Breast-Feeding

dr. Arien Himawan,M.Kes

PPDS Gizi Klinik
Th 2012

Culture and Breast Feeding

Baumslag, 1987 culture has a major influence on breast feeding is largely determined by the atitudes of her society

In most cultures, breast-feeding a newborn infant is perceived as the traditional, natural order of life

In United States, The cultural context of breast-feeding is very different Most women view breast-feeding as the optimal way to feed their infants, societal norms and customs discourage it Many women work outside the home and are unable to take extended maternal leave from their job The powerful influence of this culture can be seen in the paterns of breast feeding in women who immgrate to US from southeast asia very few breast feed

Historical Trends in Breast Feeding

Konner & Worthma n 1980
The Twentieth century
short feeds ( about two minutes per feed and four feeds per hour) continues until the child is 2 to 4 yaers old
The development and promotion of manufactured baby milk made formula feeding easy, cheap and safe Many physicians believed formula was comparable to human milk, and the use of formula in place of breast-feeding was often encouraged

in 1982

slow decline since then 52% (62%) of women in the United States initiating breastfeeding, but only 20% (40%) continuiting at five to seven months ( Fomon 1993)
Research began to identify the complex and potent immunological properties of human milk scientists became increasingly aware of the biological specificity of breast milk its unique benefits to infant health

Coates 1993

THE DEMOGRAPHICS AND DETERMINANTS OF BREASTFEEDING

Ethnicity and Breast Feeding in US

There are marked difference in breast feeding among mother of different ethnic backgrounds

Black mothers initiate breast-feeding (23%) & continue it at six month (7%) compared with White mothers (58% and 23%, respectively) Why Black mothers breast-feeding less frequently than White mothers is not clear the differences remain when income, parity and marital status are taken into account Southeast Asian women tend to consider formula feeding the norm in the United States. They associate it with the general good health of infants in this country (Coates 1993)

The good news is that the U.S. has achieved the first goal
75 % of mothers in the U.S. initiate breastfeeding

Breastfeeding at 6 months: 43 %
Breastfeeding at 12 months: 22 %

Exclusively through 3 months: 33 %

Exclusively through 6 months: 13.3 %

Di Indonesia
Th 2010 Data Kementerian Kesehatan jumlah bayi di Indonesia sekitar 4,4 juta 69 % bayi Indonesia tidak mendapat ASI eksklusif Direktur Jenderal Bina Gizi dan Kesehatan Ibu dan Anak, Kementerian Kesehatan Hanya 31 % bayi saja yang mendapatkan ASI eksklusif usia 0-6 bulan Data Kementerian Kesehatan menunjukkan hanya 41 % anak usia 6-23 bulan yang mendapatkan MPASI sesuai rekomendasi WHO

Sociocultural Determinants of Breast-Feeding in US

Age

Younger mother breast-feeding much less frequently than older mothers

Parity Geographi cs differences Marital status Educatio n

Multiparious and Primiparious women initiate breastfeeding at similiar rates

western states are much more likely to breast-fed than women from Souther or Eastern states Unmarried women are much less likely to breast-feeding At least one year of college-level education is a strong postive predictor of breast-feeding Poverty is associated with decreased rates of breastfeeding mothers working full time are less

Income
Employm ent

Breast Feeding in The Developing World

Breast-feeding was nearly universal in the developing regions of the world until the middle of the twentieth century During 1940 1970 as formula feeding displaced breast feeding in the industrialized country 1950 to 1970, breast-feeding rates sharply declined in many developing regions, particullary among the urban poor effects on infant morbidity and mortality

In developing countries, formula feeding is associated with sharply higher rates infection and lower rates of infant survival, compared with breast-feeding
Manufactured formula lacks the immunological and other healthpromoting factors of breast milk

In the poor countries of the developing world, water supplies are often contaminated and unsanitary water used to clean bottle and mix formula carries pathogenic bacteria, viruses and parasites
in 1981 documented the high cost to infant health 1 milion infants deaths were attributable to contaminated infant formula

can be a dangerous source of infection

Breast-feeding is the most important form of contraception in many highly populated developing countries. contributes to child spacing by providing a period during which the mother can recover

In the mid 1970s In1989

Papua New Guinea enacted low forbidding the advertisement of leading bottles and formula available only by prescription Rate of breast feeding was increase in 15 developing countries in Asia, Africa and Latin America
To reaffirm the impotance of breast feeding WHO and UNICEF issued the Innocenti Declaration major goals designed to protect, promote, and support beast feeding around the world

in1990

Maternal Employment & Breast-Feeding

Over half of all women in the United Stated with children 3 year old are in the workforce and most work full time

Many of these women return to work during lactation and some continue to sucessfully breast-feeding while working

The infant can be fed stored milk-milk that is expressed from the breast and frozen for that purpose

The mother can continue to breast-fed when she is home but have her infant consume formula when she is away at work

Less commonly, she can have the baby brought to her at work for feedings or she can return home througouht the day for feeding

Ten Steps to Successful Breast feeding

Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within 1 hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice "rooming in" allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no pacifiers or artificial nipples to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic
1.

A Step-by-Step Approach to Breast-Feeding

THE DECISION TO BRAEST-FEED
This important decision is usually made early : about 30% of families decide before pregnancy over 90% by the end of the first trimester of pregnancy (Post and Singer 1983) A mother choice of feeding methode is determined by a

number of individual, family and sociocultural factors :

The emotional motivations The attitude of family members and friends Social trends and role models

BREAST-FEEDING EDUCATION
Many hospitals and clinics have developed breast-

feeding education programs

 Preparation for Breast-Feeding

Nipple Conditioning Mothers should be reassured that breast size does not influence

lactation Nipple Invertion

Early Breast-Feeding
The Postpartum Environment Initiating Breast-Feeding

The First Feeding

Advantage of Early Feedings

The First Two Months of Breast-Feeding

Feeding Patterns
By the third or fourth postpartum day, an infant typically breast-feeding about 7-8 times a day consume 300-400 ml of milk/24 hours Feeding periods average about 10 minutes each breast The small size of the infants stomach the infant will need to be fed frequently some infants feeding up to 12-14 times a day

Maternal-Infant Bonding
a sense of belonging security and attachment from the

warmth of the mothers body The closeness and time spent together in the first month postpartum are important factors in maternal-infant bonding

 Importance of Support for The Mother

Support and guidance for the mother during this periode

are critical to continued breast-feeding especially for young, first-time mothers

Stooling Patterns of The Breast-Feeding Infants
Stooling begin shortly after birth during the first several days meconium is passed and

the stool appears black and tarry After the first week, the breast-feedig infants stools are a mustrad yellow liquid with a yeasty odor The mother of the breast-feeding infant shoud be aware many small, yellow, liquid stools are not diarrhea
but the normal pattern

Breast-Feeding Six Months and Beyond

Adding Solid Foods Infants are ready to accept solids Interest in adult foods show better hand mouth coordination Begain to lose their vigorous tongue thrust during nursing Shoud be given at the time of day when mothers output of

milk is lowest Teething Primary theeth began to erupt will bite and chew Most infats quickly learn not to bite Quicky removed when active suckling slow not allowed to play and nuzzle at nipple Psychological Benefits of Nursings
Feeding more sporadic

WEANING
How Long Should a Mother Breast Feed The Committee on Nutritional of The US National Academy of Science recommends exclusive breast feeding for normal Birth 4 to 6 months Supplemental feeding is recommended for the remainder of the first year Immunological benefits and growth factor during newborn period mother should be strongly encouraged to breast feed for at least the first 2 or 3months The Process of Weaning Study of culture worldwide the mean age for weaning is around 2.5 years Supplemented with other foods 4-6 months In The US 2/3 of mothers stop breast feed before 5-6 months because of culture attitudes Many infants spontaneously give up breast feeding supplemental food since 4-6 months

 Maternal Health During Weaning

Problem with plugged duct and breast discomfort soaking

with warm water and manual expression to reduce breast fullness

Weaning & Infant Health in Developing World
Weaning is a periode when the child is a sharply increased

risk for illness and death (Wharton 1991) During the breast-feeding periode, most infants grow well and stay relatively healthy As Supplemental foods began replace breast milk growth often falters and illness is more commond No provide immunological benefits of milk Supplemental foods have less nutritional value Water, food and bottles are frequently contaminated poor sanitation Diarrheal during weaning is common

Relactation and Induced Lactation

Relactation is the process of restimulating lactation
Women who delivers a low birth weight infant and

spreated from her infant for several weeks will often drop off in milk output
Induced Lactation is the stimulation of lactation in

woman who has not been recently pregnant mothers of adopted infants attempt induction and many are at least partially successful in breast feeding Relactation and induced lactation, the major to milk production is effective, regular suckling of the breasts, together with breast massage and nipple stimulationation

Extraxtion and Storage of Breast Milk

Manual Expression of Milk
A simple technique Mother should wash her hands Breast is massage for several minutes or until mother

feels milk letdown A clean, wide necked container to catch the milk should be held in one hand, while the other hand pumps the breast
Breast Pumps
Prefer to use a breast pump
More efficient and more comfortable Baby preterm or ill 8 times each day, will avoid pooling

of milk in the glands which can reduce milk secretion

Milk Storage

Maternal Concerns During Breast-Feeding

Insufficient Milk and Failure to Thrive

 Too Much Milk

The breast become uncomfortably full and leak milk

between feeding Milk output during infant suckling at the beginning of suckling during milk letdown, so fast and abudant that feeding may be uncomfortable for the infant If necessary extra milk can be manually express from the best and stored frozen for later use
Breast Problems
Engorgement Leaking Nipple soreness Plugged Milk Ducts Mastitis and Breast Abscesses

Breast-Feeding in Special Situations

 Casarean Birth
First feeding may be deleyed, successful feedings after 12 hours of

delivery Postoperative pain may inhibit the letdown reflex Mother should take pain medication after feeding allows time for the level of the drug in maternal blood to peak and fall before next feeding

Breast-feeding Twins
Feeding both infants simultaneously and Milk outputs of 1500 to

2500 ml per day

Breast-feeding after Breast Surgery

May effect a womans ability to breast feed
Surgery may disrupt the nerve around the nipple and breast, the

milk ducts, the blood supply to the glands Breast feeding is possible for most women after augmentation surgery After a breast reduction not possible to breast feeding

 Infant Disorders Respiratory infections

Upper respiratory tract infections (URIs) common during

infancy & interfere with breast feeding The mother should breast feed while sitting up and hold the infant a more upright position Nasal secretion should be cleared before beginning feeding Infant lose some appite when they have an infection need to express some milk manually, usually appetite returns in a day or two
Downs Syndrome
Congenital disorder

Can breast feed may take them longer to establish full suckling

1/3 took more then one week to establish full suckling The infant has no difficulty suckling immidiately

 Cleft lip and Palate Congenital malformations caused by incomplate closure of the lips and upper jaw during embryonic development Difficult for infant to suckle Many infants are fed formula Breast feeding is possible with some adjustments Mother assist her infant with a cleft lip in forming a seal over the nipple by pressing the clift agaist the breast and covering the gap with her finger or thumb Clift lip are repaired at three weeks postpartum and afterward the infant can ussually breast feed normally Breast milk Jaundice One of the metabolic adaptations to life oudside the uterus is acomplate changeover of hemoglobin in red blood cell which the adult form hemoglobin replaces fetal hemoglobin Severe replacing breast milk with formula, for 24 hours The mother extract regulary to maintain lactation

 Metabolic Disorders

Galactosemia is a rare 1 in 60.000 infants at birth Infant with galactosemia, one of the enzymes that metabolizes the galactose to glucose is absent Large amountsof galactose build up, have severe adverse effesct including metal retardation Galactosemia is contraindicated of breast feeding 1 in 20.000 babies born with Phenylketonuria (PKU) can not convert phenylalanine to tyrosine Diet rich phenylalanine amino acid accumulated impairing normal development of the central nervous system and producing metal retardation Healthy as long as phenylalanine intake is controlled grow and develop normally Is wean from the breast and placed on a special low phenylalanine formula 6 months as infants fed No longer contra indication to breast feeding Human milk has relatively low level of phenylalanine

 Maternal Disorders Diabetes Mellitus

have beneficial effect on blood sugar control glucose is steadily pulled from maternal blood and converted to galactose and lactose during milk

Chronic diseases can breast feed successfully long term therapy with drugs can pass into the milk and harm the infant formula feeding may be necessery Maternal infections Not contra indicated during post maternal infections Antibodies and immune cell produced by the mother in respon to infections are passed to the infant in milk The agents can provide the infant with some protection from infection excample : Rubbella can be passed through breast milk to the infant, but along with the virus travel antibodies and other immune factors

Breast-Feeding and The Human Immunodeficiency Virus

Mothers infected with the human immuno deficiency virus (HIV) can pass the virus during breast feeding

Mother who develop HIV infection postnatally, the risk of transmission during breast feeding

In 1985 the US center for diseases recommended that HIV infected women be discourages from breast feeding adopted by the other industrialzed countries

A recent study in Africa found that HIV positive mothers deficient vitamin A transmit the virus during the perinatal period

Breast Feeding & Infant Health

The unique nutritional requirements of human newborns No The best source manufactured of nutrition for formula can full term infants duplicate the during the first biologically four to six specific physical months structure and postpartum nutrient composition of (AAP 1993) human milk

Ensure optimal growth and development

Protein in Human Milk

Ideal for human infants

complate and balance Supplying optimal anounts of the essential and nonessential amino acids Rich in cystine and taurine contains only moderate amounts of phenylalanine, tyrosine and methionine contains much less protein (0.8 g versus 3.5 g / 100 ml) than cows milk

 Vitamins, Minerals, and Enzymes in Human Milk

The vitamin containt of breast milk is uniquely suited to

the newborns need (Lawrence 1994) Mature breast milk contains all of the essensial mineral necessery for infant growth and development (Riordan 1993) A variety of enzymes that have digestive functions are secreted into human milk, including lipase, amylase, and proteases are important in that they help the immature gastrointestinal tract of the newborn digest and absorb nutrient in the milk (Hamosh 1989)

 Protection from Infectious Diseases Contains a complex variety of anti infective substances and cell including lymphocytes, immunoglobulins, enzymes, anti imflammatory agents and other protective factors Breast feeding limits infant exposure to potensial pathogens in other foods and fluids Adequate breast feeding ensure the nutritional status of the infant, thereby reducing vulverability to disease (Wray 1991) Contraceptive effects (Wray 1991) Protection From Allergies Infants are thought to be susceptible to food allergy because their developing intestine is permeable to protein and peptides Breast feeding defer the introduction of foreign food

Breast-feeding, Maternal Diet and Infant Allergy

Food eaten by a mother during lactation can produce

allergies Cows milk consumed by the nursing mother has often been implicated antigens from cows milk have been found in the breast milk In families with strong history of allergy, when suspected food alergens are exclude from the diets During weaning, solid foods shoud be introduced to the infant implicated Should be observed for sign of allergy when a new food is introduced

Breast feeding and Chronic Diseases of Later Life

Obesity No firm associations between the method of feeding during infancy and later development Formula feeding does not appear to increase the risk of obesity in adulthood The cholesterol content in human milk higher than in manufactured milk formula Research has no found no consistet link between methods of infants feeding and levels of adult cholesterol or rates of artherosclerosis Human milk contains a variety of factors that hasten the maturation of new borns immune system Long term protective effects againts several diseases that have immunological or infectious causes

Artherosclerosis

Immune Disorders

Breast Feeding & Infant Mortality

In the developing countries formula fed infants have sharphy higher mortality rate

The protective effect of breast feeding is particulary strong during the first year

mortality rate reduced in infants up to age 3 years Differences in mortality rate of infection between formula fed and breast fed infants (Wray 1991) Breast-feeding still confers a protective effect (Wray 1991)

Thank You