module 4 lactation

Define a plugged duct.

Coagulated milk blocks the flow of milk from one lobule. This leads to pressure behind the duct as milk accumulates in the lobule. The surrounding tissue may become inflamed and painful. If left untreated, a plugged duct could lead to an infection (i.e., mastitis).

Identify special nutrient concerns of vegetarian mothers.

Calcium Vitamin D Vitamin B-12 Iron Zinc

Recognize that human milk is the only food needed by healthy infants for the first six months of life.

A small percentage of infants (e.g., very large or very fast-growing infants) may need complementary feeding sooner, but for most infants, breast milk provides adequate nutrition for the first 6 months of life. Also, there are some infants with medical conditions (e.g., galactosemia) who cannot tolerate breast milk, but this is very rare. You will learn more about galactosemia in Module 5. In Module 5, when we discuss infant feeding, you will see that the optimal window of time to introduce complementary foods to the infant is between 4 and 6 months of age. This recommendation comes from research on food allergies, not strictly on nutritional needs. Even though the infant can thrive on exclusive breast milk feedings until 6 months of age (with some supplements, as we'll learn in Module 5), the infant's GI tract has matured enough by 4 months of age to handle some complementary foods. Before 4 months of age, the infant's GI tract is not mature enough to handle a wide variety of food proteins. Introducing complementary foods before 4 months of age may sensitize the infant's immune system to food proteins. Based on research, between 4 and 6 months of age is the ideal age to introduce complementary foods with lowest risk of allergic response.

Recall recommendations for alcohol use during breastfeeding.

AAP: alcohol is a maternal medicine usually compatible with breastfeeding Limit alcohol intake to 0.5 g/kg maternal body weight (~1.5 fl oz liquor, ~8 fl oz wine, ~2 cans of beer) Wait for alcohol to clear maternal blood before breastfeeding

Recognize that alcohol is NOT a galactagogue (Links to an external site.).

Alcohol has been traditionally used to relax the mother, stimulate milk flow, relax and sedate fussy babies Evidence shows that alcohol actually blunts prolactin response to suckling and inhibits letdown Infants consume ~20% less milk in the hours after maternal alcohol ingestion Alcohol may negatively affect infant development Infant sleep patterns are disrupted

Describe the anatomy of the mammary gland.

Alveoli: small, hollow sacs within the breast tissue; site of milk production and storage (singular = alveolus)Secretory cells (a.k.a. lactocytes): secrete milkMyoepithelial cells: contract to eject milk A cluster of alveoli is called a lobule A group of lobules is called a lobe (simple mammary gland); each human breast has 12 to 20 lobes Lactiferous (milk) ducts: carry milk from the lobes of the mammary glands to the nipple; many lactiferous ducts carry milk to the nipple (i.e., milk exits the nipple through many small openings) Areola: pigmented area around the nipple; helps the infant to locate the source of milk

Identify medications that are contraindicated during breastfeeding.

Antineoplastic agents (a.k.a. chemotherapy) Radioactive isotopes (e.g., for imaging procedures) Drugs of abuse Drugs that suppress lactation (e.g., delay use of oral contraceptives containing estrogen until at least 6 weeks postpartum)

Describe the relationship between maternal blood alcohol content and alcohol concentration of breast milk.

Blood alcohol levels in both maternal blood and breast milk peak ~60 to 90 minutes after ingestion It takes 2 - 3 hours after initiating drinking to clear 1 drink from maternal blood

Recall recommendations for smoking during breastfeeding.

Cigarettes are not recommended while breastfeeding Mothers should be counseled not to smoke in the presence of the infant and to reduce or quit smoking Despite some risks of transferring toxins to the infant, maternal smoking is not a contraindication for breastfeeding. Infants of mothers who smoke tend to have fewer health problems if they are breastfed than if they are formula-fed.

Recognize that proper hygiene is essential to ensure safety when collecting and storing breast milk

Clean equipment in dishwasher or sterilize in boiling water Wash hands thoroughly with soap and water Polypropylene containers are best, glass containers are second best Adhere to guidelines for storage times Defrost frozen milk in the refrigerator or under warm running water; DO NOT MICROWAVE (destroys immunological properties, creates hot spots) Infants can drink stored milk cold, room temperature, or warmed

Outline the components of a thorough nutrition assessment of a breastfeeding mother.

Client history- Maternal health, History of breast surgery (if mammary glands or ducts have been damaged or removed, this could impair ability to breastfeed), Reproductive history, Infant feeding historyFeeding mode (e.g., breast, bottle, tube feeding), Type of milk (e.g., human milk, fortified human milk, human milk substitute, shared milk, pasteurized donor milk), Complementary feedings, Supplementation Challenges (e.g., painful nipples, low milk supply), Use of feeding devices (e.g., nipple shields, supplemental feeding system), Use of medications and supplements (check for compatibility with breastfeeding using a reliable source, Anthropometric assessment- Height, weight, BMIRate of weight lossWeight-loss goals, Biochemical assessment- Blood glucoseBlood lipids, Clinical assessment- Blood pressure Dietary assessment- Energy intake, dieting behaviorsFluidCalciumIronDHA (omega-3 fatty acids)Use of dietary supplementsAlcohol intakeCaffeine intake Environmental assessment- Return to work, need for breast pumpAwareness of infant hunger/satiety signalsAccess to positive role models/lactation consultant

List some societal benefits of breastfeeding.

Decreased medical costs for families and businesses Greater employee productivity (because employee's children are less likely to get sick)

Describe the possible connection between maternal diet and infant colic.

Colic: crying >3 hours/d with no medical cause The cause for colic is unknown. Most cases are not likely to be related to the infant's or the mother's diet. However, caregivers frequently assume that colic is related to the diet. Evidence indicates a possible role of some components of the maternal diet in infant colic; some infants are very sensitive to maternal diet (but most are not).Cow's milkOnionsCabbageBroccoliChocolate If a dietary cause for colic is suspected, it can be useful to keep a diary of mom's food intake and baby's symptoms. If foods/food groups are eliminated to assuage infant colic, be careful to ensure dietary adequacy. At this time, there is insufficient evidence to support administration of probiotics to the infant as a treatment for colic

Describe the nutritional qualities of colostrum (a.k.a. "liquid gold").

Colostrum: thick, yellow fluid that is secreted by the breast in the first few days after birth (end of lactogenesis I) The volume of colostrum is small, but the quality of this fluid is high Nutritional qualitiesEnergy: 16 kcal/oz (55 kcal/100 mL)Concentrated source of protein (lactoferrin, immune factors)Concentrated source of electrolytes (sodium, potassium, chloride)Concentrated source of antioxidants (vitamin E, carotenoids)

Identify common pediatric food allergens.

Cow's milk Wheat Eggs Peanuts Soybeans Tree nuts

Identify the factor that is most strongly related to milk supply.

DEMAND! Removal of milk from the breast stimulates more milk production. There are two mechanisms by which demand for milk regulates milk production (Weaver, 2016):Milk contains a protein called feedback inhibitor of lactation (FIL). When the alveoli are full of milk, this protein inhibits further milk production. Conversely, when milk is removed from the breast, the inhibitor is also removed, so milk production increases.Prolactin (the hormone that stimulates milk production) must bind to a receptor on the the surface of the milk producing cells in the alveoli. When the alveoli are full of milk, prolactin does not bind to the receptors very effectively, so milk production decreases. Conversely, when milk is removed from the breast, prolactin efficiently binds to its receptor and signals the milk-producing cells to produce more milk. Frequency of feeding is not as important as emptying of the breasts. Breast size may limit milk storage between feedings, but has little bearing on overall volume of milk production

Discuss the energy needs of breastfeeding women.

DRIs for energy intake for breastfeeding women factor in a moderate kcal deficit to allow for gradual loss of excess body fatbirth up to 6 months: prepregnancy EER + 330 kcal/d (allows for gradual weight loss of ~0.8 kg/month)6 months up to 12 months: prepregnancy EER + 400 extra kcal/d (allows for weight maintenance after excess weight has been lost) Note that the daily calorie needs for breastfeeding women are about the same as the daily calorie needs during the second and third trimester of pregnancy. Actual energy needs are highly variable- Milk production Maternal BMR, Physical activity, Use of infant formula or complementary foods Individual assessment of maternal energy needs is based on, Maternal dietary nutrient adequacy, Maintenance of milk supply, Protein-calorie malnutrition reduces milk supply, but generally does not alter milk composition

Identify risks of drugs of abuse during pregnancy.

Despite being legal in many states, marijuana is classified as a drug of abuse that is contraindicated during breastfeeding.THC levels are higher in breast milk than in mother's blood; THC is slowly metabolized by infantMay cause structural changes in brain cells, decreased motor developmentMay impair synthesis of DNA, RNA, and neurotransmitters Amphetamines, cocaine, heroin, and PCP are considered drugs of abuse and are contraindicated during breastfeedingAdverse pharmacological effectsLack of standardizationPotential for contamination

Recall the recommended duration and frequency of infant feeding.

Duration- Allow the infant to nurse (i.e., feed at the breast) as long as he wants to.Empty one breast completely, then switch to the other breast if the infant is still hungry. For the infant, this ensures that the infant gets the high-fat hindmilk to supply adequate energy for growth. For the mother, completely emptying the breast stimulates continued milk production.The length of a feeding may vary a lot from infant to infant, but is usually 20 to 40 minutes. Frequency- Allow the infant to nurse as frequently as he wants to. 10 to 12 feedings per day is normal for young infantsCluster feeding: As the infant develops a routine, it is normal for an infant to have several feedings close together during the day, and then go for a prolonged time (i.e., overnight) without feeding.There is wide variation in feeding patterns among infants. As long as the infant is gaining weight normally and the mother is not in pain, we are not worried!

Identify the hormones that regulate mammary gland development.

During puberty, the cyclic release of estrogen and progesterone stimulates early development of the mammary glands During pregnancy, placental lactogen and chorionic gonadotropin stimulate further development of the milk-producing cells

Recall cases in which dietary supplements may be appropriate for breastfeeding infants.

Fluoride: prevents dental caries; consult a pediatrician or dentist if water supply has little or no fluoride (more information will be provided in Module 5). Vitamin D: AAP recommends that all infants receive 10 mcg (400 IU) of supplemental vitamin D (administered in liquid form using a medicine dropper) until intake from foods supplies this much (more information will be provided in Module 5). Iron: preterm infants or infants born to mothers who experienced anemia during gestation may need supplemental iron; iron supplementation is recommended after 4 months of age for exclusively breastfed infants (more information will be provided in Module 5).

Recognize that the benefits of breastfeeding outweigh any potential risks from environmental pollutants.

Environmental contaminants are present in human milk, but effects on infant well-being are unknown Except in cases of extreme exposures (e.g., from work), breastfeeding is the preferred choice for infant feeding High level of antioxidants in breast milk may counter any harmful effects of environmental pollutants

Recall current recommendations of the American Academy of Allergy, Asthma, and Immunology regarding breastfeeding and infant allergies.

Exclusive breastfeeding for the first 4 to 6 months of life, followed by continued breastfeeding with addition of age-appropriate complementary foods, is the most effective strategy we have for prevention of allergic diseases There is no evidence to support maternal dietary restriction during pregnancy or breastfeeding to prevent allergies among otherwise healthy infants

Recall medicinal herbs that are traditionally used as galactagogues.

FenugreekMost commonly used herbal galactagogueAnecdotal evidence supports its use, but limited research data is availableUsual dosage is considered compatible with breastfeeding Goat's rue Milk thistle Blessed thistle

Cite several reasons why employers should support and promote breastfeeding.

Fewer absences to take care of sick children (because breastfeeding supports immune function of infant) Improved loyalty Increased employee retention

Recall the average volume of human milk production.

First month of infant feeding: ~600 mL/d Milk production usually peaks at 4 to 5 months postpartum (~750 - 800 mL/d)Up to this point, milk production has increased gradually to meet the increased energy needs of the growing infant.Most infants start to eat some solid foods after this point. Human milk should still provide the foundation of the older infant's diet, but complementary foods will supply extra energy and nutrients.

Discuss common breast anatomical issues that may impact breastfeeding success.

Flat nipples: the nipple does not readily protrude when pinched or under suction Inverted nipples: the nipple pulls inward when pinched or under suction

Discuss the fluid needs of breastfeeding mothers.

Fluid needs are highly individualizedClimateMilk productionPhysical activityBody composition Simplest assessment of hydration: urine color should be no darker than pale yellow AI for total water for breastfeeding women = 3.8 L/d (~16 c/d); this equates to ~13 c/d of fluid intake (i.e., not considering fluids from foods) Most breastfeeding women achieve adequate hydration by drinking to satisfy thirst.

Recognize that protection from allergic diseases is one of the most important benefits of breastfeeding. Distinguish between food allergy and food intolerance

Food allergy: abnormal or exaggerated immune response to a specific food protein. Food intolerance: adverse reaction to a specific food that is not mediated by the immune system; usually due to reduced or missing enzyme that affect digestion or metabolism of food component

Understand the potential impact of breast surgery on the ability to breastfeed.

For a woman who has had breast surgery, her ability to successfully breastfeed her infant depends on the extent to which the lobes, ducts, and nerves of the breast have been damaged/removed. Many women are able to successfully breastfeed after breast surgery (CDC, 2021 (Links to an external site.)). Breast reduction surgery is related to lower rates and duration of breastfeeding and perception of insufficient milk supply. The ability to breastfeed may be impaired if the lactiferous ducts have been damaged by breast reduction surgery. Breast augmentation surgery may compress the lactiferous ducts, leading to low milk supply.

Differentiate between foremilk and hindmilk.

Foremilk: produced in the first few minutes of feeding; higher in protein and carbohydrates (~20 kcal/oz) Hindmilk: produced near the end of a feeding; higher in fat (~28 kcal/oz)

Recognize infant hunger and satiety.

HungerFeed the infant when early signs of hunger are evident; it is difficult to initiate breastfeeding comfortably when the infant is distressed and uncomfortable due to hunger.Early signs of hungerMouthing, sucking on hands or fingersRooting reflexLate signsCrying SatietyInfant stops nursingInfant turns head away from breastInfant falls asleep

Recommend strategies to increase milk supply.

Frequent feeding/pumping (every 2 to 3 hours, once overnight) Ensure dietary adequacyCaloriesFluid Rest, relaxation, stress reduction Avoid use of estrogen (in contraceptives) GalactagoguesPrescription medications are effective, but may have side effectsMetoclopramide (Reglan)Domperidone (Motilium)Herbal remedies have not been adequately assessed for safety or effectiveness by FDAFenugreekMilk thistleGoat's rueBlessed thistle

Outline resources for breastfeeding support that are available for mothers before and after birth.

Health care team: 2 to 4 days after discharge, members of the health care team should follow up with breastfeeding mothers to ensure successful breastfeeding (i.e., the infant is latching on, the infant hasn't lost >7% of birth weight, the infant is producing at least 6 wet diapers per day, no pain for the mother).Doulas: support person and advocate for a woman during pregnancy, birth, and lactationLactation consultants: health care professional trained to educate mothers and provide support for breastfeeding mothers La Leche League (Links to an external site.): international group that provides education, support, and advocacy for breastfeeding mothers Friends or family members who have successfully breastfed infants Social networks (e.g., breastfeeding support groups on Facebook) Peer counselors Support groups

Describe national efforts to promote breastfeeding in the U.S.

Healthy People 2030 includes several objectives to increase the proportion of infants in the U.S. who are breastfed. A proportion of WIC budget is allocated toward promotion and support of breastfeeding.Breastfeeding mothers are eligible to receive food assistanceEducation and support are available 2010 Amendment to Fair Labor Standards Act requires employers to provide reasonable break time and private, non-bathroom space for breastfeeding mothers to express milk (does not pertain to all employers). CDC conducts research on the outcomes of breastfeeding.

Recommend strategies to prevent or relieve sore nipples.

Help the infant to latch on properly for each feeding Let nipples air dry after feeding Wash breasts with warm water only (i.e., avoid harsh soaps) Rub expressed milk on nipples after feeding Warm compress Use lanolin (non-petroleum) ointment

List resources to provide human milk to infants when the mother's own milk is unavailable.

Human Milk Banks in North America (non-profit) Human Milk 4 Human Babies (internet, not well regulated, not recommended as safe) Prolacta (for-profit)

water

Important for maintenance of fluid volume in the infant Breast milk is isotonic with plasma; infants do not need additional fluid to maintain hydration. In fact, extra water can cause hyponatremia in young infants. (Remember osmosis? Think about why plain water could lead to hyponatremia.)

Recognize the importance of proper infant positioning for successful breastfeeding.

Improper positioning of the infant on the breast can cause pain and/or damage to the nipple. Describe five tried-and-true breastfeeding positions. To facilitate deep latch-on, the breast should be presented with the nipple centered and directly in front of the infant's mouth. The infant should latch on deeply, so that all or most of the areola is in the infant's mouth. As the infant suckles, the end of the nipple should be positioned well inside the mouth, behind the infant's hard palate. The infant should swallow deeply and rhythmically. This does make some small, soft noises. However, any sounds like smacking, clicking, or slurping indicate a poor latch. A poor latch can limit the delivery of milk to the infant and also cause pain for the mother.

Discuss global efforts of the World Health Organization to support and promote breastfeeding.

In 1981, the World Health Organization adopted the International Code of Marketing of Breast-Milk Substitutes.Protects and promotes breastfeeding as the standard for infant feeding and ensures the proper use of human milk substitutes when these are necessary Health care facilities should not be used for the purpose of promoting alternative infant feedingFree or subsidized HMS, bottles, and nipples should not be providedInstructions for preparation for HMS should not be displayed In 1991, the World Health Organization and the United Nations Children's Fund established the Baby Friendly Hospital Initiative (Links to an external site.) to help hospitals provide an environment that supports and promotes breastfeeding.

Note that breastfeeding recommendations for mothers with HIV differ in developed and developing nations.

In developed nations, where infant formula is safe and affordable, mothers with HIV are advised NOT to breastfeed to reduce risk of mother-to-child-transmission of HIV In developing nations, where many families do not have access to infant formula and the water supply for formula preparation may be unsafe, it is safer for mothers to exclusively breastfeed their infants for the first six months of life, followed by continued breastfeeding through 12 months with the introduction of age-appropriate solid foods.

Recognize signs of hyperlactation (a.k.a. milk oversupply).

In the motherBreasts are not completely drained after feedingChronic plugged ductsLeaking milk between feedingsPain with letdown In the infantCoughing, choking, gagging during feedingsFrequently spitting upExcessive gasGreen, frothy, explosive bowel movementsPoor weight gain (infant gets full on foremilk, doesn't get energy-dense hindmilk)

Cite common causes of mastitis.

Ineffective milk removal from breast, which leads to engorgement, which leads to plugged duct, which leads to mastitis Tight clothing

Recognize signs of hyperactive letdown.

Infant chokes, coughs, gags, or gulps during feeding Gas pain/colic Foremilk is high in carbohydrates, which can be poorly digested by the infant, then fermented by gut bacteria The infant may swallow air while trying to gulp down the rapid flow of milk from the breast

Identify the challenges of breastfeeding preterm infants.

Infant's medical complications, weak suck, and immature swallow necessitate expression and storage of breast milk for several weeks High maternal commitment is required to establish and maintain good milk supply Education is required for proper milk collection and storage

Identify common causes of low milk supply.

Infrequent feeding/pumping Inefficient emptying of breastPoor latchIncorrect breast pump flange size

iron

Iron is necessary for red blood cell health and neurological development. Most of the iron in human milk is bound to lactoferrin. This form of iron is highly bioavailable to infants, but not available to bacteria. This is one feature of human milk that provides an immunological advantage over infant formula. Even though the overall iron content of human milk is low, most term infants have adequate iron status. Iron is transferred from the mother to the fetus in the final weeks of gestation. Thus, a term infant is equipped with enough iron to meet needs for about 4 to 6 months of life. The infant's needs for iron are a key factor in the decision to introduce complementary foods.

Identify key barriers to breastfeeding.

Lack of knowledge- No positive role model of successful breastfeeding, Misconceptions (e.g., many women believe that small breasts are not capable of producing milk) Lactation problems- Improper latch-on leads to discomfort, Low milk supply (real or perceived) Poor family and social support-Social norms, Embarrassment, Employment and child care, Demanding or irregular work schedule, Employer may not be supportive of breastfeeding Health services- Lack access to health care, Some health care workers are not adequately trained to support and promote breastfeeding

Carbohydrates

Lactose is the main carbohydrate in breast milk. Lactose enhances calcium absorption. Oligosaccharides are prebiotics, which selectively promote growth of probiotic (beneficial) bacteria. We'll talk more about human milk oligosaccharides (HMOs) in Module 5, but here's an interesting podcast to pique your interest!

lipids

Lipids provide most of the energy in human milk (~50% of total kcal). This high energy density is vital to meeting the energy needs of the infant, who has relatively high energy needs, but a small stomach capacity. Fat content varies within a feeding (foremilk < hindmilk) Maternal diet can affect the fatty acid composition, but not the total amount of fatDHA (an omega-3 fatty acid) is important for brain and eye developmentTrans fatty acids The cholesterol in breast milk is important for cell growth and development (component of cell membranes)

Spot signs of malnutrition in a breastfeeding infant.

Losing more than 7% of birth weight Apathy Difficult to wake up Weak cry <6 wet diapers per day Dark yellow or strong-smelling urine Hard, dry stools

Outline the stages of lactogenesis (milk production).

Mammogenesis: development of breast tissue, which begins in utero, continues through puberty, and is finally completed during pregnancy Lactogenesis I: early milk (colostrum) production, begins mid-pregnancy and continues through a few days after birth. Breasts may leak some colostrum late in pregnancy. Lactogenesis II: production of mature milk; usually defined as ~3 to 8 days after birth. This is the stage when "milk comes in." The mother's breasts become noticeably full - possibly engorged if the milk is not released. Lactogenesis III: maintenance of mature milk production; ~9 days postpartum until the infant is weaned

Recommend strategies to facilitate successful breastfeeding for women with flat or inverted nipples.

Manual nipple stimulation or use of a breast pump prior to feedings can draw out nipples. There are many products designed to draw out nipples. Although they are not endorsed by professional organizations, many lactation consultants recommend themBreast shell worn inside bra Nipple enhancer (similar to syringe) used immediately prior to feedings Nipple shield worn during feedings

Recall recommendations for optimal duration of breastfeeding.

Many health authorities, including the World Health Organization and U.S. Surgeon General, recommend exclusive breastfeeding for the first 6 months of life Recent research shows that the best time to introduce solid foods is between 4 to 6 months of age After 6 months of age, most U.S. health authorities recommend continued breastfeeding with the addition of age-appropriate solid foods through 1 year of age WHO recommends continued breastfeeding through 2 years of age

Recommend a safe rate of weight loss for breastfeeding mothers.

Many women still retain excess body weight by 1 year postpartum Breastfeeding mothers need at least 1800 kcal/d; consuming <1500 kcal/d decreases milk supply Modest energy restriction (deficit of ~500 kcal/d below requirements for weight maintenance) can be achieved while still maintaining nutrient adequacy Physical activity alone is not as effective as a combination of physical activity and modest calorie restriction Careful attention to micronutrient intake during weight-loss effortsCalciumVitamin DVitamin CVitamin E A safe rate of weight loss is 0.5 to 1 pound per week. Rapid weight loss is not recommendedCan diminish milk supplyIncreased risk for gallstonesDue to everyday exposure to environmental contaminants, everyone has a low level of toxins present within the body. Many environmental contaminants are stored in adipose tissue. During weight loss, any environmental contaminants that have been stored in adipose tissue will be released into the blood. Some of this may end up being secreted into the breast milk. Thus, losing weight very rapidly will result in a higher level of contaminants in the mother's milk.

Cite common causes of plugged ducts.

Milk stasisMissed feedings Incomplete emptying of breast during feedings

Identify obstacles to successful breastfeeding of multiples.

NOTE: Milk supply is not the limiting factor! Time commitment Maternal fatigue Medical problems (of mother or infants) may interfere with breastfeeding

Describe infant suckling.

Non-nutritive sucking: quick, not rhythmic Nutritive sucking: slow, rhythmicNipple is compressed between the infant's tongue and palateThe infant's tongue moves in backward, peristaltic motions to draw milk from the breastThe tongue channels milk toward the back of the oral cavity for swallowing

Recommend strategies to reduce hyperlactation.

Nurse only on one side during feedings (allows infant to get hindmilk, over time will reduce milk supply) Cold compress Cabbage leaves

List the benefits of breastfeeding preterm infants.

Nutritional composition of breast milk from mothers of preterm infants is higher in protein and energy, while slightly lower in lactose Nutrients in breast milk are easily digested and absorbed Promotes development of infant's digestive system Immune factors from breast milk (especially with skin-to-skin contact) decrease rates of many types of infections (e.g., necrotizing enterocolitis (Links to an external site.)) Improves vision Improves motor and mental development

Recognize the importance of human milk fortifier for preterm infants.

Nutritional needs for protein and many vitamins and minerals exceed the content of human milk Human milk fortifier is provided in addition to breast milkProteinVitaminsMinerals

energy

On average, mature milk provides ~20 kcal/oz (67 kcal/100 mL). Within a feeding, the energy content of human milk varies considerably because the macronutrient composition of human milk changes from the start to the end of the feeding.

Define mastitis.

Painful inflammation or Infection of the breast

Recognize the signs/symptoms of plugged ducts.

Painful knot in breast tissue

Identify the two most common reasons women stop breastfeeding.

Perceived low milk supply Nipple pain, which is most likely due to improper latch-on

Recommend strategies to prevent or relieve plugged ducts.

PreventionFrequent feedingsChange breastfeeding positionUse a larger breast pump flangeOral lecithin (emulsifier) TreatmentWarm compressGentle massageFrequent feedings on the affected breastComplete emptying of breast

Recommend strategies to prevent/alleviate mastitis.

PreventionSame as for plugged ducts Avoid abrupt weaning Treatment Adequate rest, fluids, and nutrition Ibuprofen Antibiotics

Cite the causes of sore nipples.

Problems with infant feeding/improper latch-on (MOST COMMON CAUSE) Trauma due to improper positioning of infant at the breast or poor latch Improper release of suction after feeding Disorganized or dysfunctional suck Infection Pumping problems Too much suction Incorrect flange size Dermatologic problems Use of irritating soaps or lotions Trapped moisture

Discuss several ways employers can support breastfeeding mothers.

Provide adequate maternity leave Allow break time and clean space for moms to express breast milk Provide on-site daycare Allow moms to leave work to nurse their infants during the day Allow moms to bring infants to work

Explain why dietitians (RDNs) and dietetic technicians (NDTRs) are uniquely positioned to promote and support breastfeeding.

RDNs and NDTRs have opportunities to influence pregnant or lactating mothers or breastfeeding children in a wide variety of settingsHealth care (e.g., neonatal clinic, OB/GYN office)Community nutrition services (e.g., WIC clinic)Private practiceEducationResearchPharmaceutical salesWorkplace wellnessPublic policy RDNs and NDTRs understand and appreciate the impact of nutrition on current and future health outcomes. RDNs and NDTRs are trained in translating complex scientific knowledge into practical, actionable health recommendations.

Describe the effects of nicotine on breastfed (and bottle fed) infants.

Regardless of feeding choice, exposure to smoke increases infant's risk forOtitis media (ear infections)Exacerbations of asthmaGI problems (e.g., reflux) Nicotine levels are higher in breast milk than in blood AAP removed nicotine from list of drugs with adverse effects on infant (so as not to discourage smoking mothers from breastfeeding) Smoking increases infant's exposure to environmental toxins Mothers who smoke are less likely to breastfeed, more likely to stop breastfeeding early Possible effects on milk production Lower milk outputLower fat content of milk Sparse data is available on the effects of e-cigarettes.

Identify nutritional concerns for breastfeeding mothers.

Relative macronutrient needs of breastfeeding women (yellow bars) The RDA for protein increases to 1.3 g/kg/d The RDA for carbohydrates increases to 210 g/dThe AI for fiber increases to 29 g/d The AMDR for fat remains at 20% to 35% of total kcalThe AI for linoleic acid increases to 13 g/dThe AI for alpha-linolenic acid increases to 1.3 g/d Careful attention to nutrients that are observed to be low in maternal diets Calcium, Vitamin D,Vitamin C, Vitamin B-12 (vegan moms) Recommend food sourcesLow-fat dairy products (or Ca+D fortified dairy alternatives)Whole, unprocessed fruits and vegetablesWhole grains There is no evidence to recommend routine micronutrient supplementation for breastfeeding mothers, but many practitioners recommend that breastfeeding moms continue to take their prenatal supplements. Address micronutrient shortfalls on a case-by-case basis.

Recommend strategies to stimulate letdown.

Relax (go for a walk, get a massage) Try different breastfeeding position Decrease caffeine intake Increase water intake Prescription oxytocin nasal spray (limited duration)

Recommend strategies to prevent or relieve breast engorgement.

Remove milk from the breastFrequent feedings Express milk Warm shower, warm compress Relieve painAnalgesics (e.g., ibuprofen)Cabbage leaves (may relieve pain, but evidence does not demonstrate effect on engorgement)

Recommend strategies to cope with hyperactive letdown.

Remove the infant from the breast after initiating feeding until milk flow slows down Express some milk prior to starting feeding Breastfeeding in a reclining position may help

List nutritional strategies to support a mother who is breastfeeding multiples.

Screen for nutritional problems Provide individualized nutrition education. Encourage mother to drink to satisfy thirst Encourage mother to obtain nutrients from a well-balanced, varied diet, rather than dietary supplements

Describe infant reflexes involved in feeding.

Suck reflex: the infant sucks when the roof of the mouth is stimulated; the infant can suck deeply and rhythmically enough to obtain milk from the breast while maintaining a normal breathing pattern by ~32 weeks gestation. Infants born earlier than 32 weeks gestation may not be able to suckle effectively enough to obtain adequate nutrition and will probably require supplemental feeding of infant formula and/or pumped breast milk. Gag reflex: prevents foods and fluids from entering the lungs. Oral search reflex: infant opens his mouth and thrusts his tongue forward when presented with the breast. Rooting reflex: infant searches for the nipple when the cheek or lips are stimulated.

Recognize signs of breast engorgement.

Swelling of breasts due to overfilling with milk Hardness of breasts Tenderness, pain Infant has difficulty latching on and removing milk from the breast

Identify sources of mercury to avoid during pregnancy and breastfeeding.

Swordfish (avoid) Shark (avoid) King mackerel (avoid) Tilefish (avoid) Albacore tuna (limit) Locally caught fish (pay attention to EPA advisories)

Recognize the signs/symptoms of mastitis.

Tender, hot, enlarged, wedge-shaped area in the breast Redness of the skin in the affected area (may appear as red streaks) Fever, flu-like symptoms Yellow discharge from the nipple

vitamin soluble vitamins

The B vitamins function as coenzymes for energy metabolism and are involved in neurological development. B vitamin content of human milk can be influenced by the maternal diet, but is usually adequate to meet the infant's nutritional needs. Rarely, infants may suffer neurological damage due to maternal vitamin B-12 deficiency. This is only a concern for women who follow a strict vegan diet (vitamin B-12 is only naturally found in foods of animal origin) or for women with pernicious anemia (an autoimmune disease that impairs vitamin B-12 absorption from foods).

vitamin e

Vitamin E is necessary for muscle growth and development and red blood cell membrane integrity. Breast milk provides sufficient vitamin E for term infants. Preterm infants require supplemental vitamin E. This is because fat-soluble vitamins are usually transferred from the mother to the fetus during the final weeks of gestation, so preterm infants miss this opportunity to receive vitamin E. Poor vitamin E status in the infant can lead to anemia in the infant because the red blood cell membranes rupture easily (hemolysis).

protein

The overall protein concentration of human milk is low, but the proteins are highly absorbable and ideally suited to promote infant health.Antiviral and antimicrobial effectsAnti-inflammatory effects Casein and whey are the two main proteins in human milk. Casein enhances calcium absorption.Whey aids in digestion and immune protection; it is very easily digested.` Lactoferrin (a component of whey protein) binds to iron.This form of iron is highly bioavailable to the infant.Iron bound to lactoferrin is not available to bacteria. Other sources of nitrogen (e.g., nucleotides) are important for growth and disease resistance

Relate the flavor of human milk to the infant's acceptance of solid foods.

The slight sweet flavor (from lactose) encourages the infant to eat. Infants have an innate preference for sweet flavors. Exposure to flavor compounds from the maternal diet may increase the infant's milk intake and may improve the acceptance of a variety of solid foods later in life.

Other trace minerals

Trace minerals often serve as cofactors for metabolic reactions or as structural components for growth and development. Zinc is especially important for protein synthesis. Human milk is not a good source of fluoride. Infants who live in areas without fluoridated water may need supplemental fluoride to promote oral health after 6 months of age. (We will cover this in greater detail in Module 5.)

Compare the nutritional qualities of human milk to cow's milk and infant formula.

Unaltered cow's milk is too high in protein and minerals and too low in fat to meet the infant's nutritional needs within the bounds of the infant's GI tract function.

Recall recommendations for caffeine use during breastfeeding.

Up to 3 cups of coffee per day is considered safe, although some infants may be more sensitive than others Effects of excessive caffeine on infantFussyHyperactiveWakeful

Recognize that discontinuation of breastfeeding to take a medication is rarely necessary and should only be done as a last resort.

Use of some medications can be delayed (e.g., elective drugs or surgeries) Alternative medications may be available Alternative routes of administration may be available (e.g., topical, inhaled) Timing of doses can be manipulated to minimize effects on infant "Pump and dump" during short-term use of problematic medications

vitamin a

Vitamin A is necessary for normal cell growth and development, especially for eye health. Beta-carotene (precursor of vitamin A) is responsible for the yellow color of colostrum.

vitamin d

Vitamin D is necessary for normal cell growth and development, immune function, and bone health of the infant. When maternal vitamin D status is adequate, the vitamin D content of human milk meets infant nutritional needs. However, many women have low vitamin D status. The American Academy of Pediatrics recommends that all infants receive 10 mcg of supplemental vitamin D per day until their intake of vitamin D from foods or formula reaches this level. (This will be explained further in Module 5.) Current research supports the benefit of maternal sun exposure to support maternal vitamin D status, but uncertainty remains about the dosing and effectiveness of maternal vitamin D supplements to increase the vitamin D content of breast milk.

Describe the let-down reflex.

When the infant suckles at the breast, the nerves in the nipple and areola send a signal to the brain. The hypothalamus (region of the brain that coordinates many homeostatic mechanisms) signals the pituitary gland to release hormones that regulate milk production and release from the breast. The anterior pituitary gland releases prolactin, which travels through the blood and signals the secretory cells of the mammary glands to produce milk. The posterior pituitary gland releases oxytocin, which travels through the blood and signals the myoepithelial cells of the mammary glands to release milk. This is called the let-down reflex (also called the milk ejection reflex).

Outline the nutritional qualities of mature human milk.

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NEW! Recall that maternal COVID-19 infection is NOT a contraindication for breastfeeding.

lthough viral RNA can be detected in human milk from mothers who have been infected with COVID-19, there is no evidence that the active virus can be transmitted from the mother to the infant via breast milk. Mothers (and all caregivers) with COVID-19 infection should practice handwashing before feeding and/or expressing breast milk and wear a cloth face covering when in close contact with the infant to reduce the chances of transmitting the virus to the infant (CDC, 2020 (Links to an external site.)). Breastfeeding provides immunological protection against many infections. We currently do not have enough evidence to determine whether or not breastfed infants are protected from COVID-19 by antibodies passed through human milk, but this is an area of current research (WHO, 2020 (Links to an external site.)).

Cite common causes of letdown failure.

stress, alcohol, distractions

Recognize that human milk composition varies...

within a feeding within a day as the infant matures in response to infection with menstrual cycle as nutritional status changes by geographic location