1. Breast Feeding
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. 1)Milk secretion initiated by prolactin
2) Oxytocin reflex (let down reflex or milk
ejection reflex) from post. pit - contraction of
neuroepithelial cells surrounding alveoli -
ejection of milk.

4. Varying composition of Breast Milk
• Colostrum
• Transitional milk
• Mature milk
• Fore milk
• Hind milk
• Preterm milk

5. Colostrum
• Thick, yellowish milk secreted in the first
several days (5-7 days) after delivery
• Alkaline
• Amount - approximately 100 cc's / 24-hour
• More rich in protein (2.3gm/dl) but less CHO or
fat

6. Composition
• Antibody ( Ig A) rich – protects against infection
and allergy
• Purgative( Laxative effect) - enhances GIT motility
- reducing enterohepatic circulation - clears
meconium helps prevent NNJ
• Growth factors – help intestine to mature
, prevents allergy & intolerance
• Vit A rich – reduces severity of infection

7. Composition
- Antibacterial – (lactoalbumin, lactoferin )
- Rich in cholesterol , Na , K , Cl , Zinc , Copper
, leucocytes ( macrophages , lymphocytes

8. • Transitional milk - is secreted between about
four days and ten days postpartum
• It is intermediate in composition in between
colostrum and mature milk
• The volume increases during this time

9. • Mature milk is produced from approximately
ten days after delivery up until the
termination of the breastfeeding

10. Mature milk contains on average:
• Energy (750 kcal / liter)
• Lipids - main lipids - triacyl-
glycerols, phospholipids, and fatty acids
including essential fatty acids, Cholesterol

11. Mature milk contains on average:
• Casein or curds - proteins with low solubility
which complex with calcium - much lower
concentration than in cow's milk
• Whey - The largest components are alpha-
lactalbumen, lactoferrin, lyzozyme, albumen and
immunoglobulins. Clear liquid left behind when
clotted milk stands

12. Mature milk contains on average:
• Non protein Nitrogen - Peptides, such as
epidermal growth factor, somatomedin - C
and insulin are present in this fraction - play
an important role in the immune system and
protein synthesis
• Lactose (70 g / liter) -major carbohydrate in
breast milk. It is composed of galactose and
glucose

13. Breast milk - minerals:
• Major cations-
sodium, potassium, calcium and magnesium
• Iron - low amounts but the percentage of iron
absorption is very high

14. Breast milk - minerals:
• Zinc, selenium, chromium, manganese, molyb
denum , copper and nickel are present in
small amounts in breast milk
• Vit - K is low in breast milk - hemorrhagic
disease of the newborn
• The vitamin D content of breast milk is less

15. • Hind milk - Fats and lipids are high at the end
of the feeding (hind milk)

16. Preterm milk has more of the
following
• Protein nitrogen
• Immunologic factors
• Medium chain fatty acids
• Sodium
• Chloride
• Iron
• This difference lasts approximately 4 weeks.

17. Less of
• Calories
• Protein
• Calcium/phosphorus
• Trace minerals

18. Composition human milk Vs animal
milk
Per 100ml Human Buffalo Cow
Energy 70 Kcal 88 Kcal 67 Kcal
Protein 1.3 gm 3.3 gm 3.4 gm
Fat 4.2 gm 6.7 gm 3.9 gm
Lactose 7gm 4.6gm 4.6 gm
Vitamin D 0.81 μg – 0.18 μg

19. Composition human milk Vs animal
milk
Per 100ml Human Buffalo Cow
Vit C 3.8mg 3.8mg 1.5mg
Vit B 12 0.01 μg – 0.31 μg
Calcium 35mg 210mg 124mg
Folic acid 5.2 μg 5.6 μg 5.2 μg
Iron 0.08 mg 0.05 mg 0.05 mg

20. Composition human milk Vs animal
milk
Per 100ml Human Buffalo Cow
Water 89.7g 83g 90.2g
Cholesterol – 275/100gm 330/100gm
Retinol 60 μg 72 μg 31 μg
Sodium 15mg 50 mg 52 mg
Potassium 60mg 150mg 155mg
Phosphorus 15 mg 90 mg 98 mg

21. Breast feeding Reflexes
• Rooting reflex
• Sucking reflex
• Swallowing reflex

22. Advantages of BF
1. Normal temperature
2. Economical
3. Convenient
4. Balanced diet
5. Anti-anaemic
6. Anti-allergic
7) Anti-ricketic
8) Anti-infective

23. 7) Anti-ricketic
8) Anti-infective

24. 1)Balanced diet:
A) Protein: 70% soluble ; easily digested.
B) Fat: essential fatty acid - for brain develop.
C) High cholesterol: myelination of nervous
system brain growth
E) High lactose
F) Colostrum: increasing zinc - prevent NEC
G) Low phosphate - prevent neonatal
hypocalcemic convulsions

25. 2) Anti-anaemic:
- Lower risk of iron deficiency anemia - first 6 months of life
because:
A) Higher iron content (1.5 times cow's milk)
B) Better iron absorption due to acidic medium and due to
presence vitamins C,E and copper

26. 3) Anti-allergic
It protects against - infantile eczema , allergic rhinitis , asthma
and other allergies
Mechanism:
• In the intestinal tract there are minute pores - high
molecular protein can directly pass into the circulation
leading to antibodies formation
• Breast milk has secretory IgA - which coats the GIT –
pores closed - prevents leakage of lactoproteins into the
circulation and no formation of antibodies

27. 4) Anti-ricketic
A) higher content of biologically active
vit. D.
B) Ideal Cal/phosph ratio - helps optimal
absorption of both. (Ca/P ratio = 2:1)
C) higher lactose content enhances
calcium absorption from the gut

28. • Biochemical aspect-
- Protein
Whey protein (80%) Lactalbumin
Lactoferrin
Casein (20%)
-Non protein nitrogen level is high -  immunity
-Solutes load is low.
-Lactose promotes Ca & Mg absorption

29. Microbiological aspect
- Sterile milk with less chance of contamination
- Lactoferrin (iron-binding protein) absorbs iron from bacteria
- inhibits growth of E. coli by depriving it from iron.
• B.S.S.L( bile salt stimulated lipase) kills amoeba and
giardia
- Lactose and bifidus factor promote growth of
protecting flora (lactobacilli)

30. Immunological aspect:
• Safe , non-allergic
• Milk B-lymphocytes secrete IgA
• Milk T-lymphocytes involved in cell-mediated immunity
• Milk macrophages synthesize complement , lysozyme and
lactoferrin

31. Psychological factor-
• Emotional bonding
• Maternal benefits- less risk of
ovarian/ breast ca. , involution
of uterus
• Epidemiology
- 14 times less risk of diarrhoea
- 4 times less risk of A.R.I
- 2.8 times less risk of infections.

32. Technique of breast feeding:-
1- Both hands and nipple should be clean
2- Baby should be , warm ; not wet
3- Mother relaxed (sitting or lying on her
side)
4- Support of the breast during feeding

33. Criteria of good position:-
1 Baby’s body is close to
the mother
2 Baby’s body is turned
to the mother
3 Baby’s whole body is
supported (not only
head or neck).
4 Baby’s neck is straight
or bent slightly back

34. 4 Criteria of good attachment:
1) Baby’s chin is touching
the breast
2) Baby’s mouth is widely open
3) Lower lip is turned outwards
4) More areola tissue above than
below the mouth
5) No pain while breast feeding

36. Criteria for Adequate Breast feeding
 Baby feeds at least 8 times 24 hrs
 Baby is calm satisfied after feeds
 Baby sleeps well 2-4 hours after feeding
 Normal motion no constipation
 Normal amount of urine :- 6 or more / 24 hours
 Normal weight gain (20-30 gm/ day or 150-210 gm
/ week

37. II) Criteria of under feeding
• Wt gain ; slow
• Decreased amount of urine
• Crying unsatisfied after feed
• Suckling of fists between the feeds
• Sleeplessness or v. short sleep
• Air swallowing colics, vomiting,
• Constipation or hunger stool (
frequent, small, green color)

38. Criteria of overfeeding
• Frequent regurgitation , vomiting colics
• Large bulky stools undigested curds
• Abdomen distesion
• Skin eruption sore buttocks
• Polyuria
• Excessive sweating at head
• Baby over weight

39. Burping - Method
• Baby put on left
shoulder ; support
with mother’s left
hand
• Right arm- supports
the buttocks & give
gentle pat on baby’s
back.

40. Burping - Method
2. Alternative method
• Baby placed prone in mother’s lap
• Gentle tap given on back.

41. Breast feeding- BFHI
• BFHI- Baby friendly hospital initiative.
- Global programme organised by unicef.
- Launched in 1992
- WABA- World Alliance for breast feeding
action ; global agency for promotion of
breast feeding
- World breast feeding week- 1st -7th august

42. 10 steps of BHFI
1.Written breast feeding policy given to all
health care staff
2.Training of all health care staff
3.Inform mother about benefit and
management of BF
4.Help mother initiate BF within an Hour of
birth
5.Show how to BF even if separated from
infant

43. 10 steps of BHFI
6.Unless medically indicated- no food or drink
should be given to infant
7.Practice rooming-in ; allows mother & child to
be together 24hrs a day
8.Encourage BF on demand
9.No artificial teats or pacifiers to breast feeding
infants
10.Establish BF support group and refer mothers
to them.

44. OPERATIONAL GUIDELINES on BF.
(Source : IAP’s Policy on infant feeding)
Contact points Activity
Antenatal check up Motivate exclusive breast feeding, undertake
physical examination of breast & nipples
Delivery room Initiate BF soon after delivery, discourage
prelacteal feeds, practise rooming in &
bedding in
Primary immunization sessions Confirm exclusive BF, Sort out practical
problems
Measles immunization Confirm continuation of BF & weaning foods
Booster immunization/ pulse polio/ Ensure BF & adequate food intake
any illness

45. Absolute Contraindication of BF
1. Congenital lactose intolerance
2. Galactosemia, phenylketonuria
3. Intake of anti-malignant drugs -
cyclophosphomide methotrexate ;
cyclosporine
4. Antithyroid drugs
5. Antipsychotic drugs

46. Relative Contraindication for BF
I) Maternal causes :-
a) Maternal hepatitis B
b) Maternal HIV/AIDS,TB
c) Intake of dugs - cocaine, Anticoagulants,
Thiouracil ; lithium ; bomocriptine;
chloramphenicol ; tetracycline
d) Breast abscess, crack & soreness of nipple

47. Relative Contraindication for BF
II) Baby causes ;
premature – unable to suck
congenital structural defect – cleft palate

48. Artificial feeding
when:
- Mother is critically ill
- Mother is unavailable
- Or mother is dead.

49. Process of artificial feeding
• Formula feeding
Full strength (1:1) prepared by adding
- One level measure of powder
- One ounce of 30 ml water

50. • Alternative to Formula feeding is Cow’s milk
-1st week of life – 1:1 dilution
- 2nd week – 2:1 dilution
- 3rd week – 3:1 dilution
- 4th week onwards – undiluted milk
* Adverse effect – diluted cows milk has low
nitrogen and calories so more chances of
malnutrition.

51. Adverse effects of artificial feeding
1. Malnutrition due to dilution
2. More diarrhea and respiratory infections due
to contamination
3. More allergy & milk intolerance
4. Salt sensitive hypertension
5. Hypercholesterolemia
6. Coronary artery disease and cerebrovascular
disease

52. 7. Iron deficiency anemia
8. High incidence of diabetes mellitus
9. Lowered IQ
10.Protein intolerance
11.Hypocalcemia - Tetany , Convulsion
12. Vitamin A deficiency
13.Overweight
14. Interferes with bonding

53. Average Feeding levels
- Average daily number of feeds
0 to 1 week – 6 to 10 times per day
1wk to 1 month- 6 to 8 times per day
1-3 months - 5 to 6 times per day
3 to 7 months – 4 to 5 times per day
4 to 9 months – 3 to 4 times per day
8 to 12 months – 3 times per day

54. • Average quantity of milk per feed
- 1st to 2nd week- 60 to 90 ml
- 3rd week to 2nd month – 120 to 160 ml
- 2 to 3 months - 150 to 180 ml
- 3 to 4 months - 180 to 210 ml
- 6 to 12 months - 210 to 240 ml

55. Thank you
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Medical Post [ www.themedicalpost.net ]