BREASTFEEDING

IAP UG Teaching slides 2015-16 1

 BREASTFEEDING

Itisthebestgiftthatmothercangivetoherbaby.

Breastfeeding fosters a physical & emotionalbonding

contactbetweenmother&baby.

It can be a means to protect , promote and supportthe

healthofbothmother&thebaby.

Exclusivebreastfeedingfor6monthshaspotentialtoreduce
under5mortality.

IAP UG Teaching slides 2015-16 2

 ANATOMY

Eachmammaryglandformsalobeofthebreast,whichconsists
ofasinglemajorbranchofalveoli,milkductsandonelactiferous
sinusthatnarrowstoanopeninginthenipple(nipplepore).

Alveoli cells secrete milk. They are surrounded by a networkof

band like myoepithelial cells which cause alveoli tocontract,
when stimulated by the oxytocin released during the letdown
reflex.

Thisactionexpelsthemilkintotheductulesandintotheducts.

IAP UG Teaching slides 2015-16 3

ANATOMYOFBREAST

IAP UG Teaching slides 2015-16 4

 AREOLA

Thedarkerpigmentedareaaroundthenipple.

IAP UG Teaching slides 2015-16 5

 MYTHS

Manywomendonotproduceenoughmilk.
Thereis no enough milk during the first 3 or 4days
afterbirth.
Thebabyshouldbeonthebreastfor20minuteson
eachside.
Breastfeedingbabyneedsextrawaterinhotweather.
Itiseasiertobottlefeedthanbreastfeed.

IAP UG Teaching slides 2015-16 6

 If the baby has diarrhea or vomiting, the mothershould
stopbreastfeeding.

Mothers who have had undergone breastreduction

surgerycannotbreastfeedthebaby.

Women with small breast produce less milk comparedto

largebreast.

Breastfeedingwomencannottakeabirthcontrolpill.

Womenwithinvertednipplecannotbreastfeed.

IAP UG Teaching slides 2015-16 7

 HORMONALINFLUENCES

Estrogen:stimulatestheductulesystemtogrow.

Progesterone:increasesthesizeofalveoliandlobes.

Prolactin: during pregnancy, it contributes to theaccelerated

growth of the breast tissue. During lactation, the alveolarcells
makemilkinresponsetothereleaseofprolactinwhenthebaby
sucksatthebreast.

Oxytocin: contraction of the smooth muscle layer ofbandlike

cellssurroundingthealveolitosqueezethenewlyproducedmilk
intotheductsystem.Itisnecessaryformilkejectionreflex.
IAP UG Teaching slides 2015-16 8
 INITIATIONOFBREASTFEEDING

As early as possible breast feeding has to be initiated inboth

normalandLSCSdeliverywithinonehouroflife

Afterbirthbabyisbiologicallyready&initiationiseasy,Lateron
babygoestoprolongedsleepandhenceitsdifficult.

Frequency23hourly/demandfeeding.

Durationexclusivebreastfeedingfor6months.

Timeforeachfeed:1520minutes.

IAP UG Teaching slides 2015-16 9

 EXCLUSIVEBREASTFEEDING

Breastfeedingforthefirstsixmonths.

Noprelactealfeeds.

Noformalfeeds.

Nopacifiers.

Noadditionalfluids.

IAP UG Teaching slides 2015-16 10

 REFLEXESINBREASTFEEDING

REFLEXESINBABY

There are three reflexes, namely rooting, suckling&

swallowingreflexeswhichhelpinbreastfeeding.

ROOTINGREFLEXWhenthenippleisallowedtotouchthe
cheekofthebaby,babyopensthemouth.

IAP UG Teaching slides 2015-16 11

SUCKLINGREFLEX:
Thisreflexhelpsthebabydrawoutmilkfromthebreast.

Itconsistsof:
oDrawinginthenipple&areolatoformanelongatedteat
insidethemouth.
oPressingthestretchednippleagainstthepalate.
oDrawingmilkbyperistalticmovementofthetongue
underneaththeareola&compressingthemagainstthe
palateabove.

IAP UG Teaching slides 2015-16 12

SWALLOWINGREFLEX:
Ittakes23sucklestofillthebabysmouthmilk.

Whenthemouthisfilledwithmilkthebabyswallowsthemilk
&thenbreathes.

Thesuckleswallowbreathecyclelastsforaboutasecond.

IAP UG Teaching slides 2015-16 13

 REFLEXESINBREASTFEEDING

Nipplestimulation
IAP UG Teaching slides 2015-16 14
Milkproduction(prolactin)reflex&milkejection(oxytocin)reflex
initiate&maintainlactationinthemother.

PROLACTINREFLEX(MilkSecretionReflex)

Suckingactsastheafferentstimulus,wherethenerveendings
inthenipplecarrytheimpulsestotheanteriorpituitarywhich
inturnreleasesprolactin

Theprolactinisthenreleasedinthebloodstream&induces
cellsofthealveolitoproducemilk&distendsit.

Themorethebabysucksthegreaterthemilkproduction.

IAP UG Teaching slides 2015-16 15

 MILKEJECTIONREFLEX

Oxytocinisproducedbytheposteriorpituitaryglandinresponse
to stimulation to the nerve endings in the nipple by sucklingas
wellasbythought,sightorsoundofthebaby

Oxytocinisresponsibleforcontractionofmyoepithelialcells.

Milkisthenemptiedfromthealveolitothelactiferousducts.

Reflex is affected by mothers emotions, relaxed,confident

attitudehelpsthemilkejectionreflex.

Ontheotherhand,tension&stresswillhinderthemilkflow.

IAP UG Teaching slides 2015-16 16

IAP UG Teaching slides 2015-16 17
IAP UG Teaching slides 2015-16 18
 FACTORSDECREASINGMILKPRODUCTION

Dummies,pacifiers,bottles.

Givingsugarwater,honey,prelactealfeeds.

Painfulbreastconditionslikesoreorcrackednipple&congested
breast.

Lackofnightfeedinginterferingprolactinproduction.

IAP UG Teaching slides 2015-16 19

 COMPOSITIONOFBREASTMILK

COLOSTRUM:
Secretedduringinitial34daysafterdelivery.
Smallquantity,yellowthick.
Containslarge amount of proteins &immunoglobulins,
vitaminA,D,E,K.

TRANSITIONALMILK:
Secretedafter34daysupto2weeks.
Richinfat&sugarcontent

IAP UG Teaching slides 2015-16 20

MATUREMILK:
Thinner&watery.
Containsallessentialnutrients.

FOREMILK:
Secretedinthestartoffeed.
Watery,richinprotein,sugar,vitamins,minerals&water.
Satisfiesbabiesthirst.

HINDMILK:
Richerinfats.
Comeslatertowardsendofthefeeds.
Providesmoreenergy,givesthesenseofsatiety.

IAP UG Teaching slides 2015-16 21

 POSITIONOFTHEBABY
Makesurethebabyiswrappedproperly.

i)Babyswholebodyissupportednotjusttheneckorshoulders.

ii)Babysheadandbodyareinonelinewithoutanytwistinthe
neck.

iii)Babysbodyturnedtowardsthemother.

iv)Babysnoseisatthelevelofnipple.

IAP UG Teaching slides 2015-16 22

IAP UG Teaching slides 2015-16 23
 SIGNSOFGOODATTACHMENT

Babyschinclosetothebreast.

Babystongueunderlactiferoussinuses&nippleagainstthe
palate.

Mouthwideopen,lowerlipturnedoutwards.

Moreareolavisibleabovethebabysmouththanbelowit.

IAP UG Teaching slides 2015-16 24

IAP UG Teaching slides 2015-16 25
 SIGNSOFPOORATTACHMENT

Babysucksonlythenipple.

Mouth is not widely open&much

oftheareolaisoutsidethemouth.

Baby s tongue is also insidethe

mouth & does not cover upthe
breasttissue.

Chinisawayfromthebreast.

IAP UG Teaching slides 2015-16 26


BENEFITSOFBREASTMILK

NUTRITIONALSUPERIORITY: breastmilkcontainsallthe
nutrientsababyneedsfornormalgrowthanddevelopment,in
anoptimumproportionandinaformthateasilydigestedand
absorbed

CARBOHYDRATES:
Lactoseisinahighconcentration(67g/dl)
Galactose is necessary for optimal brain developmentof
growinginfants.
LactosehelpsinabsorptionofCalcium
Lactoseenhancesthegrowthoflactobacilliintheintestine

IAP UG Teaching slides 2015-16 27


BENEFITSOFBREASTMILK
FATS:

Rich in polyunsaturated fatty acids necessaryfor

myelinationofnervoussystem.
Containomega3(longchainfattyacids).
Docosa hexaenoic acid(DHA),provides theright
substances for manufacturing myelin, the fattysheath
thatsurroundsnervefibers.
LipidspresentinhumanmilkincludesEPA,prostaglandin
precursor,fatsolublevitamins,steroids&phospholipids.

IAP UG Teaching slides 2015-16 28


BENEFITSOFBREASTMILK

Proteins:
Theproteinismostlywheyprotein(60%)richinLactalbuminand
Lactoferrin&therestiscasein(40%)whichareeasilydigestible.
Lactalbuminisrichintryptophan,theprecursorofserotoninthat
playsanimportantroleasaneurotransmitter.
Lactoferrinensuresabsorptionofiron&zinc&itisbacteriostatic
aswell.

IAP UG Teaching slides 2015-16 29


BENEFITSOFBREASTMILK

ENZYMES:
Peroxidases,lipidlipases,bilesaltstimulatedlipase(BSSL)killsthe
microbesbyfacilitatingfatabsorption&hydrolyzebacteriallipids.
Thebifidusfactor&acidicpHassociatedwithhumanmilkleads
tocolonizationbyLactobacillus.
Lactobacilli&lacticacidthathelpindigestionarecalledprobiotic
substances

IAP UG Teaching slides 2015-16 30 30


BENEFITSOFBREASTMILK
IMMUNOLOGICALLY:
Itissafe,nonallergic.
Contains immunoglobulin's, secretory components&
secretory IgA. Also Plasma cells, polymorphs, lysosomes,
lactoperoxidase,growthfactors,etc.
Serum IgA provides surface protection to the respiratory&
GItracts
S IgA resist proteolytic degradation in the neonatal gut,and
offersprotection.
Breastmilkcontainscellularelemente.g.macrophages(upto
80%)lymphocytes(TandB).Thesearetheprimarydefense
againstinfection.
BreastmilksuppliesT&Blymphocytes.

IAP UG Teaching slides 2015-16 31


BENEFITSOFBREASTMILK

Vitaminshumanmilkisagoodsourceofvitaminsexceptvit
K&D.

Minerals:inbreastmilklikeiron,zinc,etc.arepresentin
smallquantities,butthebioavailabilityismuchbetter
becauseofcarrierproteins.

Osmolalityislowdecreasedsoluteloadonneonatalkidney

IAP UG Teaching slides 2015-16 32

 BENEFITSTOMOTHER

AcceleratesInvolutionofUterus.

Reducesthechancesofpostpartumhemorrhage.

BurnoffextrafataccumulatedduringPregnancy.

LowerstheriskofOvarianandBreastcancer.

HelpsindelayingnextPregnancy.

IAP UG Teaching slides 2015-16 33

 ADVANTAGESTOFAMILYANDSOCIETY

MoreeconomicalthanArtificialfeed.

PromotesFamilyPlanning.

ReducestheneedforHospitalizationofchildren's.

ReducesInfantmortalityandmorbidity.

IAP UG Teaching slides 2015-16 34

IAP UG Teaching slides 2015-16 35
 BFHI
After introduction of Baby friendly hospital initiative (BFHI)
organized by UNICEF in 1992, Exclusive demand feedingis
acceptedastheonlymodeofearlyfeeding.
BFHI Plus Program incorporates other child survival andsafe
motherhood components like immunization, antenatalcare,
ORT.
World Alliance for Breastfeeding Action (WABA) is theglobal
agencyforpromotionofbreastfeeding.
BreastfeedingPromotionnetworkofIndia(BPNI)isthenational
agencyforbreastfeeding.
WORLDBREASTFEEDINGWEEK(WBW)iscelebratedfrom1stto
7thofAugust

IAP UG Teaching slides 2015-16 36

 TENSTEPSINBFHI

1. Have a written breastfeeding policy that isroutinely

communicatedtoallhealthcarestaff.

2. Trainallstaffinskillstoimplementthispolicy.

3. Inform all pregnant women about the benefitsand

managementofbreastfeeding.

4.Helpmothersinitiatebreastfeedingasearlyaspossible.

5. To show mothers how to breastfeed and how tomaintain

lactationeveniftheyshouldbeseparatedfromtheirinfants.

IAP UG Teaching slides 2015-16 37

6. Give newborn infants no food or drink other thanbreast
milk,unlessmedicallyindicated.

7. Practice roomingin & allow mothers & infants toremain

together24hrsaday.

8.Encouragebreastfeedingondemand.

9. Give no artificial teats or pacifiers(also called dummiesor

soothers)tobreastfeedinginfants.

10.Fostertheestablishmentofbreastfeedingsupportgroups&
refermotherstothemondischargefromthehospital.

IAP UG Teaching slides 2015-16 38

 PROBLEMSOFBREASTFEEDING

FlatorInvertednipple

Breastengorgement

SorenippleandCrackednipple

Blockedduct

MastitisandBreastabscess

Notenoughmilk

IAP UG Teaching slides 2015-16 39

 FLATORINVERTEDNIPPLE

Normallyitgetscorrected
whenthebabysuckles.

Ifproblempersistsfollowing
techniquesshouldbetried,
Invertedsyringetechnique.
Doublesyringetechnique

IAP UG Teaching slides 2015-16 40

INVERTEDSYRINGEANDDOUBLESYRINGETECHNIQUE

IAP UG Teaching slides 2015-16 41

 BREASTENGORGEMENT
Breastmilkproductionincreasesduring2nd&
3rddayafterdelivery.

Iffeedingdelayed/infrequent/notwell
positioned,milkaccumulatesinthealveoli.

Asthemilkproductionincreasesamountof
milkproductionsexceedsstoragecapacity
leadingtoengorgement.

Clinicalfeatures
Swollen,hard,warm&painfulbreast
IAP UG Teaching slides 2015-16 42
 BREASTENGORGEMENT
Treatment:
1. Moistheatthroughwarmwater35timesbeforefeed.

2. Gentlemassagestrokingthebreasttowardsnipple.

3. Frequentfeedsevery2hoursforatleast1520minoneach
side.

4. Feedinaquiteandrelaxedplace.

5. Paracetamolforpainrelief.

IAP UG Teaching slides 2015-16 43

 SORENIPPLE&CRACKEDNIPPLE

Incorrectattachment

Babydoesntgetenoughmilk

Sucksmorevigorously

Sorenipple

Iffeedingcontinues

Physicaltrauma

Crackednipple,Mastitis,Breastabscess

IAP UG Teaching slides 2015-16 44

 CRACKEDNIPPLE

Othercauses:
Frequentwashingwithsoap&water

Pullingthebabyoffthenipplewhile
sucking

oralthrushinthebaby(usuallyafter
fewweeks)

IAP UG Teaching slides 2015-16 45

TreatmentofSorenipple/Crackednipple
Correctposition&attachmentofbabytobreast.

Hindmilkhastobeappliedtonippleafterfeed.

Nippleshouldbeairdriedtoallowhealing

Washthenippleoncedailyonlywithwater

Infantwithoralthrush:

Apply1%gentianvioletovernippleaswellasbabys
mouth

Maternalfungalbreastinfections:

GiveMiconazole/Fluconazole250mgTIDfor10days
IAP UG Teaching slides 2015-16 46
 BLOCKEDDUCT

Impropersucklesoveraparticularsegment

>accumulatedthickmilkblockslactiferousduct

>painfulhardswellingoverthatsegment

Notassociatedwithfever

IAP UG Teaching slides 2015-16 47

 BLOCKEDDUCT

Treatment

Improvedremovalofmilkfromthatsegmentbyholdingtheinfant

withchintowardsaffectedsegment

Avoidtightclothing.

Ifnotrelieveddogentlemassageoverthatsegmenttowardsnipple.

IAP UG Teaching slides 2015-16 48

 MASTITIS&BREASTABSCESS

Persistentengorgement/blockedduct

>superveningofinfections

>Mastitis

>Ifnottreated>Breastabscess

Clinicalfeatures:

Red,hot,tender,swollenbreast

Highgradefeverinabscess.

Raisedbloodcounts
IAP UG Teaching slides 2015-16 49
IAP UG Teaching slides 2015-16 50
 MASTITIS&BREASTABSCESS

TREATMENT
Supportivecounseling
Reassuranceaboutvalueofbreastfeeding.
Safetocontinue.
Milkfromaffectedbreastwillnotharmbaby.
Breastwillrecoverbothitsshape&function.

Effectivemilkremovalby
Properattachment.
Encouragefrequentfeeding.
Ifnecessaryexpressmilkbyhandorpump.

IAP UG Teaching slides 2015-16 51

 MASTITIS&BREASTABSCESS
Antibiotictherapyif
Cell&bacterialcolonycounts&cultureavailable
Severesymptomsfrombeginning.
Visiblenipplefissure.
Noimprovementafter1224hoursofimprovedmilk
expression.
Durationofantibiotictherapyis1014days.

Symptomatictreatment
Ibuprofenreducesbothpain&inflammation.
Paracetamolisoptional.

IAP UG Teaching slides 2015-16 52

 NOTENOUGHMILK

Commoncauses
Infrequentfeeding.
Tooshort/hurriedfeeding.
Poorsucklingposition.
Pooroxytocinreflex.
BreastengorgementorMastitis.

IAP UG Teaching slides 2015-16 53

 TREATMENT

Reassurance.
Feedmorefrequently,speciallyduringnight.
Makesurethattheattachmentisproper.
Feedinacalmplace,inarelaxedposition.
Treatthepainfulconditionslikesorenipple,mastitis.

IAP UG Teaching slides 2015-16 54

 BREASTFEEDINGINSPECIALCIRCUMSTANCES

Whenthebabyisill?
Breastmilkistheeasilydigestiblefoodforillbaby.
Bestpacifier.
Lifesaviortomanybabies.
Satisfiesbothnutritional&fluiddemands.
Ithasprotective&immunologicalfactors.

Sobreastfeedingshouldbecontinuedinmostoftheillnesseslike
Rhinitis,Viralfever
Diarrhealdiseases
Respiratoryinfections
IAP UG Teaching slides 2015-16 55
 DiscontinuebreastfeedingifthereareGIcontraindicationsto
oralfeeding.

Ifthebabysuckswithlessvigoroffermorefrequentfeeds.

Ifthebabycan'tsuckofferExpressedbreastmilk.

BabieswithCCFdowellwithEBMasitcontainslesssodium.

IAP UG Teaching slides 2015-16 56

 WHENTHEMOTHERISILL?

Breastfeedingcanbecontinuedduringmostofthematernal
illnesseslike

Viralfever
UTI
Breastabscess
Tuberculosis
HepatitisB

IAP UG Teaching slides 2015-16 57

 BREASTFEEDINGINTUBERCULOSIS

Contraindicateduntilcompletionof2weeksofmaternal
chemotherapyinwestern.Indiabreastfeedingisnot
contraindicated.

Ifmotherisanopenc/oTB

Startheronchemotherapy.

BabyshouldbeputonchemoprophylaxiswithINH&
Rifampicin.

IAP UG Teaching slides 2015-16 58

 After3monthsensuremotherissputumnegative&do
Monteuxtesttobaby.

IfMonteuxtestnegativeStopdrugs&giveBCG.

IfMonteuxtestpositivecontinuechemoprophylaxisfor
69months.

IAP UG Teaching slides 2015-16 59

 BREASTFEEDINGINHEPATITISB

Babyshouldbegiven
HepBImmunoglobulinfollowedby
HepBvaccination.
Nodelayintheinitiationbreastfeedingis
required.

IAP UG Teaching slides 2015-16 60

 BREASTFEEDINGINHIV/AIDS

PerinataltransmissionofHIVinAIDSis30%.
TransmissionthroughBreastfeedingis510%.
RecommendationsforHIVmotheris
1. DeliverybyCesareanSection.
2. ArtificialfeedingifAFASS
affordable,
feasible,
acceptable,
safe,
sustainablefor6months
3. Drugtherapytomother&babyasperPPTCTguidelines.

IAP UG Teaching slides 2015-16 61

 InUSA:breastfeedingiscontraindicatedinHIV.

Inothercountries:

IfArtificialfeedingisAFASSBreastfeedingiscontraindicated.

OtherwiseBreastfeedingshouldbecontinued.

Mixedfeedingisdangerousas

Artificialfeedingdamagesmucosalbarrier&

BreastfeedingwillleadtoeasytransmissionofHIVvirus
throughdamagedmucosa.

IAP UG Teaching slides 2015-16 62

 BREASTFEEDINGINPOSTPARTUMPSYCHOSIS

Breastfeedingisallowedundersupervision.

IAP UG Teaching slides 2015-16 63

 CONTRAINDICATIONSTOBREASTFEEDING

Congenitallactoseintolerance.
Galactosemia
Maternaldrugintakeof
Anticancerdrugs.
Antithyroiddrugs.
AntipsychoticslikeLithium.
Ergotderivatives.
Iodinatedradiocontrasts.
HIVifArtificialfeedingisAFASS.

IAP UG Teaching slides 2015-16 64

OPTIONSTOWORKINGMOTHERS

IAP UG Teaching slides 2015-16 65

 ContinueEBFaslongaspossiblebeforeresumingtowork.

TakethebabytoDayCareCentreatworkplace&feedin
betweenwork.

ChangetheworkplacetonearHouseorviceversa.

Express&keeptheEBMwhenthemotherisaway.

Breastfeedbeforeleavingtowork,onreturningfromwork,
duringnights&holidays.

Extendmaternityleavetill46monthsoravailhalfpayor
lossofpayleaveifpossible.
IAP UG Teaching slides 2015-16 66
 EXPRESSION&STORAGEOFMILK

Expressedbreastmilkisthemainstayoffeedingin

Preterm,LBWbabies&sickbabies.

Severalworkingmothers.

Illness/hospitalizationofmother/babythatprecludes
breastfeeding.

Torelievebreastengorgement.

Beforeexpressingmilkgoodhandwashing&hygieneshould
bemaintained.
IAP UG Teaching slides 2015-16 67
 EXPRESSION&STORAGEOFMILK

Electricbreastpumpsarebettertoleratedthanmechanical
pumpsormanualexpression.

Collectingkitsshouldberinsed,cleanedwithhotsoapywater
&airdriedaftereveryuse.

Useclean,cappedglassorhardpolypropyleneplastic
containersorspecialfreezingbags.

IAP UG Teaching slides 2015-16 68

 EXPRESSION&STORAGEOFMILK
Canbestored

1. Inroomtemperaturefor6hrs.

2. Inrefrigeratorfor2448hrs.

3. InCommercialfreezersfor36months.

PasteurizationdoesntaffectFAcomposition.

Sterilizationcauseslossof13%ofFat.

Heating&Microwavingarenotrecommendedasitcauses
lossofAntiinfectivefactors.

Thawedmilkshouldbeusedwithin24hrs.
IAP UG Teaching slides 2015-16 69
THANKYOU

IAP UG Teaching slides 2015-16 70