Breastfeeding and Lactation PDF

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Breastfeeding and LactationPutting BF into contextWHO recommend breastfeeding exclusively until 6 months of age – continuing until 2years and beyond.Breastmilk benefits: Readily available No cost Perfect temperature Infant can regulate intake Breastfeeding benefits for infants: Lowers risk of: Diarr...

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Breastfeeding and Lactation Putting BF into context WHO recommend breastfeeding exclusively until 6 months of age – continuing until 2 years and beyond. Breastmilk benefits: - Readily available - No cost - Perfect temperature - Infant can regulate intake Breastfeeding benefits for infants: Lowers risk of: - Diarrhoea - Chest infections - Obesity and Diabetes (1 and 2) - Leukemia - SUDI - Necrotising enterocolitis (portion of the bowel dying) This is because breastmilk is high in LCPUFA (long-chain polyunsaturated fatty acids) and breastfeeding allows psychological stimulation and maternal-infant bonding. For mothers it lowers the risk of: - Osteoporosis - Ovarian and breast cancer - Type 2 diabetes - Postnatal depression - Hypertension, CVD, allergies and Crohns disease - Lowers cholesterol - Higher IQ Also - Helps mothers return to their pre-pregnancy weight - Regulates fertility - Releases oxytocin and enables uterine involution - Reduces blood pressure (systolic and diastolic) in the 2 days following birth Breastfeeding immediately assists in the separation of the placenta and a reduction in post-partum blood loss. There are economic and environmental benefits from breastfeeding - Formula costs money

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Illnesses preventable by breastfeeding costs DHBs Formula feeding has a large impact on the environment and contributes to landfill waste and global warming.

Who breastfeeds? Young mothers from low socioeconomic areas are the least likely to breastfeed Role models, education and maternity care are big influences on breastfeeding rates. As we are living in a bottle-feeding society it can be difficult to represent a positive example of breastfeeding for mothers in economically deprived areas. White mothers are the least likely to breastfeed when compared to other ethnic minorities. -

Mothers with greater support cope better An early latch to the breast Mothers with less pain

Early weaning: Early introduction of foods to infants can lead to ill health. This is associated with mothers from education and economic deprived communities and those who are less likely to breastfeed. Mothers have weaned their children for: - Hunger - Energy needs - Infant size - Gender - Interest in food There is a lack of understanding surrounding BF guidelines to exclusively feed until 6 months. UNICEF baby friendly initiative: -

10 steps to successful breastfeeding (WHO) Recognises breastfeeding is a large part of establishing successful relationships SSC and rooming in have become a part of routine practice Have made it a global requirement for BMS marketing to demote formula and promote BF

Breastfeeding in public: Negative attitudes among society towards breastfeeding have become a barrier that has prevented mothers from feeling comfortable feeding their child in a public environment.

Healthcare professionals need to become aware of the social barriers that result in mothers facing breastfeeding inequities which can lead to an early cessation of breastfeeding. By gaining awareness and understanding of what influences the actions of mothers, midwives and other maternity carers can provide comprehensive support and knowledge that can enable mothers to continue with BF.

Building relationships Increase in neuroscience research that has shown parental relationships have a longterm positive impact on the neurological development of infants. A secure mother-infant attachment can have a positive influence on wellbeing.

Monday 12th November: Breastfeeding and Lactation

Case study: 2000 words. Watch video online. Use ISBAR to present a women’s experience and then focus on an aspect of her experience, a problem or feature you can research and writing about it. Provide a general overview and present your ideas and understanding. Make sure you focus on the breastfeeding issue and the mothers experience, it is not as essential to talk about the care of the baby. - Antenatal expressing - Natural supplements to aid in milk supply Question the evidence and critique the research with what is relevant.  Weave in Turanga Kaupapa and partnership  Critique her experience, positives and negatives  Relevant details are provided, and her history is comprehensive (history – social/cultural context in addition to time and place)  Meaningful links between midwifery plan of care (advice) and how would you approach this – evidence-based practice.  Recent relevant sources (more than 10) – USE PROFESSIONAL AND ACADEMIC SOURCES within the last 5 years (2013 – present)  Well-constructed and coherent, grammar and good referencing.

Tuesday 13th November: Anatomy and Physiology

Understanding the anatomy and lactogenesis is important for depicting BF issues. Breast development // Mammogenesis Week 4: Embryogenesis – lines appear extending from the axilla to inguinal (groin) region on each side. Puberty: Mostly adipose tissue: Growth of lactiferous ducts, alveoli, nipple and areola are under the influence of estrogen and progesterone. Early trimester: nipples and breasts become tender and can be heavy. Nipples begin to darken due to an increase in melanocytes. Third trimester: The breasts enlarge. At birth the alveoli grow and in pregnancy stimulates the formation of lobes at 32 weeks, filling with milk to create lobules. ANATOMY Lies on the pectoralis major muscle extending from the 2nd to 6th intercostal space. In the frontal plane starts at sternum and extends to axilla. Coopers ligament supports the breast. Mammary glands are located right behind the alveoli 4–18 milk ducts average 9 Glandular tissue producing milk is close to nipple 65% is 30mm from the nipple. Subcutaneous fat is minimal at the nipple The external shape and size are not an indicator of efficiency. An alveolus: Contains lactocytes and this is where milk is produced. Square shaped cells are full and have few gap junctions whereas if they are empty, they are columns. Oxytocin causes the myoepithelial muscle to squeeze lactocytes milk into ducts. Lactogenesis is the initiation and production of milk, happens in 3 stages – first 2 driven by hormones (in BF and BMS mothers). The third stage is influenced by postbirth events Placenta controls stage 1 – hormones and progesterone/estrogen inhibit prolactin to prevent milk out early. Birthing the placenta will decrease prog/estrogens which causes prolactin to increase its effect. 30-40 hours birth lactogenesis 2 occurs. Mechanoreceptors counteracts the action of prolactin inhibiting factor (dopamine) also stimulates oxytocin production for milk ejaculation.

Lactogenesis 3 occurs from 10-14 days through to 4-6 weeks locally regulated by supply and demand. Hormones oxytocin and prolactin increase concentration. 800mls a day average. Changes from endocrine to (after 30-40hours) autocrine controlled. Prolactin – stimulates milk production Oxytocin – stimulates ejection. Oxytocin effects let down reflex and can stimulate afterpains during the early postnatal period. FIL – feedback inhibitor of lactation. The more milk stored in the alveoli and this will cause lactocytes to respond less to prolactin (therefore it is important breasts are regularly emptied to stimulate further production). Avoid irregular feeding and BMS. Mind body connection Her behaviours and emotions, support, whanau etc effects breastfeeding Be calm, warm, relaxed and rooming in with baby. NEUROENDOCRINE effect of oxytocin: Stimulated before and during a feed. Affected by sensory input. Modulated by neural influences by higher brain centres. More powerful than nipple hypothalamic pathway. Most milk is released within the first 7 min. How do particular factors prevent lactation? – IMPORTANT FOR EXAM How does surgery affect BF Women who have had breast augmentations are 3x more likely to suffer from breastfeeding issues. Modern medical surgery techniques are better than traditional procedures. Storage capacity of the breast is determined by the number of fully developed glands. Small and large storage capacity can make the same amount of milk just can’t store it. Volume is 500-1200mls. Babies remove around 76% at each feed. Each breast can vary in supply.

Birth: 5mls // first feed 24hr: 7-123 // 3-8 feeds a day 2-6 days: 395-868 // 5-10 feeds a day 1 month: 395-868 // 6-18 feeds a day 6 months: 710-803 // 6-18 feeds a day

Lactation and Breastfeeding: Anatomy and Physiology Tutorial 13/11/2018 ___________________________________________________________________________ Antenatal Ruth is G1P0 Ruth has a history that includes breast surgery. Based on these resources below 1. What questions would you ask Ruth about her breast surgery (use Breastfeeding after breast & nipple surgery, 2016) www.bfar.org (see sidebars: reduction, implant, lift).

- When did you have your breast surgery? - Do you want to breastfeed, what are your plans for feeding? - What type of surgery did you have? May be good to get her medical notes, contact women and ask for her doctor. You determine that Ruth has had simple breast augmentation 1. What anatomical or physiological aspects will you consider? Where the implant resides, is it sub glandular or sub muscular? Sub muscular is preferred as the implant is behind the muscle. 2. What antenatal advice could you offer to Ruth to prepare her for breastfeeding once baby is born? (see Pollard, 2018, p., 130-132 and use bfar.org to support knowledge) Remove as much milk as possible in the first two weeks to increase supply/demand Breastfeed early by establishing a good latch within the first hour of birth. Keep a close eye on output and weight gain. Engage in pumping to establish a substantial supply See nerve sensitivity of the breasts. Natural supplementation Hand expression to increase stimulation SSC, rooming in, on demand feeding

Day 2 PN: Ruth had a normal vaginal delivery 2 days ago at a primary unit at 40 weeks. She birthed a healthy 3500g baby girl. Ruth is tearful and tired as baby Aroha has been non-stop breastfeeding. Ruth is worried she does not have enough milk.

1. Can you explain to Ruth what is expected at this stage in terms of milk volume? Milk is not expected to come in until day 3, your baby’s stomach is very small and only needs 5-7mls of colostrum per feed. This colostrum is high in energy and nutrients. Cluster feeding is normal baby behaviour, you’re doing amazing. 2. How does responsive feeding and skin to skin encourage Lactogenesis II (Pollard, 2018, p., 42 & 49). Emptying the ducts and feeding when the baby is hungry is important as it establishes a supply and demand for your baby. SSC increases oxytocin production which increases milk ejaculation. When the baby empties your breast regularly it stimulates prolactin to create breastmilk. 3. Looking at the diagram below, can you explain to Ruth how breastfeeding baby Jules is influenced by the hormones oxytocin and prolactin? Oxytocin levels increase significantly during a feed as this ejects milk. Prolactin levels increase after the feed to increase lactogenesis 3 and the production of milk to prepare for the next feed. 4. How would you explain to Ruth what to expect overnight or the next day and what strategies could you suggest to her? Her milk would be expected to come in. Take frequent naps during the day to prepare for cluster feeding. Have a support person with you who isn’t tired who can help you.

Day 3 PN

Ruth is day 3 and is tired and tearful and feels her breasts are very heavy and warm, she feels her milk has “come in” now and thankfully baby Jules is feeding for longer and settling for longer periods after a breastfeed. 1. Can you explain to Ruth why her breasts are feeling this way and what has occurred? Lactogenesis III occurred and baby is receiving higher amounts of milk and can settle for longer periods whilst milk regenerates. What changes have happened and why? Lactocytes in the breasts have been influenced by prolactin as progesterone levels have dropped – increasing prolactin’s effect on these milk producing cells – increasing overall supply. Prolactin levels increase significantly at night. 2. Is this a normal part of lactation in the first week? YES 3. Can this be avoided? No 4. Explain the difference between full breasts and engorgement (Pollard, 2018, p. 105). Engorged breasts can appear shiny. Are painful and feel hot. 5. What coping strategies might you advise? Use warm compress before a feed and engage in massage, then using cold compresses such as frozen nappies after a feed. 6. Hand Expressing-when should this be demonstrated /taught to Ruth? a. Hands on or Hands off? b. When would hands on be most appropriate? Wash hands and create a sterile technique, use massage and touch to stimulate the letdown reflex and oxytocin production. Create a C shape and create a rhythmic motion moving back and forth. Day 7 PN Ruth calls you to say that she has a hard, tender lump on her breast, She is 7 days post partum and has had ongoing engorgement and has been following your advice. 1. What could be causing this symptom? Blocked milk duct a. What do you recommend to Ruth? (Pollard, 2018, p.106-107) make sure to massage and put a hot compress on the area to empty the milk supply, If breasts are engorged discontinue extra pumping and feed on demand. Massage whilst feeds to encourage milk duct to clear, change the positioning of the baby to what is normally carried out – point the baby’s nose to the area of blockage (blocked duct). 2. Using your knowledge of breast anatomy, indicate the part of the anatomy of the breast where this might occur. SOCIAL AND CULTURAL INFLUENCES OF BREASTFEEDING Wet nursing was common in the 1700s Late 1840s Maori women would breastfeed children Breastfeeding has been a part of global culture for centuries.

Babies today are more likely to feed artificially over breastfeeding. Colonisation has facilitated in urbanisation and reduced access to traditional food, as well as a change in birthing culture, this has influenced breastfeeding rates in the south pacific. Industrialisation and urbanisation in the 18th and 19th century. There were higher rats of infant mortality, and so by the end of the 19th century steps were taken to change maternity and infant education. 1907 Truby king founded the royal NZ society for the health of women and children (now Plunket) monitoring health and development. Hospitalisation of birth in the 1920/30s introduced strict medical regimes. Breastfeeding rates were the lowest in NZ among the 1960s. Now in 2017 69% of mothers breastfed at 6 months. Many initiatives used to promote breastfeeding: WHO 10 steps, baby friendly initiative, Nga Maia, MOH NZ, Plunket, LC Breastmilk is the best for the baby. Exclusive until 6 months. Makes a positive contribution to health and wellbeing of mother and baby. HAPU WANANGA – Maori breastfeeding initiative to support birthing and BF with a focus on Tikanga and traditional Maori practices. Positive information. Challenges: - Employment - Career choices and economic pressure to return to work - Colonisation - Socio-economic trends - Urbanisation - Loss of cultural identify - Immigration Key factors - Employment - Body image - Family support - Commodification of formula - Public BF - Sexualisation of breasts Dominant or mainstream NZ culture is pakeha BF attitudes differs between cultures Why maori women have been diverted from BF - Interruption of a BF culture - Difficulty establishing BF within first 6 weeks

- Poor or insufficient professional support - Perception of an inadequate milk supply - Returning to work Sexualising breasts in contemporary western society has made it difficult for women to publicly breastfeed leading to an early cessation of BF. Body image: there is a common belief that it will result in the sagging of the breasts, association of weight loss can influence BF and positive body image supports BF.

Wednesday 14th November COLOSTRUM Secreted from 16/40 weeks to 10 days postnatally Thick yellow/transparent fluid The small volume of colostrum allows the baby to learn to suck swallow and breathe and not stretch the stomach. 2-10mls of fluid Rich in fat soluble vitamins Laxative Aids in maturation of the GIT Transitional milk Igg levels decrease Colostrum levels change to transitional milk at day 3-6 Volume gradually increases Protein concentration remains high, calories, fat and lactose increases By 10th day major changes complete End of the month protein levels become consistent Mature milk Composition changes between feeds Foremilk- high protein and lactose and water (quenches thirst) Hind milk is rich in fat – low volume The high fat content satisfies the baby’s hunger. Important for brain development – myelination. If a woman’s baby is constantly feeding or not feeding for long enough feed on one side and stimulate the baby to allow the baby to reach the hind milk. Baby’s that have too much foremilk: wake constantly for feed, their output is very runny (green) Green poo is a reflection of too much foremilk

Birth: 5mls // first feed 24hr: 7-1235 // 3-8 feeds a day 2-6 days: 395-868 // 5-10 feeds a day 1 month: 395-868 // 6-18 feeds a day 6 months: 710-803 // 6-18 feeds a day Macronutrients: Fats, carbohydrates and proteins Breastmilk is whey dominant. Soluble proteins and get small curds. Cow’s milk however is made if casein proteins which are harder to digest. Breastmilk: At early lactation: 90 whey: 10 casein Mature milk 60 : 40 Late lactation 50 : 50 Cows milk 20 : 80 Formula 20 : 80 – 60 : 40 The acidity of the stomach can cause casein to precipitate into a bolus, a new-born can thus have difficulty digesting a high quantity of casein. Babies do not have the enzymes necessary, cow’s milk has alpha casein whereas BM has beta which is easier to digest for babies. Human milk whey proteins constitutes 60-80% of protein in BM. - Alpha lactalbumin: high in amino acids role is to be antimicrobial, enhances immunity and has a prebiotic function, enhances calcium binding and transport, has a role in cancer tumour cells. Rich in tryptophan an important component of the enzyme lactose synthetase.

- Lactoferrin: Binds and increases iron absorption from the gut - Secretory immunoglobin A: protects against disease. important as it is specific to the environment that the mother is in, enhancing immune function to illnesses in the direct environment.

AMINO ACIDS: 19 amino acids essential to human development Mothers who have premature baby’s have higher protein levels Balance of amino acids are essential for max functioning of enzyme functions

important acids: Glutamic acid, taurine amino acid (abundant in human BM but low in cow’s milk) Taurine configure bile salts which increase fat emulsification and thus aids in absorption of fats for nervous system. Formula has a high toll on the kidneys as composition is unpredicted, can increase diabetes rates. CHO: Lines the gut and helps in brain development Helps with calcium and iron absorption Mainly lactose 98% Also glucose, glucosamines and nucleotide sugars Lactose is quickly broken down into glucose for energy stores Provides 40-50% of energy Lactose is important for the development of the nervous system Relatively insoluble and thus is slowly digested Linked to water and mineral content Needed for growth of lactobacillus bifidus. You need 800 more calories a day to produce BM. Bifidus factor

Only present in breastmilk Is a nitrogen containing polysaccharide that promotes growth of gram positive lactobacillus bifidus bacteria: - Enhances gut acidity - Enhances calcium, phosphorus and iron absorption - Makes lactoferrin easier to bind to iron - Inhibits bacteria, fungi and parasite growth

FATS BM is 50% fat More than 100 Triglycerides: 90-98% easy to digest and absorb One of these is cholesterol and is high in BM and needed for a rapidly growing CNS, essential for brain and eye development and nervous system. Long chain fatty acids: Linoleic acid is high levels: promotes prostaglandin synthesis which matures digestive cells and adds to the anti-infective BM properties DHA omega 3: crucial for eye and brain development Influe...