BREASTFEEDING Breast milk. is an ideal food for a normal neonate.

It _is the best gift that a mother can give tc) her baby. It contains all the nutrients for normal growth and developmerit of a baby from the time of birth to the first six months of he. Ensuring exclusive breast feeding for six months has a potential to reduce under-5 mortality rate by 13. by far the /not effective intervention that are known to reduce newborn and child deaths.. To accrue the maximum benefib, the breastfeeding must be exclusive (only breast milk nothing other than breast milk except vitamin drops, if indicated)-, initiated within half an hour of birth, and continued through first six months after birth. Recently National Family Health Survey-3 documented that only a quarter of infants who were ever breastfed started breastfeeding within half an hour of birth. 57% of mothers gave additional drinks other than breast milk in the three days after delivery which is an improper practice. Exclusive breastfeeding rate is only 28% at 4-5 months of age. Benoftts of Moog Milk Nutritional supertority: Breast milk contains all the nutrients a baby needs for normal growth and development, in an optimum proportion and in a form that is easily digested and absorbed Carbohydrafr , . kit toot is in a high concentration (6-7 gi 411) in breast gala( tose is necessary for formation of galactocerebrosides Lactose helps in absorption Of osis!UM and t 01am - es the growth of lactobacilli in the intestine, Figs 7.22A and B: Kangaroo mother care being provided in postnatal ward Proteins: The protein content of breast milk is low (0.9-1.1 g/dL) as the baby cannot effectively metabolize a high protein load. Most of the protein is lactalbumin and lactoglobulin (60%), which is easily digested. Human milk contains amino acids like taurine and cysteine which are necessary for neurotransmission and neuromodulation. These are lacking in cow's milk and formula, Fats: Breast milk is rich in polyunsaturated fatty acids, necessary for the myelination of the nervous system. It also contains omega 2 and omega 6 (very long chain fatty acids) which are important for the formation of prostaglandins and cholesterol, required as a base for steroid hormones. Vitamins and minerals. The quantity and bioavailability Of vitamins and minerals is sufficient for the needs of the baby in the first 6 months of lite. Vater and 4.16 whites: Breast iffilk has a water cow( nt of 88% henk:e a breastfed 11,01\ I( ( . s nid itquiro any additional `vater in the first low intmilr, hio evon in summer nwnths. 'The osmolality cif hre.1 , ,t raailk k low, presenting, a low solnic load to the ncon.a.)1 kidney. Immunolot o sverioi ity: Breast milk k_untain:-, a numI f or

of protective factors which include i mmunoglobulm, mainly secretary IgA, macrophages, lymphocytes, lactoterrin, lysozyme, bifidus factor, interferon and other protective substances. Eireastfed babies are less likely t() develop infection. A breast-fed baby is 14.2 times less I i keI v to die of diarrhea and 3.6 times less likely to die of respiratory infection. Other benefits: Breast milk contains a number of growth factor, enzymes, hormones, etc. The epidermal growth factor in breast milk enhances the maturation of the intestinal cells and thus reduces the risk of allergy in later life. Enzymes like lipases increase the digestion of fats in the milk. Protection against other illness: Breastfed babies have a lower risk of allergy, ear infections and orthodontic problems. They have a lower risk of diabetes, heart disease and lymphoma in later life. Mental growth: Babies who are breastfed are better bonded to their mothers. Studies have shown that babies who were breastfed had a higher IQ than those babies who were given other forms of milk. Benefits to mother: Breastfeeding soon after birth helps uterine involution, reducing chances of postpartum hemorrhage. It provides protection against pregnancy due to lactational amenorrhea. If the mother is exclusively breastfeeding her baby and not resumed menses then there is no need for any other contraception during initial 6 months after delivery. Breastfeeding is most convenient and time saving. it reduces the risk of cancer of breast and ovary. Breastfeeding is the most effective way of shedding extra weight that mother has put on during pregnancy. Breast MilkWhere and How It is Produced Anatomy The breast is made up of glandular tissue, supporting tissue and fat (Fig. 7.23). The glandular tissue consists of small clusters of sac-like spaces which produce milk.. Around each sac is a ba4et-like array of muscle cells known as mvoepithelial cells, Milk prckiuced in the alveoli is carried. along 20 small ttibe._., or ducts towards the nipple. Before reaching the nipple, the ducts widen to form 10-15 lactiferous sinuses which store milk, The lactiferous sinuses lie beneath the circle cat dark skin around the 'tipple called the areola. The areola and nipples are extremely sensitive as they artb supplied by a rich network of nerve endings.. On the Oxytocin makes Muscle cells them contract { Prolactin makes them secrete milk Milk secreting cells Lactiferous Milk collects sinuses here Nipple Areola Montgomery's glands 124 Supporting tissue Alveoli

and fat Fig. 7.23: Anatomy of breast areola are small swellings of glands which produce an oily fluid to keep the nipple skin soft. Since the lactiferous sinuses lie beneath the areola, a baby must suck at the nipple and areola (gum line of the baby should rest at the junction of areola and rest of breast tissue in order to exert pressure on lactiferous sinuses) to draw out the milk. The glandular tissue is responsible for production of milk. The fat and the supporting tissue are responsible for the size of the breast; hence a mother can produce enough milk despite small size of the breast. Physiology Milk is produced as a result of the interaction between hormones and reflexes. During pregnancy an.d. lactation the glandular tissue is stimulated to produce milk due to various hormonal influences. Two hormones come into play during lactation. Pro!actin reflex (milk secretion reflex): Prolactin produced by the anterior pituitary gland is responsible for milk secretion by the alveolar epithelial cells (Fig. 7.24A). When the baby sucks, the nerve ending in the nipple carry message to the anterior pituitary which in turn release prolactin and that acts on the alveolar glands in the breast to stimulate milk secretion. This cycle from stimulation to secretion is called the prolactin reflex or the milk secretion reflex. The more the baby sucks at the breast, the greater is the milk production. The earlier the baby is put to the breast, the sooner this reflex is initiated. The greater the demand, more is the milk produced. It is, therefore, important for mothers to feed early, frequently and completely empty the breasts at each feed and ensure that the baby is properly attached to the breast. Since prolactin is produced during night time, breastfeeding during night is very important for maintenance of this reflex. Even a single supplemental feeding would interfere with successful breast milk production. Oxytot in reflex (milk ejection reflex): Oxytocin is a hormone produced by the posterior pituitary. It is responsible for contraction of the milk from the glands into the lactiferous sinuses and the lactiferous ducts. This hormone is produced in response to stimulation to the nerve endings in the nipple by suckling as well as by the thought, sight, or sound of the baby (Figs 7.2413 and C). Since this reflex is affected by the mother's emotions, a relaxed, confident attitude helps the milk ejection reflex. On the other hand, tension and lack of confidence hinder the milk flow. This stresses the importance of a supportive health professional or a relative to reassure the mother and help her gain confidence so that she can successfully breastfeed her baby. Factors which Lessen Milk Production Dummies, pacifiers, bottles. Studies have revealed that even one or two supplemental feed would hinder successful breastfeeding. Giving things like sugar water, gripe water, honey, breast milk substitutes or formula, either as prelacteal (before establishment of breastfeeding) feeds or

supplemental (at any time later) feeds. Painful breast conditions like sore or cracked nipples and congested breast. Lack of night feeding, as it interferes with prolactin reflex Inadequate emptying of breast such as when sick or small baby is unable to suck on the mother's breast. and mother does not manually express breast milk. Reflexes in the Baby A baby is born with certain reflexes which help the baby to feed. These include rooting, sucking and swallowing reflexes. The rooting reflex: When the mother holds her baby and her breast touches the baby's upper lip, cheek or the side of the mouth, the baby opens her or his mouth and searches for the nipple with an open mouth. This is called rooting reflex. This reflex helps the baby to find the nipple and helps in proper attachment to the breastThe 514,41ins reflex, This reflex which is very strong immediately after birth helps the baby draw out milk from the mother's breast, The sucking action consists of: Drawing in the nipple and areola to form an elongated teat inside the mouth. Pressing the stretched nipple and areola with the law and tongue against the palate (which is sensitive for the suckling action). Drawing milk from the lactiferous sinuses b` k like* peristaltic movement of the tongue on the More prolactin secreted at night Suppresses ovulation Protoctin Secreted after feed to produce next feed fro(actin in blood Baby suckling A Sensory impulses from nipple Oxytocin Reflex Works before or during feed to make milk flow Oxytocin in blood Baby suckling Sensory impulses from nipple II Makes uterus contract B Helping and hindering the oxytocin reflex These HELP reflex Newborn Infant, 125 Oxytocin Reflex IP IP Thinks lovingly O C)

of baby Sound of baby k. Sight of baby CONFIDENCE Worry Stress Pain Doubt C Figs 7.24A and B: Prolactin and oxytocin reflex (C) Factors which help and birder oxytocin reflex These HINDER reflex underneath of the areola and the nipple and compressing them against the palate above. Ensuring a good attachment at breast is a skill which both the mother and the baby have to learn. To suckle effectively, the baby should be well attached (latched on) to the breast to be able to take both, the nipple and the areola, into the mouth for effective suckling. The method of suckling at the breast and bottle is entirely different. Suckling on a bottle already filled with milk requires less effort to draw out milk. Here the baby uses the tongue only to control the flow of milk into the mouth. A baby who has been fed with a bottle finds it difficult and confusing to suckle at the breast, aptly termed as 'nipple confusion'. The swallowing reflex: It may take one to three suckles to fill the baby's mouth with milk. When the mouth is filled with milk, the baby swallows the milk and then breathes. The suckle-swallow-breathe cycle lasts for about one second. Composition of Breast Milk The composition of breast milk varies at different stages after birth to suit the needs of the baby. Milk of a mother who has delivered a preterm baby is different from milk of a mother delivered a term baby. 1. Colostrum is the milk secreted during the initial 3-4 days after delivery. It is yellow and thick and contains more antibodies and cells and increased amounts of vitamins A, D, E and K. 2. Transitional milk is the milk secreted after 3-4 days and until two weeks. The immunoglobulin and protein content decreases while the fat and sugar content increases. 3. Mature milk follows transitional milk. It is thinner and watery but contains all the nutrients essential for optimal growth of the baby. 4. Preterm milk is the milk of a mother who delivers prematurely. It contains more proteins, sodium, iron, immunoglobulins and calories as they are needed by the preterm baby. 5. Fore-milk is the milk secreted at the start of a feed. It is watery and is rich in proteins, sugar, vitamins, minerals and water that satisfies the baby's thirst. 6. Hind-milk comes later towards the end of feed and is richer in fat content and provides more energy, and satisfies the baby's hunger. Thus, the composition of

milk also varies during the phase of feeding. For optimum growth, the baby needs both fore and hind milk. The baby should, therefore, he allowed to empty a breast completely before switching over to the other breast. Technique of Breastfeeding Most mothers can successfully breastfeed. Some mothers are at a higher risk for problems in breastfeeding. hese A C Figs 7.25A to C: Different postures of feeding 126 Essentiaf Pediatrics include primipara mothers, mothers who have had problems in breast-feeding in previous pregnancy, mothers with breast problems like retracted nipple and mothers who have not been motivated to breastfeed. These mothers require more support to have a successful breastfeeding. Positioning Position of the mother: The mother can take any position that is comfortable to her and her baby. She could sit or lie down. Her back should be well supported and she should not be leaning on her baby (Figs 7.25A to C). Position of baby: Make sure that baby is wrapped properly in a cloth. - Baby's whole body must be well supported not just neck or shoulders. Baby's head and body are in a line without any twist in the neck. Baby's body turned towards the mother with the baby's abdomen touching the mother's abdomen. - Baby's nose is at the level of the nipple. Attachment: After proper positioning, the baby's cheek is touched and that will make the baby open her mouth (rooting reflex). Allow the baby to have a wide open mouth and the baby should be quickly brought on to the breast ensuring that the nipple and most of the areola is within the baby's mouth (Fig. 7.26). It is important that baby is brought on the mother rather than mother leaning on to the baby. Signs of good attachment 1. The baby's mouth is wide open. 2. Most of the nipple and areola in the mouth, only upper areola visible, not the lower one. 3. The baby's chin touches the breast. 4. The baby's lower lip is everted. Effective suckling Baby suckles slowly and pauses in between to swallow. One may be able to see the movement of throat bones and muscles and hear the gulping sound indicating that baby is swallowing milk. Baby's cheeks are full and not hollow or retracting during sucking. Problems in Breastfeeding Inverted nipples: Flat or short nipples which protract well (become prominent or pull out easily) do not cause difficulty in breastfeeding. Inverted or retracted nipples sometimes make attachment to the breast difficult. These mothers need additional support to feed their babies. Treatment is started after birth of the baby. The nipple is manually stretched and rolled out several timer-, a day. A

pump or a plastic syringe is used to draw out the nipple and the baby is then put to the breast (Fig. 7.27). Fig. 7.26: Good attachment Fig. 7.27: Syringe treatment for inverted/flat nipple Sore nipple: A sore nipple is caused by incorrect attachment of the baby to the breast. A baby who sucks only on the nipple rather than areola does not get enough milk. Therefore he sucks vigorously often in frustration and inflicts injury on the nipple causing soreness. Frequent washing with soap and water, pulling the baby off the breast while he is still sucking may also result in sore nipple. Candida infection of the nipple is also a cause of a sore nipple after the first few weeks. Treatment consists of correct positioning and latching of the baby to the breast. A mother would be able to feed the baby despite sore nipple if the baby is attached properly. Hind milk should be applied to the nipple after a feed and the nipple should be aired and allowed to heal in between feeds. She should be advised not to wash nipple each time before/a.fter feeding. She can clean breast and nipple once daily at time of bathing. Breast engorgement: The milk production increases during the second and third day after delivery. If feeding is delayed or infrequent, or the baby is not well positioned at the breast, the milk accumulates in the alveoli. As milk production increases, the amount of milk in the breast exceeds the capacity of the alveoli to store it comfortably. Such a breast becomes swollen, hard, warm and painful and is termed as an 'engorged breast' iFig. Breast engorgement can be prevented by early and frequent feeds and correct attachment 01 the baby to tilt. breast. Treatment consists of local warm water packs, Mother gently pulls the piston Step one Step two 4- Insert piston /-- from cut end 4 Step three Newborn Infants 127 Fig. 7.28: Engorged breast. Note tense and shiny skin, nipple shows excoriation breast massage and analgesics to the mother to relieve the pain. Milk should be gently expressed to soften the breast and then the mother must be helped to correctly latch the baby to the breast. Breast abscess: If a congested, engorged breast, an infected cracked nipple, or a blocked duct and mastitis are not treated in the early stages, then an infected breast segment may form a breast abscess. The mother may also have high grade fever and a raised blood count. Mother must be treated with analgesics and antibiotics. The abscess must be incised and drained. Breastfeeding must be continued. Not enough milk: First make sure that the perception of "not enough milk" is correct. If baby is satisfied and sleeping for 2-3 hours after breastfeeding and passing urine at least 6-8 times in 24 hours and gaining weight, then the mother is producing enough milk.

There could be a number of reasons for insufficient milk such as incorrect method of breastfeeding, supplementary feeding, bottle feeding, no night breastfeeding, engorgement of breast, any illness, painful condition, stress or insufficient sleep in the mother. Try to identify the possible reason and take an appropriate action. Advise mother to take sufficient rest and drink more fluids. Feed the baby on demand. Let the baby feed for as long as possible on each breast. Feed only at breast. Advise the mother to keep the baby with her. Expressed Breast Milk it a mother is not in a position to feed her baby (e.g. ill mother, preterm baby, working mother, etc.), she should express her milk in a clean wide-mouthed container and this milk should be ted to her baby. Expressed breast milk can be stored at room temperature for 6-8 hours, in a refrigerator for 24 hours and a freezer at -20 4 V for 3 months. Method of Milk Expression Ask the mother to wash her hands thoroughly with soap I'' ery time before she expresses. Make herself coin tortab le. (.;antsy massage tht' breast (Fig. 7.29). Hold the t:otitainer 128 ediatrics Express one breast until the flow of milk slows and null ( only drips out, and then express the other breast until the milk only drips. Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes. Stop expressing when the milk no longer flows but drips from the start.

Eswiltiai P