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2010-03-28 21:48:19
Lecture # 2 Management Final

Lecture # 2 Breastmilk
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  1. What are the benefits of breastmilk?
    • Nutritional Gold Standard - AAP
    • Health and immunity
    • Developmental and intellectual
    • Psychological and Social
    • Economic
  2. What are the contraindications to receiving breast milk?
    • Galactosemia
    • HIV+ mother in developed countries
    • HSV lesions on the breast- she can breastfeed on the breast that doesn’t have lesions/ pump and dump on the other breast
    • Mother develops chicken pox days before delivery
    • Hepatitis C if titers are high
    • Human T Lymphocytic Virus-1
  3. How does breast tissue develop?
    • Characterized by increase in alveoli and gland size
    • Alveoli are made up of cuboidal epithelial and myoepithelial cells
    • Division and differentiation of cells occurs in 3rd trimester
  4. How is milk made in the breast (lactogenesis)?
    • Alveolar cells secrete and release milk
    • Colostrum - 12 weeks before partuition thru 2 - 3 days postpartum
    • Transitional milk - 2 - 10 days postpartum (more antiinfective properties)
    • Mature milk - 10 days postpartum
  5. How is milk maintained –Galactopoiesis?
    • Dependent on intact hypothalamic - pituitary axis
    • Prolactin - stimulates milk synthesis and secretion
    • Oxytocin - causes ejection reflex
  6. What is important about maintaining milk?
    If not nursing need to pump or signals arent sent to brain to keep making.
  7. What is the relationship between diabetes and brestmilk?
    High amounts of protein in infancy is r/t diabetes so low protein in bst is good
  8. What is the Composition of Human Milk?
    • Protein – 6-8% total cals as 40% casein and 60% whey
    • Fats – 40- 50% total cals, essential fatty acids, PUFA and vitamins (Fat content increases during a feeding)
    • Carbohydrate – 40-50% total cals as lactose and oligosaccharides
  9. Why is colostrum so good?
    • Mean energy value higher
    • Na, K, and Cl concentrations are higher
    • Protein content higher and fat content lower
    • Fat soluble vitamins and mineral content higher
    • Facilitates L-bifidus and meconium passage
    • Inverse relation between length of gestation and concentration of protective factors in colostrum
    • Rich in cytokines, and other immune agents
  10. How are cytokines beneficial in breastmilk
    Bacteriostatic, bacteriocidal, antiviral, antiinflammatory, immunomodulatory
  11. What are the concerns with breastmilk in premature infants.
    • Calcium and phosphorus
    • Protein
    • Sodium
    • Energy
    • Multivitamins
    • Iron
  12. Why is there Difficulty Achieving Optimal Growth for the Preemie
    • Immature organs systems
    • Unphysiologic volume of milk
  13. Why is breastmilk Suitable for Preterm infants GI function?
    • Trophic factors
    • Gastric emptying
    • Gastric motility
    • Feeding tolerance
    • Bioactive substances
    • Enzymes
  14. What are the Protective Factors in Breast milk?
    • Species specific
    • Antibacterial, viral and protozoan
    • Anti-inflammatory properties
    • Anti-allergic properties
    • Promotes organ system maturity
  15. What is the function of sIgA in breastmilk?
    passive immunity through enteromammary immune system
  16. What is the function of lactoferrin in breastmilk?
    inhibits growth of iron dependent bacteria and yeast in gut
  17. What is the function of lysozymein breastmilk?
    Lysozyme - nonspecific antimicrobial factor in gut flora maintenance
  18. What is the function of oligosaccharides in breastmilk?
    Prevents bacterial attachment to host mucosa
  19. What is the function of mucins in breastmilk
    anti - rotavirus
  20. What is the function of lipids in breastmilk
    Disrupt enveloped viruses
  21. What is the Bioactive Substances in Human Milk
    • Secretory IgA, lactoferrin, lysozyme
    • Oligosaccharides
    • Anti-infective lipids
    • Nucleotides
    • Inositol, carnitine taurine
    • Growth factors
    • Hormones
  22. What are the enzymes in human milk that make nutrients bioavailable
    • Lipase - Optimal digestion of fat
    • Amylase - Optimal digestion of starch; Not produced by infant prior to 6 months
    • Protease - Optimal digestion of protein; Fights infection
  23. How is the bronchus and gut associated lymphoid tissue protected by breastmilk
    • Mom is able to produce specific antibodies based on what is going on with the baby
    • Mom has to be exposed to the same germs and antigens as the baby in order to produce the antibodies
  24. What is the increase in diseases when not fed human milk
    • Otitis media 2-5 x increase
    • Respiratory illness 1.5 x increase
    • GI infections 1.7-1.9 x increase
    • Hospitalizations 2 x increase
    • SIDS 3-5 x increase
    • Higher mortality rate, ages 1-12 months
    • Childhood cancer 1.3 x increases
    • Juvenile onset diabetes 2-4 x increase
    • Obesity 1.2-1.6 x to be overweight
    • Higher cholesterol levels as adults with 11% increase in heart disease
    • Children, adolescents and adults all score higher on IQ tests
    • Higer incidence of hypertention
  25. What did the Chen and Rogan study find
    • 1.8 postnatal lives /10000 live births saved by breastfeeding
    • 720 lives in US 1988
  26. What is the Potential Health Care Cost Savings From BF
    • Infant diarrhea $630 million
    • RSV $31 million
    • Insulin dependent DM $ 72 million
    • Otitis media $660 million
    • WIC moms breastfeed, yearly basic food savings $2,665,715.00
  27. What did studys find with Breast Milk and Neonatal Necrotizing Enterocolitis
    • Incidence 6 times more common in formula fed infants
    • Incidence 3 times more common if fed formula and 50% breast milk
    • Pasteurized donor milk seemed to be as protective as raw maternal milk
  28. What did Sisk find with breastmilk and NEC
    Decrease by sixfold if fed 50% HM first 14 days
  29. How does NEC impact the LOS and Costs of Hospitalization
    • Increase risk of death, infection and need for CC
    • Surgical NEC LOS extended 60 days ($ 186,200 additional costs/pt)
    • Medical NEC LOS extended 22 days
  30. How much does Human Milk Feedings in the ICN Protect Against Nosocomial Sepsis
    • Day 1 -10 of life: Sepsis 5% in HM vs 10% in FF
    • Day 11 - 24 of life: Sepsis 9% in HM vs 20 % in FF
    • Day 25 - 38 of life: Sepsis 0% in HM vs 15 % in FF
    • E coli+Enterococcus colonization increased in HM fed stools (remember that when the ecoli is where its supposed to be its competing with the bad stuff so the ecoli wins and the bad stuff is expelled)
  31. How do infection rates differ in infants fed Human Milk Infection and are VLBW Infants
    • Sepsis and meningitis: 32.6% for PF vs. 19.5% in MM
    • Multiple infections: 8% for PF vs. 3.3% in MM
    • MM dose response effect not noted
  32. What are the Beneficial Outcomes of Feeding FHM vs. PF
    • Host defense or feeding tolerance- FHM no affect
    • Mortality- 1 in FHM and 3 in PF
    • Medical and surgical NEC- 1 in FHM and 9 in PF
    • Late onset sepsis- significant decrease in FHM
    • Prescribed anti-reflux meds- lower with FHM
    • Hospital stay- 2 weeks earlier and 500 gms leaner with FHM
  33. Effects of Maternal Milk on Neonatal Morbidity of VLBW Infants
    • Incidence of sepsis at 2,4,6 weeks with MM vs. PF
    • MM greatly reduced incidence of sepsis if at 50 ml kg day minimum by factor of 0.27 (95% CI 0.08-0.95)
    • Greater mean vol of MM after 2 weeks the lower the incidence of sepsis up to 6 weeks
    • No difference in NEC, CLDN, ROP, LOS
    • Concerns: study sample size too small to show differences
  34. What do Randomized Trials of DBM vs. PF in Extremely Premature Infants show
    • NEC: MM 6%, DM 6%, PF 11%
    • Sum of death, infection events
    • Fewer cases Stage 3 ROP
    • LOS (time in hospital) decreased 1 week
    • Less CLDN in MM and DM
    • DM showed little short term advantages vs. PF
    • Concerns: All infants fed 50 cc kg day MM
  35. What are the protective Effects of Breast milk Against NEC
    • Lactobacillus predominates in breast milk stools
    • Gram neg bacteria predominates in formula stools
    • Molecules prevent attachment and transport through gut wall
    • WBC’s kill, ingest or give rise to antibodies in the gut
    • Enhancement of antimicrobial activity
    • Enzymes degrade inflammatory mediators
    • Stimulation of gut to mature and grow
  36. How does Human Milk Enhances Cognitive and Retinal Function in Premature Infants
    • 4-8 point difference in IQ scores
    • Higher visual developmental scores
    • Higher Bayley developmental score of 4 points
  37. What Essential Fatty Acids for Brain and Retinal Development are beneficial in breastmilk
    • Arachidonic acid (AA) and docosahexaenoic acid (DHA)
    • Long chain polyunsaturated fatty acids
    • Term and preterm infants synthesize 5-10% needed
    • Both found in CNS and retinal tissues
    • Affect gene expression and cell membrane function
  38. What components in breastmilk Improve Visual Function
    • Long chain polyunsaturated fats
    • Antioxidant activity of B-carotene, taurine and vitamin E
    • Diagnosis of ROP 2.3 times greater if formula fed
    • Severity of ROP less if human milk
  39. What are the Health Benefits for Breastfeeding Mothers
    • Earlier return to prepregnant weight
    • Delayed ovulation with increased child spacing
    • Improved bone remineralization postpartum
    • Reduced risk of ovarian and premenopausal breast cancer
  40. What are the obstacles to the initiation and Continuation of Breastfeeding
    • Insufficient pre and postnatal education
    • Disruptive and inappropriate hospital policies
    • Maternal employment
    • Lack of societal support
    • Commercial promotion of formula
  41. Characteristics of High Breastmilk Use Sites
    • MD’s openly voice support
    • RN’s facilitate breastmilk use
    • RN’s help maximize mothers BM supply
    • RN’s convey need, expectations of production and provide guidance
  42. What is the Role of the NNP in Promoting Breastfeeding ( BF )
    • Educates parents about benefits of breast milk and BF
    • Become knowledgeable and skilled in clinical management of BF
    • Promote hospital policies that facilitate BF
    • Collaborate to ensure BF education, support and counsel
    • Promote BF as a normal part of daily life
  43. Establishing a Breast milk Supply for Preterm Infant
    • Initiate milk expression within 6 hours of birth
    • Counsel on use and frequency of piston style pump (Medela has a new special pump for premies)
    • Secure pump for Mom prior to discharge home
    • Counsel on medications and drugs
    • Teach how to collect, handle, store and transport milk
  44. How can the mother maintaine a Breast milk Supply for Preemie
    • Praise efforts pumping milk
    • Kangaroo care
    • Galactagogues: dopamine antagonist (fenugrag, reglan)
    • Identify and use support system
  45. Why do moms have Difficulty Maintaining Milk Supply for Preemie
    • Physiologic suckling must be mimicked with pump
    • Piston style electric pump needed
    • Time commitment to mother and family
    • Difficulties latching on, staying awake and emptying breast
    • Maternal stress, rest and nutrition
  46. How is Slow Weight Gain in Breast Milk Fed Preemies managed
    • Increase milk intake to 200 cc/kg/day
    • Hindmilk, use crematocrits or exogenous fat source
    • Minerals, calories and multivitamins – fortifiers
    • Pre and post weights
  47. How can you initiate Breastfeeding the Preterm Infant
    • Attempt BF at 32 weeks at pumped breast
    • Educate mother on cues, position and latch
    • Avoid use of bottle until can successfully BF 1-2x day
    • Use a slow flow nipple for breastfeeding babies
    • Teach use of infant scale, nipple shields and supplemental nurser system
    • Plan to BF 23-25 weeker only 2 or 3 times a day – need extra calories from the other feeds
  48. How should you educate the Preterm BF Infant Going Home
    • Educate how to determine infant is eating enough
    • Teach infant feeding and elimination patterns
    • Provide with BF support group or LC referral
    • Obtain Dr. appointment 2 - 3 days after discharge
  49. How do you manage Drugs and Breastfeeding
    • Almost all drugs pass into breast milk
    • Premature infants are at a higher risk
    • If you can give it to the baby it’s OK
    • Usually an infant dose less than 10% is safe
    • Avoid the peak and long acting drugs – phenobarb
    • Recommend taking pain meds right after breastfeeding
    • Choose drugs with short half lives, high protein binding, low oral bioavailibility or high molecular weight
    • AAP recommendation
  50. What are the Lactation Risk Categories
    • L1: safest. Controlled studies or not orally bioavailibility
    • L2: safer. Limited studies, remote risk
    • L3: moderately safe. Minimal adverse effects, weigh benefits vs. risk
    • L4: Possibly hazardous
    • L5 : Contraindicated
  51. How does nicotine effect the breastmilk
    • Impairs milk production
    • Rapidly enters milk after exposure
    • Potential for nicotine intoxication
    • Concentration is double in milk compared to maternal blood
    • What are the hazards of second hand smoke
    • Eliminates beneficial effect of breastfeeding on SIDS risk
    • Limit to smoking just after a breastfeeding
  52. How does caffeine effect breastmilk
    • Baby ingests 7-18% of maternal dose
    • Peak milk level is 1 hour after maternal ingestion
    • Newborn elimination is slow
    • Limit to less than 300 mg/day (4cups of coffee/1 L soda)
    • Irritability reported with high maternal intake
    • More than 4 cups of coffee a day
    • More than 1 liter of cola a day
  53. Caffeine in Foods and Beverages
    • Hershey’s milk chocolate bar: 25 mg
    • Espresso, 1-oz shot: 40 mg
    • Coca Cola 20 oz bottle: 60 mg
    • Brewed tea, 8 oz: 50 mg
    • Brewed coffee, 12 oz cup: 200 mg
    • Excedrin pain reliever, 2 tabs: 130 mg
  54. How does Ethanol effect the infant
    • Dose dependent effects
    • Wide genetic variability in metabolism
    • Inhibits milk ejection reflex, decreases production
    • Alters milk odor and feeding behavior
    • May impair motor development with regular use
    • Wait 2 hours to breastfeed after every drink
  55. What is Breastmilk Jaundice
    • Late onset jaundice – manifests 2 nd week
    • Affects 2-4% BF infants
    • Bilirubin exceeds 10 mg/dl
  56. How do you manage breastmilk jaundice
    • Evaluate infants growth, intake and output
    • All other causes must be ruled out
    • Treatment is observation over few weeks
    • For those with no patience
    • Temporary substitute of mothers milk
    • Other milk is provided along with mothers milk
    • No neurodevelopmental concerns
    • Higher fat content in BM risk factor for breastmilk jaundice
  57. How does lactose intolerence affect the infant
    • Lactose intolerence=lactase deficiency
    • Lactose metabolizes to glucose and galactose
    • Lactase, found in the intestinal brush border mucosa
    • Necessary to convert lactose into simple sugars
    • Enhances calcium absorption
    • Lactase activity correlates with higher lactose intake, gut growth and maturation
    • Malabsorption of lactose may increase risk of NEC
  58. What are the Carbohydates in breast milk and formula
    • Breastmilk: lactose predominates as 40-50% total calories
    • Preterm formula approx 42% total cals, ½ lactose + ½ corn syrup solids
  59. What is Cow’s Milk Protein Allergy in Breastfed infants
    • Probably the cause of intolerence instead of lactose
    • FF prevalence of cow’s milk protein allergy is 2-3%, less common in BF infants
    • Bovine milk is the most common single allergen affecting infants
    • Symptoms: vomiting, diarrhea, occult bleeding, eosinophilic esophagitis
    • Allergen enters intestine and provokes non IgE symptoms
  60. How do you treat cows milk protein allergy
    • Mom exclude for 1 week: Cow’s milk, Egg, fish, nuts
    • Use a hydrolyzed or a free amino acid formula