Rasmussen Update 2017 final version 12-21-2017 handouts · •Thinks lovingly of baby •Sight & sounds of baby •Touches baby •Confidence •Feeing relaxed, calm ... • Cell

Essentials of Breastfeeding. E‐Course on Programming for IYCF. © UNICEF and Cornell University. 2017. 1

Essentials of Breastfeeding

Kathleen M. Rasmussen, ScD

ProfessorDivision of Nutritional SciencesCornell UniversityDecember 20, 2010 (updated 2017)

Objectives• To review the physiology of breastfeeding and the

important aspects of milk composition

• To describe 3 major recommended breastfeeding practices

• To describe potential benefits of breastfeeding forwomen and communities

Objectives• To review the physiology of breastfeeding and the

important aspects of milk composition

• To describe 3 major recommended breastfeeding practices

• To describe potential benefits of breastfeeding forwomen and communities

We will begin with some basic information about the breastfeeding process.

The amount of milk made and the releaseof milk are controlled by hormones

PROLACTIN OXYTOCIN


PROLACTIN


PROLACTIN

MammaryGland



PROLACTIN

Suckling


PROLACTIN

Neuralarc


PROLACTIN

?

Prolactin release

?


PROLACTIN

?

Prolactin(in blood)


PROLACTIN

?

MammaryGland


PROLACTIN

?



PROLACTIN OXYTOCIN


OXYTOCIN


OXYTOCIN


OXYTOCIN Oxytocin(in blood)

Uterus


OXYTOCIN

The let-down reflex is required!

• Worry

• Stress

• Pain

• Doubt

These hinder reflexThese help reflex

• Thinks lovingly of baby

• Sight & sounds of baby

• Touches baby

• Confidence

• Feeing relaxed, calm


Inhibitor in breast milk:supply and demand

FIL

Knight CH, et al. Rev Reprod 1998;3:104-12


If the breast remains full of milk, secretion stops because of an inhibitor in the breast.

FIL



If the breast remains full of milk, secretion stops because of an inhibitor in the breast.

If mother and infant are separated, milk removal must be continued to maintain its production.

FIL


Breast milk is an exceptional foodBioactive Components of Human Milk

Nutrients Protective Agents

Adaptive Immune System

• Humoral (sIgA, other Igs)• Cell-mediated

(macrophages, white cells, lymphocytes)

Non-specific Immune System

• Prebiotics• Multifunctional milk components• Cell surface receptor homologs• Immunomodulatory agents

Adapted from: Newburg DS. J Nutr 2005;135:1308




















Adaptive Immune System • Humoral (sIgA, other Igs)• Cell-mediated (macrophages,

white cells, lymphocytes)









Non-specific Immune System• Prebiotics• Multifunctional milk components• Cell surface receptor homologs• Immunomodulatory agents


New

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:130

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Breast milk protects against infectionEnteromammary Circulation


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New

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New

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New

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8Breast milk protects against infection

Enteromammary Circulation

New

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8


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Breast milk helps to develop and sustain the infant’s gut microbiome

Individualized components of breast milk:

• Bacteria from the mother’s skin and the microbiome of her milk

• Carbohydrates that support the development of a healthy gut microbiome in her infant

Guran T. Nature’s first functional food. Science 2014;345:747-9

Victora CG, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016;387:475-90

Verduci E, et al. Epigenetic effects of human breast milk. Nutrients 2014;6:1711-24

Mayer-Davis EJ, et al. Breast-feeding and risk for childhood obesity: does maternal diabetes or obesity status matter? Diabetes Care2006;29:2231-7

Common problems with artificial feeding

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Preparation with contaminated water

Infection

Bottles difficult to clean

Infant drinks from contaminated

bottle

Formula is expensive

Dilute preparation

Inadequate nutritionInfection


Recommended breastfeeding practices

• Immediate skin-to-skin contact and early initiation of breastfeeding (within first hour after delivery)

• Breastfeed exclusively for 6 months

• Continue breastfeeding to 24 months and beyond

Suboptimum breastfeeding and deaths of children <5

Black RE, et al, Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013;382:427-51

44.7%

19.4%

11.6%

2.3%

1.7%

12.6%

14.4%

14.7%

11.8%

0% 10% 20% 30% 40% 50% 60%

Proportion of total deaths of children <5 years

Fetal growth restriction (<1 month)

Stunting (1 to 59 months)

Underweight (1 to 59 months)

Wasting (1 to 59 months)

Zinc deficiency (12 to 59 months)

Vitamin A deficiency (6 to 59 months)

Suboptimum breastfeeding (0 to 23 months)

Joint effects of fetal growth restriction and sub-optimum breastfeeding in neonates

Joint effects of fetal growth restriction, suboptimum breastfeeding, stunting, wasting, and vitamin A and zinc deficiencies (<5years) 0% 10% 20% 30% 40% 50%

Recommended practice:

Initiate breastfeeding early

Nilsson L, Hamberger L. A Child Is Born. New York: Dell Publishing,1993

What is colostrum?

• First milk produced

• Higher nutrient density than mature milk– Protein, fat, vitamin A

• Rich in antibodies, growth factors

• Amount of colostrum produced matches the newborn’s stomach capacity

www.newborn.stanford.edu

Effect of breastfeeding regimen on the continuation of lactation

Treatment group

Timing of lactogenesis

(% < 48 hours)

Proportion still breastfeeding (%)

6 weeks 12 weeks

Early/2 hour*

(n = 29)55 69 64

Early/4 hour

(n = 27)22 74 56

Late/2 hour*

(n = 27) 52 70 56

Late/4 hour

(n = 28)14 54 46

*Significantly different from the corresponding 4-hour group

Salariya EM, et al. Lancet 1978;ii:1141-3



Treatment group


(% < 48 hours)


6 weeks 12 weeks

Early/2 hour*

(n = 29)55 69 64

Early/4 hour

(n = 27)22 74 56

Late/2 hour*

(n = 27) 52 70 56

Late/4 hour

(n = 28)14 54 46




Treatment group


(% < 48 hours)


6 weeks 12 weeks

Early/2 hour*

(n = 29)55 69 64

Early/4 hour

(n = 27)22 74 56

Late/2 hour*

(n = 27) 52 70 56

Late/4 hour

(n = 28)14 54 46




Treatment group


(% < 48 hours)


6 weeks 12 weeks

Early/2 hour*

(n = 29)55 69 64

Early/4 hour

(n = 27)22 74 56

Late/2 hour*

(n = 27) 52 70 56

Late/4 hour

(n = 28)14 54 46




Treatment group


(% < 48 hours)


6 weeks 12 weeks

Early/2 hour*

(n = 29)55 69 64

Early/4 hour

(n = 27)22 74 56

Late/2 hour*

(n = 27) 52 70 56

Late/4 hour

(n = 28)14 54 46




Treatment group


(% < 48 hours)


6 weeks 12 weeks

Early/2 hour*

(n = 29)55 69 64

Early/4 hour

(n = 27)22 74 56

Late/2 hour*

(n = 27) 52 70 56

Late/4 hour

(n = 28)14 54 46




Treatment group


(% < 48 hours)


6 weeks 12 weeks

Early/2 hour*

(n = 29)55 69 64

Early/4 hour

(n = 27)22 74 56

Late/2 hour*

(n = 27) 52 70 56

Late/4 hour

(n = 28)14 54 46




Early initiation saves lives

Mullany LC, et al. J Nutrition 2008;138:599-603

Early initiation saves lives

20% of neonataldeaths

Mullany LC, et al. J Nutrition 2008;138:599-603

Early initiation saves lives – NEOVITA study

NEOVITA Study Group. Timing of initiation, patterns of breastfeeding, and infant survival: prospective analysis of pooled data from three randomised trials. Lancet Glob Health 2016;4:e266-75

Compared to infants who were put to the breast within 1 hour of birth,

• the risk of dying in the first 28 days of life was 41% higher for those infants who were breastfed within 2-23 hours

• and 79% higher for those infants who initiated breastfeeding after 1 day

How does early initiation save lives?

• Colostrum (first milk) is rich in immune and non-immune components that fight infection and accelerate intestinal maturation

• Promotion of warmth and protection may reduce risk of death from hypothermia

• The alternative, prelacteal feeding, may disrupt normal physiologic gut priming

Edmond KM, et al. Pediatrics 2006;117:e380-6

Beyond saving lives:other benefits of early initiation

• Earlier onset of ample milk production

• Longer duration of breastfeeding

• Improved mother/infant bonding

• Decreased infant distress

• Stronger uterine contractions that reduce uterine bleeding

Anybreastfeeding

Exclusive breastfeeding

Avoid prelacteal feeds:they shorten breastfeeding duration

Pérez-Escamilla R, et al. Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras. J Nutr 1996;126:2765-2773

Water-basedprelacteal feeds

Milk-basedprelacteal feeds

714 Honduran infants, 0-6 months old


Anybreastfeeding






81% reduction


Anybreastfeeding






81% reduction


Anybreastfeeding






81% reduction

79% reduction

Pérez-Escamilla R, et al. Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras. J Nutr 1996;126:2765-2773 Source: UNICEF Global Databases. 2016

Few women initiate breastfeeding early

Percent of newborns put to the breast within one hour of birth, by country and region, 2015

Why aren’t women initiating early?

• Lack of support in hospital

• Traditional beliefs– Dirty because of color

– Milk has “gone bad” (been in the breasts too long)

• Women who deliver at home don’t receive adequate support

• Prelacteal feeds are givenLatin America and the Caribbean

Eastern and Southern Africa

CEE/CIS

West and Central Africa

South Asia East Asia and the Pacific

Middle East and North Africa

Other

Skilled birth attendant(e.g., doctor, nurse, midwife)

Skilled birth attendants can provide vital support for early initiation – we need to seize this opportunity

Untraditional birth attendant (e.g. traditional) or others (e.g., relatives) t

Source: UNICEF Global Databases. 2016

Percent of newborns put to the breast within one hour of birth by birth delivery attendant, by region, 2015


Latin America and the Caribbean

Eastern and Southern Africa

CEE/CIS

West and Central Africa

South Asia East Asia and the Pacific

Middle East and North Africa

Other

Skilled birth attendant(e.g., doctor, nurse, midwife)

Skilled birth attendants can provide vital support for early initiation – we need to seize this opportunity

Untraditional birth attendant (e.g. traditional) or others (e.g., relatives) t


Percent of newborns put to the breast within one hour of birth by birth delivery attendant, by region, 2015

Recommended practice: Breastfeed exclusively for 6 months

Source: UNICEF

Any woman can breastfeedExclusive breastfeeding saves lives

0

2

4

6

8

10

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Diarrhoeamortality

Pneumoniamortality

Diarrhoeaincidence

Pneumoniaincidence

All causemortality

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Predominant breastfeeding Partial breastfeeding Not breastfeeding

Black RE, et al. Lancet 2008;371:243-260

Sankar MJ, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr 2015;104:3-13

Exclusive breastfeeding saves lives

0

2

4

6

8

10

12

14

16

Diarrhoeamortality

Pneumoniamortality

Diarrhoeaincidence

Pneumoniaincidence

All causemortality

Rel

ativ

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k co

mp

are

d t

o e

xclu

sive

b

rea

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ing

for

0-5

mo

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Predominant breastfeeding Partial breastfeeding Not breastfeeding


Black RE, et al. Lancet 2008;371:243-260

Sankar MJ, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr 2015;104:3-13

Weight-for-age z-scores from 0 to 6 months: breastfed infants, USA v. Honduras.

Exclusively breastfed children grow just as well

Cohen RJ, et al. Lancet 1994;334:288-293
























Early child development

• Emotional bonding– Close, loving relationship

between mother and baby

– Mother is more emotionally satisfied

– Baby cries less– Baby may be more

emotionally secure

• Cognitive development– Children perform better

on intelligence testsSource: UNICEF

Few women breastfeed exclusively for 6 months


Percent of infants 0‐5 months of age exclusively breastfed, by country and region, 2015

Why don’t women exclusively breastfeed for 6 months?

• Cultural and social myths– Not enough milk!

• Breastfeeding is perceived to be difficult– Lack of social support– Lack of adequate maternity leave– Lack of workplace support

• Widespread marketing of breast milk substitutes

• Obesity

Recommended practice: Continue to breastfeed for 24

months and beyond

Martine Korpel and her son Quinten (2 years)© Argos Fotoburo

Breast milk is an important sourceof nutrients

Savage King F, Burgess A. Nutrition for Developing Countries. New York: Oxford University Press,1993


Breast milk provides energy

Dewey KG, Brown K. Food Nutr Bull 2003;24:5-28

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6-8 months 9-11 months 12-23 monthsEst

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Total energy Energy from breastmilk Energy from complementary food

Breast milk provides energy

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Total energy Energy from breastmilk Energy from complementary food

Dewey KG, Brown K. Food Nutr Bull 2003;24:5-28

Breast milk provides fat

Recommended% of total

dietary energy from fat

Level of breast milk

intake

Energy (%) needed from fat in complementary foods,

by level of breast milk intake

6-8 months 9-11 months 12-23 months

35 Low 27 30 33

35 Medium 4 16 25

35 High 0 0 2

Joint FAO/WHO Expert Consultation on Fats and Fatty Acids in Human Nutrition. Interim Summary of Conclusions and Dietary Recommendations on Total Fat and Fatty Acids 2008. www.who.int/nutrition/topics/FFA_interim_recommendations/en/index.html





intake




35 Low 27 30 33

35 Medium 4 16 25

35 High 0 0 2






intake




35 Low 27 30 33

35 Medium 4 16 25

35 High 0 0 2


Continued breastfeeding and growth

• Good growth after infancy depends on breastfeeding, intake of complementary foods and illness in a complex manner– Women continue to breastfeed children who

are perceived to be too small, especially when they are ill or consume too little complementary food

– In contrast, women wean children who are growing well, consume adequate amounts of complementary foods and are not ill

Marquis GS, et al. Int J Epidemiol 1997;26:349-56


Globally, less than half of children are still breastfed at 2 years


Percent of children 20‐23 months of age who are breastfed, by country and region, 2015

Why don’t women breastfeed to 24 months?

• Conflict with work

• Cultural beliefs – Nursing during another

pregnancy

– Loss of milk’s nutritional value

• Family and peer pressure to stop, especially after 12 months

Benefits of breastfeeding for the mother, family, and community

Lazarov M. Zero to Three. 2000;21:15

Benefits of breastfeeding for the mother

• Delays the return of fertility

• More rapid return to prepregnancy weight; lower postpartum weight retention

• Lowers risk of postpartum depression

• Lowers risk of pre-menopausal breast cancer and ovarian cancer

• May reduce the risk of hip fracture

Benefits of breastfeeding for the family and community

• Decreases absence in the workplace because of decreased family illness

• Lowers expenditures for food and health care

• Provides a safe food in emergency and disaster situations

• Supports the environment, reducing use of fuels, pharmaceuticals, plastic, and waste from the dairy industry

Recommended breastfeeding practices

• Immediate skin-to-skin contact and early initiation of breastfeeding (within first hour after delivery)

• Breastfeed exclusively for 6 months

• Continue breastfeeding to 24 months and beyond


© A

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Co.

, Ltd

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Thank you!

This training course was jointly developed by the

Infant and Young Child Feeding Unit,

Nutrition Section, UNICEF Headquarters,

and

Cornell NutritionWorks, Division of Nutritional Sciences,

Cornell University.

Copyright 2017

Documents

Rasmussen Update 2017 final version 12-21-2017 handouts · •Thinks lovingly of baby •Sight & sounds of baby •Touches baby •Confidence •Feeing relaxed, calm ... • Cell