Lesson 4 Nutrition during Lactation Chapters 6

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Lesson 4 Nutrition during LactationChapters 6
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• One of the best things that only you can do is
  breastfeed your baby for as long as possible. The
  longer a mom and baby breastfeed, the greater the
  benefits are for both mom and baby.
• The National Womens Health Information Center,
  2002

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Key Nutrition Concept 1

• 1. Human milk is the best food for newborn
  infants for the first year of life or longer.

Key Concept
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Key Nutrition Concept 2

• 2. Maternal diet does not significantly alter
  the protein, carbohydrate, fat and major mineral
  composition of breast milk, but it does affect
  the fatty acid profile and the amounts of some
  vitamins and trace minerals.

Key Concept
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Key Nutrition Concept 3

• 3. When maternal diet is inadequate, the quality
  of the milk is preserved over the quantity for
  the majority of nutrients.

Key Concept
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Breastfeeding Goals for the United States

• Healthy People 2010 contains wide-ranging
  national health goals focusing on two major
  themes
• Increasing the quality and years of healthy life
• Eliminating racial and ethnic disparities in
  health status
• A specific objective related to breastfeeding is
  to increase the proportion of women who
  breastfeed

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Lactation Physiology Key Terms

• Mammary gland
• source of milk for offspring, AKA breast
• Alveoli
• rounded or oblong shaped cavity present in breast
• Secretory cells
• cells in acinus (milk gland) that are responsible
  for secreting milk components into ducts

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Lactation Physiology More Key Terms

• Myoepithelial cells
• line the alveoli can contract to cause milk to
  be secreted into ducts
• Oxytocin
• hormone produced during letdown that causes milk
  to eject into ducts
• Lactiferous sinuses
• larger ducts for storage of milk behind the nipple

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Lactation Physiology And More Key Terms

• Lobes
• rounded structures of mammary glands
• Lactogenesis
• term for human milk production

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Breast of a Lactating Female
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Stages of Lactogenesis

• Lactogenesis I (birth to 2-5 days) milk formation
  begins
• Lactogenesis II(begins 2-5 days after birth)
  increased blood flow to breast milk comes in
• Lactogenesis III(begins at 10 day after birth)
  milk composition is stable

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Hormonal Control of Lactation

• Prolactin
• Stimulates milk production
• Released in response to suckling, stress, sleep,
  sexual intercourse
• Oxytocin
• Stimulates letdown
• Tingling of the breast may occur corresponding to
  contractions in milk duct
• Causes uterus to contract, seal blood vessels,
  shrink in size

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The Letdown Reflex

• An infant suckling
• at the nipple
• usually causes
• letdown

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Human Milk Composition

• Human milk is the only food needed by the
  majority of healthy infants for 6 months
• It nurtures protects infants from infectious
  diseases
• The composition changes over a single feeding,
  over a day, based on age of the infant, presence
  of infection in the breast, with menses,
  maternal nutrition status

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Colostrum

• The first milk secreted during the first few days
  postpartum
• Very high in proteins
• such as secretory IgA lactoferrin

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Water and Energy in Human Milk

• Water
• Major component in human milk
• Isotonic with maternal plasma
• Energy
• 0.65 kcal/mL
• Higher-fat milk has more calories than lower-fat
  milk
• Lower in calories than human milk substitute (HMS)

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Lipids in Human Milk

• Lipidsprovide ½ the calories in human milk
• Effect of maternal diet on fat composition
• Fatty acid profile reflects dietary intake of
  mother
• Very ? fat diet with adequate CHO protein, milk
  is ? in medium-chain fatty acids

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DHA, Trans Fatty Acids, and Cholesterol in Human
Milk

• DHA (docosahexaenoic acid)
• Essential for retinal development
• Associated with higher IQ scores
• Trans fatty acids
• Present in human milk from maternal diet
• Cholesterol
• Higher in human milk than HMS
• Early consumption of cholesterol through breast
  milk appears to be related to lower blood
  cholesterol levels later in life

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Proteins in Human Milk

• Total proteins
• Lower than in whole cows milk (0.32 vs. 0.98
  g/oz)
• Have antiviral antimicrobial effects
• Casein
• Main protein in mature human milk
• Facilitates calcium absorption

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Proteins in Human Milk

• Whey
• A soluble protein that precipitates by acid or
  enzyme
• Some minerals, hormones vitamin binding
  proteins are part of whey
• Non-protein nitrogen
• 20-25 nitrogen in human milk
• Used to make non-essential amino acids

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Milk Carbohydrates

• Lactose
• Dominant CHO
• Enhances calcium absorption
• Oligosaccharides
• A medium-length CHO
• Second dominant CHO
• Prevent binding of pathogenic microorganisms to
  gut, which prevents infection diarrhea

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Fat-Soluble Vitaminsin Human Milk

• Vitamin A
• Content in colostrum is double that of mature
  milk
• Yellow color from beta-carotene
• Vitamin D
• Most as 25-OH2 vitamin D
• Content reflective of mothers exposure to sun

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Fat-Soluble Vitamins

• Vitamin E
• Level linked to milks fat content
• Level not adequate to meet needs of preterm
  infants
• Vitamin K
• 5 of breastfed infants at risk for K deficiency
  based on clotting factors
• Infants who did not receive K injection at birth
  may be deficient

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Water-Soluble Vitaminsin Human Milk

• Water soluble in general
• Content reflective of mothers diet
• Vitamin most likely to be deficient is B6
• Vitamin B12 and folate
• Bound to whey proteins
• Low B12 seen in women who
• have hypothyroidism or latent pernicious anemia
• are vegans or malnourished
• have had gastric bypass

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Minerals in Human Milk

• Minerals contribute to osmolality
• Content related to growth of infant
• Concentration decreases over 1st 4 months, except
  for magnesium
• Bioavailability
• Most have high bioavailability
• Exclusively breastfed infants have very low risk
  of anemia despite low iron content of human milk

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Trace Minerals in Human Milk

• Zinc
• Bound to protein highly available
• Rare defect in mammary gland uptake of zinc may
  cause zinc deficiency that appears as diaper rash
• Other trace minerals
• Fluoride is only mineral not affected by mothers
  diet

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Taste of Human Milk

• Flavor of foods in mothers diet influences taste
  of breast milk
• Infants seem more interested in mothers milk if
  flavor is new
• Exposure to a variety of flavors may contribute
  to infants interest acceptance of new flavors
  in solid foods

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Benefits of Breastfeedingfor Women

• Hormonal benefits
• Increased oxytocin stimulates uterus to return to
  prepregnancy status
• Physical benefits
• Delay in monthly ovulation resulting in longer
  intervals between pregnancies
• Psychosocial benefits
• Increased self-confidence bonding with infant

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Benefits of Breastfeedingfor Infants

• Nutritional benefits
• Immunological benefits
• Lower infant mortality in developing countries
• Fewer acute illnesses
• Reductions in chronic illnesses
• Breastfeeding childhood overweight
• Cognitive benefits
• Socioeconomic benefits
• Analgesic effects

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Breast Milk Supply and Demand

• Can women make enough milk?
• Does the size of the breast limit a womans
  ability to nurse?
• Is feeding frequency related to the amount of
  milk a woman makes?
• Pumping or expressing milk
• Can women breastfeed after breast
  reduction/augmentation?
• Does silicone from breast implants leach into the
  milk?

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The Breastfeeding Infant

• Optimal duration of breastfeeding
• AAP? 1 year or longer
• U.S. Surgeon General? exclusively for 6 months
  best to breastfeed for 12 months
• Reflexes
• Gag reflexprevents infant from taking things
  into lungs
• Oral search reflexinfant opens mouth wide when
  close to breast thrusts tongue forward
• Rooting reflexinfant turns to side when
  stimulated on that side

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The Breastfeeding Infant

• Breastfeeding positioning

Positions for breastfeeding - proper positioning
of infant is important for breastfeeding success
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AttachmentInfant will open his mouth wide
should be brought to the breast with the nipple
centered in his mouth.Process called latching
on.
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The Breastfeeding Infant

• Identifying hunger and satiety
• Hunger is signaled by infant bringing hands to
  mouth, sucking on them, moving head from side
  to side
• Crying is late sign of hunger
• Allow infant to nurse on one breast as long as
  they want to ensure they get hindmilk with its
  high fat content that provides satiety
• Note High lactose content of foremilk may cause
  diarrhea

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The Breastfeeding Infant

• Feeding frequency
• 10-12 feedings/day are normal for newborns
• Stomach emptying occurs in 1½ hours
• Vitamin supplements for breastfeeding infants
• Vitamin Kall U.S. infants receive injections at
  birth
• Vitamin Dexclusively breastfed infants need
  supplements at 2 months

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Identifying Breastfeeding Malnutrition

• Normal weight loss for newborns
• 7 of birthweight in 1st week
• Weight loss of 10 needs evaluation by lactation
  consultant
• Malnourished infants become sleepy,
  non-responsive, have a weak cry, wet few
  diapers
• By day 5 to 7, infants should have 6 wet diapers
  3-4 soiled diapers

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Maternal Diet

• Based on MyPyramid, a breast-feeding woman needs
  2,400 calories with diet to include
• Grains, 8 ounces
• Vegetables, 3 cups
• Fruits, 2 cups
• Milk, 3 cups
• Meats beans, 6.5 ounces
• Oil, 7 teaspoons

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Case Study 6.1Page 171
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Energy and Nutrient Needs for Lactation

• Energy needs vary by activity level
• DRI is ?500 kcal/day for the 1st 6 months ?400
  kcal/d afterward
• Components of maternal diet may be linked to
  colic.
• Culprit foods cows milk, eggs, peanuts, tree
  nuts, wheat, soy, fish

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Maternal Energy Balance and Milk Composition

• Protein-calorie malnutrition
• results in reduction in milk volume but not
  quality
• Weight loss during breastfeeding
• Theoretically, the caloric DRI assume a loss of
  0.8 kg/month
• Most women do not reach prepregnancy weight by 1
  year after birth
• Modest or short-term energy reductions do not
  decrease milk production

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Exercising and Breastfeeding

• Modest energy restriction combined with increased
  activity may help women lose weight body fat
• Exercise does not inhibit milk production or
  infant growth
• Aerobic activity enhances fatty acid mobilization
  
• Restriction in energy intake enhances prolactin

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Other Factors of Maternal Diet

• Vitamin and mineral supplements
• Not needed in well-nourished women
• Functional foods
• No adverse effects based on studies to date

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Other Factors of Maternal Diet

• Fluids
• Women should drink to thirst
• Alternative diets
• Type diet determines supplement that may be needed

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Barriers to Breastfeeding Initiation

• Embarrassment
• Time social constraints
• Lack of support from family friends
• Lack of confidence
• Concerns about diet health
• Fear of pain

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Breastfeeding Promotion, Facilitation, and Support

• Role of the health care system in supporting
  breastfeeding
• Prenatal breastfeeding education and support
• Lactation support in hospitals and birthing
  centers
• Lactation support after discharge
• The work place
• The community

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Lactation Support after Discharge

• A pediatrician, nurse or other knowledgeable
  health care practitioner should see all breastfed
  infants at 2-4 days of age
• Le Leche League
• Founded in 1956
• International organization that provides
  education, information, support encouragement
  to women who want to breastfeed

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The Community

• Establish a multidisciplinary breastfeeding task
  force with representatives from
• Physicians
• Hospitals and birthing centers
• Public health
• Home visitors
• La Leche League
• Government, industry, school boards
• Journalists

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Public Food and Nutrition Programs

• National Breastfeeding
• Policy

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Public Food and Nutrition Programs

• USDA WIC Program
• Model Breastfeeding Programs
• WIC National Breastfeeding Promotion
  ProjectLoving Support Makes Breastfeeding Work
• Wellstart International

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Key Nutrition Concept

• Most medicationsincluding over-the-counter as
  well as prescription drugs, drugs of abuse,
  alcohol, nicotine, and herbal remedies taken by
  nursing mothersare excreted in breast milk.

Key Concept
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Key Nutrition Concept

• Twins and other multiples can be successfully
  breastfed without formula supplementation.

Key Concept
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Common Breastfeeding Conditions

• Sore nipples
• Letdown failure
• Hyperactive letdown
• Engorgement
• Plugged duct
• Infection

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Condition Sore nipples

• May be prevented by
• proper positioning of
• baby on breast
• The areola should be
• in the babys mouth
• with tongue extended
• against lower lip

Areola
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Herbal Remedies

• Scientific information about herb use during
  lactation is sparse
• Medicinal herbs should be viewed as drugs
• Many herbs are contraindicated during lactation

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Herbs Widely Used in the U.S. with Impact on
Breastfeeding

• Echinacea - not recommended
• Ginseng root - not recommended
• St. Johns wort - may suppress lactaion
• Ephedra (ma huang) - not recommended
• Fenugreek - infants may be allergic
• Cabbage leaves - safe for topical use to reduce
  engorgement

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Alcohol and Other Drugs

• Alcohol
• Nicotine (smoking cigarettes)
• Marijuana
• Caffeine
• Other drugs of abuse
• Environmental exposures

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Alcohol

• Alcohol consumed quickly passes to breast milk
• Level of alcohol in breast milk is same as in
  maternal plasma
• Peak plasma levels occur at 30-60 min. after
  consumption if consumed w/o food and 60-90 min.
  if consumed with food
• Contrary to popular belief, alcohol decreases
  oxytocin and let-down

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Impact of Alcohol on Lactation

• Contrary to popular belief, alcohol decreases
  oxytocin let-down
• Affects odor of milk
• Decreases volume consumed by infant
• Interferes with sleep pattern of infant

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Other Drugs and Lactation

• Nicotine (smoking cigarettes)
• Levels are 1.5 to 3 times higher in breast milk
  than mothers blood
• Half-life of nicotine is 95 minutes, so best to
  delay feeding as long as possible after smoking
• Marijuana
• May change DNA/RNA the proteins needed for
  growth

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Other Drugs and Lactation

• Caffeine
• Level in breast milk is only 1 of that in
  mothers plasma
• May accumulate in infants younger than 3 to 4
  monthsvaries from infant to infant
• May interfere with sleep or cause hyperactivity
  fussiness of infant

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Other Drugs and Lactation

• Other drugs of abuse
• Amphetamines, cocaine, heroin, phencyclidine
  (angel dust, PCP) are classified by the AAP as
  drugs of abuse that are contraindicated during
  lactation

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Breastfeeding Multiples

• Breastfeeding twins, triplets quadruplets is
  possible
• Main obstacle is the time fatigue of mother
• Frequent nursing increases milk supply
• Parents of multiples need support in
• Organization
• Feeding
• Individualization
• Stress management

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Infant Allergies

• Exclusive breastfeeding for 4 months protects
  against allergies, ectopic dermatitis wheezing
• Development of food allergies influenced by
  numerous factors
• genetics, duration of breastfeeding, time of
  introduction of other foods, maternal smoking,
  air pollution, etc.
• Consumption of omega-3 fatty acids by lactating
  mother may protect against allergies

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Food Intolerance

• No scientific evidence shows gassy foods in
  mothers diet produce gas in infant
• Low-allergen maternal diet associated with
  reduction in distressed behavior (colic)
• Allergenic foods eliminated were cows milk,
  eggs, peanuts, tree nuts, wheat, soy, fish

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Breastfeeding and HIV Infection

• HIV infection may be transmitted to infant by
  breast milk
• Transmission rates 5 to 40 depending on duration
  of breastfeeding
• DHHS recommends HIV infected women should not
  breastfeed or provide their breast milk for the
  nutrition of their own or other infants...

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Milk Banking

• Human milk banks
• Provide human milk to infants who cannot be
  breastfed by their mothers
• Some neonates ICUs had milk banks until the 1980s
  when HIV infections became prevalent

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Lactation Case Study

• Mary comes to you for healthy eating and weight
  management after having her baby 6 months ago.
  She is 53 and is currently weighing 130 lbs.
  She gained a total of 30 lbs in her pregnancy and
  has lost 20 lbs. so far, but thinks she is not
  losing fast enough. Mary walks 3 times per week
  for 30 minutes and attends mother-baby classes.
• Marys 24 hour recall reveals
• B Large bagel with cream cheese, coffee and 2
  tsp sugar, maybe fruit
• L Chicken Caesar salad with croutons, coke and
  chocolate cake
• D Turkey burger with fries, lemonade
• Snacks include cheese and crackers, fruit,
  yogurt or jell-o, fruit roll-up

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Lactation Case StudyQuestions

1. Evaluate her food intake. Is she lacking in any
   nutrients?
2. Evaluate her activity level. What do you
   recommend?
3. What information would you include in your
   counseling session?
4. How would you advise her on healthy weight loss
   postpartum?