein-bound CHOs

• Cholesterol

  • Growth & replication of cells 

  • Not impacted by maternal diet

• Vit A → growth & development through 6 mo. 

  • Colostrum has x2 conc. as mature milk

  • Deficient infants → increased risk of eye problems, infection, iron deficiency anemia, & growth failure

• Vit D → calcium absorption & bone metabolism

  • Deficiency occurs when mother is deficient – predisposed to neonatal hypocalcemia & rickets

• Vit E → antioxidant, maintains neurological structure & function

  • Muscle & RBC integrity

• Vit K → development of clotting factors & prevents bleeding in newborns

  • Vit K shot at birth prevents deficiency bleeding 

• Water-soluble vitamins are responsive to content of maternal diet or vitamin status

  • Milk provides adequate W-S vitamins

  • Rare vit B₁₂ status 

• Minerals

  • Growth

  • Contribute to osmolality of milk

  • Highly available → magnesium, calcium, iron, & zinc

• Iron

  • Vit C & lactose promote iron absorption

  • Maintained up to 9 mo.

  • Exclusively breastfed infants are less likely to be anemic

• Zinc

  • Bound to protein & highly available

  • Rare deficiency – appears as dermatitis or intractable diaper rash

  • Defect in mammary gland uptake of zinc causes low milk conc.

• Trace minerals – copper, selenium, chromium, manganese, molybdenum, nickel, & fluorine are present in small conc.

  • Essential for growth & development

  • Not influenced by mother’s diet

Stages of lactogenesis & how they are different from each other

Lactogenesis I: milk begins to form, lactose & protein content of milk increase. 

• Large gaps between alveolar cells

• Begins at 16 wks gestation → few days PP

• Colostrum: higher in immunological factors, growth factors, vitamin A, protein, & CHO

Lactogenesis II: increased blood flow to mammary gland & decrease in maternal progesterone levels. Significant changes to milk composition & quality.

• 2–8 days PP

• Tight junctions between alveolar cells close

• Clinically – onset of copious milk secretion

• Transitional Milk: higher in lactose & lower in sodium.

Lactogenesis III (galactopoiesis): milk production begins, is maintained, and milk composition becomes stable.

• 9 days PP

• Mature milk: higher in cal & fat.

Letdown reflex: an infant suckling at the breast stimulates the pituitary to release the hormones prolactin & oxytocin.

Maternal diet while breastfeeding – what is important? How many extra calories are needed? What nutrients should be a focus?

• + 500 kcal, minimum 1800 kcal/day

• Organic, non-GMO, less processed food

• Lean proteins → lentils, beans, lean meats

• Healthy fats → salmon, chia seeds

• Whole grains → oatmeal or quinoa

• Fruits & vegetable → colorful

• Low-fat milk products → yogurt, cheese

• Water → drink to thirst

  • RDA: 3.8 L

• Well-nourished breastfeeding women do not need routine vitamin or mineral supp.

  • Should target specific needs

Importance of breastfeeding promotion & support

• Key teaching points prior to birth

  • Request early first feeding & skin-to-skin contact

  • Practice frequent, exclusive breastfeeding

  • Ask to be taught swallowing indicators 

  • Learn indicators of sufficient intake

  • Ask for help if it hurts

  • Know sources for help

  • Understand PP rest & recovery needs

  • Avoid supp. unless medically indicated

• Peer counselors & peer group discussions

• Programs supporting breastfeeding

  • Farmers Market Nutrition Program

  • WIC

  • USDA

  • Baby Friendly Hospital Initiative

  • WHO’s International/UNICEF Code on Marketing of Breast Milk Substitute

Maternal exposures effects on breastmilk — DRUGS

• Cytotoxic drugs that may interfere with the cellular metabolism of the nursing infant

• Drugs of abuse for which adverse effects on the infant during breastfeeding have been reported

• Radioactive compounds that require temporary cessation of breastfeeding

• Drugs for which the effect on nursing infants is unknown, but may be of concern

• Drugs that have been associated with significant effect on some nursing infants and should be given to nursing mothers with caution

• Maternal medications usually compatible with breastfeeding

• Food and environmental agents having no effect on breastfeeding

• Recommendations 

  • Specific knowledge about a medication’s safety

  • Closely monitor milk production (some meds suppress)

  • Progestin-only oral contraceptive & implants 

  • Steroid implants & Depo-Provera shot 6 wks PP

  • Avoid long-acting forms

  • Schedule doses carefully

  • Evaluate the infant

  • Choose drug that produces least amt in milk

Maternal exposures effects on breastmilk — ALCOHOL

• Quickly passes into breastmilk

• Oxytocin release is blocked, prolactin increased

• Gives infant sleeping problems

• Infant won’t consume as much milk

  • Change in odor & flavor of milk

Maternal exposures effects on breastmilk — NICOTINE (SMOKING)

• Health risks for infants

  • Otitis media

  • Exacerbations of asthma

  • Respiratory infection

  • GI dysregulation (colic, & acid reflux)

  • SIDS

• Lower milk output

• Lower fat concentrations 

• Change in odor & flavor of milk

• Within gradual intake in days time → infant can metabolize nicotine in liver & excrete chemical in kidney

• Exposure to organochloride pesticides, PCBs & hexachlorobenzene through breast milk & second-hand smoke

• Safety of nicotine gum in lactation has not been determined

• Stop smoking or avoid smoking before feeding & around infant

Maternal exposures effects on breastmilk — E-CIGARETTES & VAPING

• Little research about effects

• Stop smoking or avoid smoking at least 30 min before breastfeeding & breastfeed right before smoking

Maternal exposures effects on breastmilk - MARIJUANA

• Delta-9-tetrahydrocannabinol (THC), an active ingredient in marijuana, transfers and concentrates in breast milk and is absorbed and metabolized by the nursing infant

• decrease in infant motor development at 1 year of age

• impairment of DNA & RNA formation & neurotransmitter systems essential for proper growth & development has been described

• increased risks in behavior & neurodevelopmental problems

Maternal exposure effects on breastmilk — CAFFEINE

• Moderate intake causes no problems for most breastfeeding mothers & babies

• A dose of caffeine equivalent to a cup of coffee results in breast milk levels of 1% of the level in maternal plasma &, consequently, low levels in the infant

• Accumulates in the infant

• symptoms – infants being wakeful, hyperactive, & fussy

• Some infants are sensitive to caffeine intake, monitor it

Recommendations for limiting exposures to breastmilk

• Avoid smoking & drinking

• Be aware in purchasing homes built before 1978 (lead paint)

• Eat variety of foods low in animal fats

• Increase consumption of grains, fruits, & veggies 

• Eat organic if possible

• Avoid fish high in mercury (swordfish, shark, tuna, king mackerel, tilefish, & locally caught fish from areas with fish advisories)

• Limit exposure to chemicals 

• Tap water through home filter 

• Remove plastic cover of dry-cleaned clothing, air out garments

• Avoid occupational exposure to chemical contaminants

• Alert other family members to be sensitive to contaminant residue they may bring into the home

Neonatal jaundice

yellow discoloration of the skin caused by too much bilirubin in the blood (hyperbilirubinemia)

• Common & benign, goes away on its own/minimal intervention

• Serum bilirubin levels: 5–7 mg/dL (85–199 mol/L)

• Risk factors (maternal)

  • Diabetes

  • Rh sensitization

  • Previous child with phototherapy

  • Race: East Asian or Mediterranean

• Risk factors (infant)

  • Premature or late-term

  • High total serum bilirubin levels at discharge

  • Poor breastfeeding in exclusive breastfed infant 

  • Blood group incompatibility e.g. ABO

  • Hemolytic disease e.g. Glu-6-P dehydrogenase deficiency (G6PD)

Kernicterus

The chronic and permanent clinical sequelae that are the end result of very high untreated bilirubin levels. Excessive bilirubin in the system is deposited in the brain, causing toxicity to the basal ganglia and various brainstem nuclei.

• AKA bilirubin encephalopathy

• Mortality 50%

• Survivors burdened with — cerebral palsy, hearing loss, paralysis of upward gaze, intellectual & other handicaps

• Increased bilirubin leads to seizures and brain damage

• Treatment & Prevention

• AAP guidelines for the management of hyperbilirubinemia in healthy term infants

• Guidelines for newborns in the nursery

  • All babies should be monitored over the first few weeks

• Continuation of breastfeeding

Breastfeeding preterm infants

• Nutritional benefits 

  • Ease of protein digestion

  • Fat absorption

  • Improved lactose digestion

• Healthy & Development Benefits

  • Better visual acuity

  • Greater motor & mental development (1.5 yrs)

  • Greater verbal intelligence (7-8 yrs)

  • Lower incidence of serious infectious disease 

    • Enterocolitis & sepsis

  • Nosocomial infection rates decreased

  • Antibodies in milk via entermammary system