TEMA 02

Mc Millan J, y col. Oski’s pediatrics principles and practice of pediatrics. 3ra ed.
2000.

BREAST-FEEDING

BENEFITS: An increasing amount of evidence indicates that breast milk from a

healthy mother is the ideal source of nutrition for a healthy term infant. Human
breast milk contains protective immunologic factors; breast-fed infants are less
susceptible to gastroenteritis, otitis media, early wheezing illnesses, and allergic
reactions. Breast milk has the added practical advantage of being stored at the
appropriate temperature in an aseptic environment, with rapid food delivery
determined by a feedback process, partially controlled by the infant. The act of
breast-feeding also offers a unique opportunity for mother-infant bonding.

PREPARATION: Prepartum nipple preparation begins with examination of the

breasts of a mother who intends to breast-feed. Insufficient glandular tissue is
suggested by a lack of increased breast size during pregnancy. Prior surgical
scars raise the question of whether ducts and nerves are intact. Inverted nipples
(retraction toward the chest wall on stimulation) may be addressed by having the
mother wear breast shells coupled with gentle pulling and rolling of the nipples.
Prenatal breast-feeding classes are encouraged.

DELIVERY: A healthy infant should be breast-fed within an hour after delivery.

Support personnel should be available to counsel a first-time mother with breast-
feeding technique. The infant is put to breast as often as the baby is awake and
will suckle. If supplementation is required, it should be offered to the infant only
after breast-feeding. The liquid can be delivered to the infant's mouth with a
dropper or by squirts from a needleless syringe. Bottle nipples and pacifiers are
discouraged in order to avoid “nipple confusion.” Close follow-up for the first-time
breast-feeder is important until feeding is well established.

FEEDING: Classically, the mother holds her arm (on the side of the breast she
offers) as if it were in a sling. The baby is placed on its side atop her arm with the
baby's head near her elbow and her hand supporting the buttocks. The infant's
arms should be tucked out of the way. The mother's free hand grasps the breast
with the thumb above and two fingers below the nipple. Touching the nipple to
the cheek of the infant activates the rooting reflex. The nipple and areola are
inserted into the infant's mouth as far as possible. When properly positioned, the
infant's mouth covers the nipple and areola and breast tissue is sucked into the
mouth. After this latching-on process, the mother need not hold on to the breast.
Infant suckling activates the letdown reflex. When the mother wishes to remove
the infant from the breast, the suction can be broken by inserting her fifth finger
into the infant's mouth beside the nipple.
LACTATION: The milk produced during the first few days, termed colostrum, is
yellowish and translucent. Colostrum is more viscous than mature milk and is
richer in protein and many minerals. Colostrum is relatively rich in
immunoglobulins but has low levels of carbohydrate, fat, and vitamins. The
infant's glycogen stores allow tolerance for this low-calorie waiting period
(approximately 3 days) until mature milk is produced. Mature milk is a thin, oily,
blue-white liquid that provides 65 to 75 kcal/100 mL. The breasts become
swollen, firm, and often painful when the mature milk comes in. The discomfort is
relieved when the infant empties the breasts.

SCHEDULE: Suckling is limited to 5 to 10 minutes per breast in the first day to

prevent nipple soreness. Over the next 3 to 4 days, nursing can increase to 15 to
20 minutes per breast as the mother's nipples toughen. The young infant nurses
10 or more times in 24 hours, initiating feeding every 2 to 3 hours. A pattern
develops that may entail, for example, the baby suckling for 10 minutes on one
breast and, after burping, continuing ad libitum on the other breast. The
subsequent feeding is started with the second breast from the previous feeding.
Normally, the infant surpasses birth weight at 2 weeks and gains 28 g (1 oz) per
day thereafter. As the infant ages, he or she gradually allows more time to elapse
between feedings. Ideally, feeding is scheduled by the infant's demand.

EXCRETION: Adequately nourished breast-fed infants urinate (colorless) at least

eight times per day. In the early weeks, infants produce a soft, seedy, yellow
stool after almost every feeding. Hard, dry stools are not expected. Stool
frequency decreases only after 1 to 2 months of breast-feeding.

PROBLEMS: Insufficient lactation, sore nipples, maternal mastitis, breast milk

jaundice, maternal dietary insufficiency, infections, and drug ingestions.

SUPPLEMENTATION: A breast-fed infant with insufficient sunlight exposure may

develop vitamin D deficiency. A daily dose for infants of 400 IU is recommended
for optimal calcification of bone and prevention of rickets. Iron in breast milk is
low in absolute terms but highly bioavailable. After 4 to 5 months, however, iron
supplementation for infants is required; 0.25 mg/day of fluoride is also
recommended for breast-fed infants beginning shortly after birth. Nursing
mothers should eat a hearty, balanced diet. No attempt to decrease maternal
weight should be made at least until breast-feeding is well established. Intake of
caffeine and alcohol should be modest. Appropriate supplements are given to
vegetarian mothers, who can produce milk that is deficient in B vitamins.

WEANING: Weaning is accomplished in a way that is developmentally

acceptable for the mother and child. Most breast-fed infants between ages 4 to 6
months outgrow their reliance on exclusive breast-feeding because of increased
caloric needs and the development of oral-motor mechanisms that allow drinking
and eating.
CONTRAINDICATIONS: Because most medications taken by the mother can be
detected in breast milk, nursing mothers should avoid over-the-counter
preparations and remind prescribing physicians that they are breast-feeding. The
safety of each drug prescribed should be checked. Infants with hereditary
metabolic disorders may require special formulas that preclude breast-feeding.
Infants with galactosemia, for example, cannot be breast-fed. Some maternal
infections can be passed to the infant through breast milk or close contact;
therefore breast-feeding is temporarily or permanently suspended in such cases.