Chapter 8 Breast Feeding

Transcription

1 87 Chapter 8 Breast Feeding Chapter 8 Breast Feeding...87 Breast-feeding...88 Advantages of breastfeeding...90 Practical Aspects of Breast Feeding...91 When to commence breastfeeding?...94 Baby Friendly Hospital...94 Problems that sometimes arise with breast feeding...95 Decline in breast-feeding...96 Figure 8.1 Mammary gland at end of pregnancy...88 Figure 8.2 The Let-down Reflex...89 Figure 8.3 Immunoglobulins in breast milk...90 Figure 8.4 Mother Infant interaction during breastfeeding...91 Figure 8.6 Initiating the...92 Figure 8.7 Attachment to the breast. Note nipple and part of the areola in baby s mouth...92 Figure 8.8 Attachment to the breast...92 Figure 8.9 Suckling a wave of contraction along the baby s tongue...93 Table 8.1 Dealing with common problems in breast feeding

2 88 Breast-feeding Establishment of proper lactation is an important part of infant care in developing countries. A baby who is not breast-fed has a very poor chance of survival in such a situation. Most rural homes do not have the facilities for coping with hygienic methods of bottle-feeding; the principles of sterilization are poorly understood and the fuel required for boiling the milk or water is always scarce. Bottle-feeding in these conditions invariably results in diarrhoea. Furthermore, the cost of artificial feeding is beyond the budgets of most households so that the baby is offered diluted milk and suffers undernutrition. During pregnancy the high levels of estrogens and progesterone in the mother's blood promote growth of the milk secreting cells and of the mammary gland as a whole. Soon after childbirth, the blood level of these hormones begins to fall, and the pituitary gland secretes another hormone called prolactin. Under the influence of prolactin the mammary gland secretes milk. (See Fig. 8.1) Figure 8.1 Mammary gland at end of pregnancy 88

3 89 The production of milk thus initiated is maintained by two other factors: 1 The regular emptying of the breasts at each feed by the infant. 2 The sensory stimulus produced at the nipple by the act of suckling. This sensory stimulus on reaching the hypothalamus causes the secretion of two hormones from the pituitary. The anterior pituitary secretes prolactin and the posterior pituitary secretes oxytocin. Oxytocin causes contraction of the involuntary muscle fibres of the mammary gland and thus aids the flow of milk along the ducts to the nipple, and the complete emptying of the breasts. This is called the 'let down' reflex. (See Fig. 8.2) Figure 8.2 The Let-down Reflex Normally, rural mothers have very little difficulty in breast-feeding their infants. Such mothers are natural 'milk secretors'. Occasionally it has been found that attempts to teach the technique of breastfeeding to such mothers causes confusion and anxiety which may interfere with the secretion of milk. Usually it is women from higher socio-economic groups who have the problem of inadequate lactation. It is believed that undue anxiety and worry in such mothers suppresses the nervous impulses from the hypothalamus and interferes with milk secretion. The average baby in developing countries who is breast-fed grows at the same rate as his counterpart in Europe until the age of six months. After this age the demand for nutrients cannot be met by breast milk 89

4 90 alone, even with maximum secretion, and additional foods need to be added to the baby's diet. In a mother who is not well nourished, milk secretion can be poor and the baby may stop gaining weight at an earlier age. In such mothers, it has been found that though the quality of milk remains almost the same, the quantity becomes progressively smaller and the mother cannot produce enough milk to meet the growing demands of the baby. In a study of women in a low socio-economic group in South India, it was observed that the daily output of breast milk varied from about 600 ml in the first 6 months of lactation to about 350 ml between the 18th and 24th months. In the composition of the milk, fat varies more than any other constituent. It may vary from one pregnancy to another in the same woman, or even from feed to feed or from the beginning of lactation to the end. Protein and lactose tend to vary much less. Human milk contains only traces of iron and the calcium content is lower than that of cow's milk. Advantages of breastfeeding Breast milk provides balanced nutrition for the infant and in most cases newborns double their birth-weight in 3-4 months on breast milk alone. Besides being the natural food of the baby, breast milk contains several substances which help protect the baby against infections, especially those of the gut and the respiratory tract. (See Fig. 8.3). The incidence of diarrhoeal disease is much lower in breast-fed babies than in those who are artificially fed. Breast milk also contains a large number of white cells, mainly macrophages and lymphocytes, which help to protect the baby against bacterial and viral infections. Figure 8.3 Immunoglobulins in breast milk The endocrinological response of the breast-fed infant is different from the response of a baby fed on formula. Human milk contains several hormones and enzymes which influence gut function in a number of ways. In addition various growth factors present in human milk influence the growth and proliferation of cells in the gastro-intestinal tract. All these properties of human milk indicate that it is 90

5 91 a biological mediator of functions in the newborn besides being a nutritive and protective substance. (See Fig. 8.4) Figure 8.4 Mother Infant interaction during breastfeeding The act of breast-feeding provides the close contact and intimacy necessary. for mother-infant bonding. Hence it plays an important role in the emotional development of the infant. Active lactation in the mother suppresses ovulation and subsequent pregnancy is delayed. In rural communities where breast-feeding is common, the average birth interval tends to be months. On the other hand, if the baby is stillborn or if there is neonatal death so that breast-feeding does not occur, the subsequent pregnancy tends to be much earlier. Several studies have shown that the familyspacing effect of breast-feeding is at a maximum during the first 9 months of lactation, after which it decreases, almost disappearing by 27 months after delivery. Practical Aspects of Breast Feeding All healthy full term infants are born with reflexes that enable them to obtain milk from the mother s breasts. These are the Rooting Reflex which helps with attachment to the breast.when the baby s lips are touched with the nipple the baby s mouth opens wide to take it into the mouth. The Suckling Reflex in which the nipple and part of the areola are rhythmically compressed between the baby s tongue and hard palate. A wave of contraction passes along the baby s tongue from the tip in front to the base at the back resulting in the breast being milked. The Swallowing Reflex in which each mouthful of milk is passed along the esophagus by a wave of peristalsis and into the stomach. With a little help at the time of first feed the normal newborn gets these reflexes going. After a few successful feeds baby and mother both learn and are able to synchronize the letting down of the milk 91

6 92 on the part of the mother and feeding on the part of the baby. First time mothers may need help with initiating breastfeeding by being shown the following: Holding the baby in close body contact with the baby s nose near the nipple Gently squeezing the breast until a drop of milk is visible on the nipple Touching the baby s lips with the nipple Wait a second or two for the baby to open his mouth wide (the Rooting Reflex) Moving the baby gently onto the breast ensuring that the baby has taken whole of the nipple and the areola well into the mouth so that the baby s lower lip is well below the nipple (See Figs. 8.5 to 8.8). Figure 8.5 Initiating the Rooting Reflex Figure 8.6 Attachment to the breast. Note nipple and part of the areola in baby s mouth Figure 8.7 Attachment to the breast 92

7 93 Figure 8.8 Suckling a wave of contraction along the baby s tongue Signs of correct attachment to the breast are: Baby s mouth is wide open There is more of the areola visible above than below the mouth Baby s chin touches the breast, the lower lip is rolled down and the nose is free. Baby suckles with slow deep sucks with occasional pauses No pain is felt by the mother Signs that a baby is feeding successfully: Swallowing is audible and visible There is a sustained rhythmic suck Arms and hands are relaxed The mouth is moist in between feeds There are regular soaked nappies. Stools change in colour from dark to light brown or yellow by day 3. 93

8 94 When to commence breastfeeding? Early breastfeeding immediately after or within the first hour of birth has many advantages: It reduces the risk of postpartum haemorrhage for the mother The first milk colostrum has rich anti-infective properties and has many benefits for the baby Entry of milk into the baby s gut starts the digestive processes besides providing fuel for metabolism and body warmth Close contact with mother s body keeps the baby warm and helps with bonding. Baby indicates readiness for feeding by opening the mouth and making searching movements Exclusive breastfeeding (only breastmilk feeds without any fluid or milk being offered by bottle) for the first six months of life is now universally promoted. After that age breast feeding should be continued with gradual introduction of gruel made from local staple. Baby Friendly Hospital In 1991 UNICEF and WHO proposed that hospitals (and maternity units) may declare themselves as being friendly to the welfare of babies by implementing the following Ten Steps: 1. Have a written policy on breastfeeding that is routinely communicated to all staff members. 2. All health workers are trained in skills necessary to implement the policy. 3. Inform all pregnant women (and their families) about the benefits and management of breastfeeding. 4. Help mothers to initiate breastfeeding within half hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants. 6. Give newborns no drinks by bottle unless medically indicated. 7. Practice rooming-in (allow mothers and infants to be together all 24 hours of the day). 8. Encourage breastfeeding on demand. 9. Give no artificial feeds or pacifiers to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or maternity. 94

9 95 Problems that sometimes arise with breast feeding If milk secretion is inadequate, the following signs occur: 1 Failure to gain weight. If the baby is gaining weight regularly, there is probably no need to worry. The gain in weight may fluctuate from week to week. When in doubt the baby should be weighed weekly for 3 weeks. 2 Crying. If the baby is satisfied after a feed he may fall asleep for 3-4 hours until the next feed is due. A baby who is hungry may sleep for a shorter period of time and cry earlier, or may even cry soon after the feed. 3 Constipation. Normally a breast-fed baby has about 3-4 stools per day which are soft in consistency. In babies who are underfed, constipation may occur. A variety of factors besides maternal anxiety and malnutrition can interfere with the establishment and maintenance of adequate milk secretion (Table 8.1). Thus, any acute illness in the mother will result in a reduced flow. It is important in such cases to maintain the milk supply as far as possible since complete drying up of the milk could be disastrous. Whenever a mother is admitted to hospital her breast-fed infant should stay with her as a 'lodger'. If the mother is too ill to nurse the baby, the milk should be expressed by hand or with a breast pump, since complete emptying of the breasts is essential to maintain secretion. Localized disease affecting the breast, such as cracked nipples or a breast abscess, may interfere with feeding. Here, also, the affected breast should be expressed and emptied several times a day to keep the milk secretion going. In some instances the baby may not be able to suckle vigorously, as in cases of low birth-weight or where the baby has a congenital malformation, such as hare-lip or cleft palate. In these cases, after the baby has finished suckling, the milk should be expressed and fed by means of a cup or spoon. The practice of unilateral breast-feeding is fairly common. In many cases the mother has been told either by the elders in the family or by the local medicine man that one of the breasts is secreting 'bad milk'. She has then stopped feeding the baby on that breast and eventually the milk on that side has dried up. If the mother is reassured that her milk is good and is encouraged to put the baby on that breast at the beginning of each feed (after which he can be transferred to the secreting side) the milk flow will gradually become adequate. A similar method is used for mothers who are secreting only small quantities and whose infants are marasmic and 'starving on the breast'. These mothers are better admitted to hospital to give them a rest from their daily chores and to supervise their nutrition. They are put on a nourishing diet with vitamin supplements and extra milk (full cream if available). To allay anxiety a sedative may be added, for example chlorpromazine 25 mg twice daily. The baby is put to the breast every 4 hours, for at least 10 minutes on either side. After this, if he is still hungry, a feed of fresh milk may be offered. On this regime the milk supply increases gradually and the amount of supplementary feed needed will diminish. In the case of a maternal death, any female relative with children can adopt the baby and the above method may be utilised to induce lactation. Once the baby is discharged, breast-feeding can be on demand. The author has successfully applied this technique to promote milk secretion in grandmothers in the event of maternal death. 95

10 96 A special problem in breast-feeding arises in the case of babies whose mothers have pulmonary tuberculosis. If the mother is under treatment, and is sputum-negative, the baby can be given BCG at birth and the mother can breast-feed the baby. If the sputum is positive, the baby should be put on isoniazid 6 mg/kg daily and the mother should breast-feed her baby. A similar situation arises if the mother is HIV positive. The risks to the baby to be infected through breast milk are about 15 per cent. With exclusive breast feeding (no artificial feeds; no solids) the risks are much less at about 6.0 per cent. A number of solutions are being proposed based on destroying the virus by home pasteurization of breast milk. The method was first described by researchers in Pretoria and the method is called Pretoria Pasteurization. HIV is heat sensitive and Holder pasteurization is commonly used in milk banks in many hospitals. Typical pasteurization involves heating the milk to 63 0 Centigrade and maintaining to that temperature for 30 minutes. An alternative method is to heat to Centigrade and maintaining the temperature for 15 seconds. Pretoria pasteurization which is intended for homes with poor resources uses a one litre capacity aluminium pot containing 450 ml of water which is heated to boiling, then taken off the fire and a glass jar containing 100 ml expressed breast milk is stood in the water. Researchers found that the milk reaches a temperature of 60 0 Centigrade in about 7 minutes. The milk temperature remains between 56 0 and Centigrade for about 12 to 15 minutes. Under experimental conditions samples of milk from HIV infected mothers (mean serum viral load copies/ml and mean milk viral load copies/ml) showed no evidence of viral replication when treated in this manner. Obviously these findings need to be validated in other settings with different ambient temperatures and glass jars of different makes and thicknesses. Similar result can be achieved by flash pasteurization. For flash pasteurization 50 ml of expressed breast milk is taken in a glass jar and stood in an aluminium pan containing 450 ml of water. Heat is applied and the water is brought to rolling boil. The milk is immediately removed from the water bath and allowed to cool to body temperature (37 0 C). In experimental conditions the procedure of flash pasteurization has been shown to inactivate cell-free HIV-1. Breast-feeding is so important that even in such conditions as maternal tuberculosis it must be continued. In a developing country, to stop giving breast milk to a baby for any reason may have tragic results. Decline in breast-feeding In recent years many developing countries have experienced a steep decline in breast-feeding. The decline is more common in large towns and cities, but similar trends are also present in rural areas. Several factors have contributed to this decline in the incidence of breast-feeding, such as rapid urbanization and changing social values, but by far the most important causes are the intensive advertising and aggressive sales practices of the manufacturers of infant formulae. Attractive displays and catchy slogans in the mass media, 'gift packs' issued to mothers in maternity wards, milk nurses visiting young mothers at home, and free hand-outs of starter cans in children's clinics have together dealt a strong blow to breast-feeding. The baby is thus not only deprived of the benefits of his mother's milk, but in the unhygienic environment of most rural homes he is also offered contaminated feeds causing recurrent diarrhoea. Another disadvantage is that of cost. Many families find that, to feed the baby properly on artificial milk, they must spend almost half their income. Hence the baby's feeds are over-diluted and he begins to lose weight. One of the commonest causes of marasmus in infants in developing countries is bottle-feeding. Animal studies have shown that growth failure in an organism affects mainly that organ of the body which is growing maximally at the time. The tragedy of marasmus occurring in early infancy is that its worst effects occur in the brain, which happens to be the organ growing maximally during the first two years of life. 96

11 97 Problem Table 8.1 Dealing with common problems in breast feeding Management Flat nipples If diagnosed during pregnancy: Show the mother how she can apply gentle traction on the nipples and pull them out to make them more protractile. This manoeuvre should be performed several times daily throughout the pregnancy. If diagnosed after childbirth: Show the mother how to help the baby to suckle by pressing the areola gently together using her fore fingers before putting the nipple into the baby s mouth. Engorged breasts Cracked or sore nipples Mastitis Mother thinks she has insufficient milk Show the mother how to express the milk manually to relieve engorgement before offering the breast to the baby. She should continue breastfeeding with short frequent feeds. Show the mother how to empty the breast manually and feed the expressed milk to the baby with a tea spoon or cup. Apply chlorhexidine or antibiotic ointment to the sore nipple. Tell the mother to: Continue breastfeeding. Try short frequent feeds from the sore nipple. Let the nipple dry in the air after breastfeeding or expressing milk. After the sore is healed, during feeding the entire nipple should be introduced into the baby s mouth so that his gums press on the areola and not on the nipple. Give the mother antibiotics. Refer to more skilled care if necessary. Show the mother how to express breast milk and feed it to the baby while she has the infection. Reassure the mother. Check if the baby s weight gain is normal. If normal, find out the reasons for the mother s anxiety. Reassure her and recommend more frequent feeding. If weight gain is less than normal encourage the mother to continue breast feeding, and to increase the number of feeds, especially at night. If the baby still does not gain weight, supplement breast milk with cow s milk or solids if he is more than 4 months old. 97

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