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Pediatrics: Breastfeeding and malnutrition

Lecturer: Dr. Eva Bautista
August 26, 2015 | September 2, 2015

BREASTFEEDING

I. Anatomy of the breast:

External structures Internal structures

nipple lactiferous ducts

areola lactiferous sinuses

Montgomery’s tubercle milk ducts

alveolus

II. Phases of lactation

III. Variations in Breast Milk Composition
mammogenesis • generally means
colostrum transitional mature
development of breasts
• during pregnancy, ductal first milk
system increases and
branches thick sticky, creamy thinner and
clear to deep whiter, 80%
lactogenesis synthesis and expression of
yellow to water (watery);

breast milk
orange more creamy
galactokinesis • ejection of the milk from the towards the
breast high in protein; end of feeding
• discharge of the milk from high in due to fats
mammary gland immunoglobuli
• dependent on suckling n
movement from the infant’s
produced in about 2-6 days about 10-15
mouth
late preg until after birth days after birth
• use aids given for manual
few days after lasts 7-10 days
expression i.e. manual or
birth
electric breast pumps
small quantity increasing increasing
galactopoeisis • maintenance of milk and
amount amount
lactation,
• stage throughout the mother high in protein lower protein, more fat
is breastfeeding the infant  and vit a than higher lactose, lactose water
mature milk
fat vitamins soluble
high in CHO
calories vitamins and
antibodies IgA
fat soluble
Initially, the endocrine system is held accountable vitamins than
for development of the breasts in pregnancy. low fat
mature milk
Soon after birth however, this becomes autocrine.
[lecture] easy to digest, less protein,
alkaline minerals and
reaction, fat solible
higher specific vitamins than
Exclusive breastfeeding = best way and fastest
way to go back to pre-pregnancy weight. 500-600
gravity
mature milk

ml/day is expressed daily, burning 600kcal/day.

[lecture]

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term preterm Preterm milk has:
• more protein
colostrum: lower CHON high CHON content • high levels of minerals including iron and more
(35%) immune properties than mature milk, making it
electrolytes low volume more suitable for the needs of the premature baby.
lower amount of lactose
and fat
Nutrition for >6 months, exclusiveley breastmilk!
transitional milk has
No need for additional water!
negligible difference in
CHON

high caloric density

at 1-12 weeks, term

milk is same as preterm
milk

foremilk hindmilk

milk at the beginning of milk at the end of the

the feeding feeding

lower fat content creamy

fat content is higher in • Breastfeeding decreases the incidence of ff:

the afternoons and      1. obesity/overwt/diabestes type II
lower in mornings      2. hospitalisations
     3. infant mortality 9saves 1.3 milion lives yearr
fat content increases      4. malnutrition/impaired dev
with duration of each      5. pneumonia/ diarrhoea/UTI
feed • breastfeeding lowers risk of breast cancer and

beneficial properties:
fresh stored pasteurized • immunoglobulins igA igG, igM
• lactoferrin - binds to iron preventing infection
sugar sugar sugar-Beta- caused by bacteria using iron??
lactose lactose lactose • cytokines - for inflammation
• nucleotides - enhances immune response
decreased:

• Bifidus factor - supports growth of lactobacillus

• IgA

• b12 binding protein - competes with bacteria

• lactoferrin I

requiring vitamin b12

• lysozyme

• some cytokines

• GF
• exclusive breastfeeding (BFing) for six months

• homones • postpartum, sent home usually within 24 hours;

(insulinelike GF, kapag CS, 3 days usually.

adiponectin, • follow up of neonates: within 24-48 hours after

insulin and discharge; ask for breastfeeding concerns, i.e.
leptin
“Walang lumalabas na gatas”, “Hindi makainom ng
• reduced maayos ang baby”, “Masakit pag nagbebreastfeed”

antioxidant
capacity

• less lipase
activity

• lower IgM For preterm feeding: OGT or cup.

concentr.

• reduced WBC Never ever use bottle feeding/pacifier!

count

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III. Ten steps of successful breastfeeding
policy:
1. have a written policy that is routinely
communicated to all health care staff - write
comments, i.e. newborn has galactosemia
therefore breastfeeding is contraindicated;
Breast feeding promotion entitles the banning of
photos of babies on formula milk; instant formulas
are not seen in groceries.
IV. Proper attachment during feeding
• full support of head, and body of the baby by
mother

mother refuses to breastfeed, respect • face and body faces the mother’s chest

decision, but encourage; 
 • chin should touch the breast 

• mouth should be wide open 

2. train all health care staff in skills necessary • open airway 

to implement this policy
 • upper part of areola should be more visible

than the lower part of areola; painful if infant
3. inform all pregnant women about the is only able to suck nipple

benefits and management of breastfeeding • infant’s neck is straight or slightly bent

4. help mothers initiate breastfeeding within a backwards; chin SHOULD NOT BE pointing
half-hour of birth (magkasama baby and down to neck.

mother in DR, RR, until ward; except if • lower lip is curled out

conditions are critical -> separation)


5. show mothers how to breastfeed and how

to maintain lactation


6. give newborn infants no food or drink other

than breast milk unless medically indicated
(anxiety lessens production)


7. practice rooming in; allow mothers and

infants to remain together 24h/d; except if
there is critical situation


8. encourage breastfeeding on demand
 V. Breastfeeding positions

9. give no artificial teat or pacifiers (also • lying down on side position - most
called dummies or soothers) to BFing comfortable for C-section delivered baby; 

infants: acceptable ang milk formulas watch out for infant’s nose; instruct mother
especially made for preterm babies, and to press upper part of breast so baby can
special cases
 breathe

10. foster the establishment of breastfeeding

support groups 

Laws regarding breastfeeding policies are the ff:

1. RA 7600 (Breastfeeding and rooming in act)
2. EO 51 of 1986 (Milk code)

Essential Intra-partum Newborn Care (EINC)

1. immediate and thorough drying of newborn
2. early skin-to-skin contact between mother
and newborn
3. properly-timed cord clamping and cutting
4. unang yakap (first embrace) of the mother
and her newborn for early breastfeeding
initiation 

*Steps 1, 2 and 3 are the responsibility of

pediatricians [lecture] *
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• cradle position - when mothers are not at VI. Breastfeeding concerns:

home; baby’s lower arm is tucked around

mother’s side
A. Improper attachment:

B. Nipple pain

• observation and hx taking for sore nipples

C. Engorgement
• cross-arm position - used for small and sick
baby; secure baby’s head not too tightly;
mother offers breast
• firm, overfilled and painful, NOT TENDER
• improper attachment 
• infection - candida albicans red, shiny, flaky
• exczema, dermatitis, and other skin conditions
• DO NOT:
◦ stop breastfeeding
◦ limit frequency or length of
breasteeds
◦ apply any substances to the
nipples that would be harmful for
the infant
• delay in starting to breastfeed soon after
baby’s birth
• poor attachment, so that milk is not
removed effectively
• infrequent feeding, not feeding at night or
short duration of feeds
• 2nd stage of lactogenesis
• due to incomplete removal of milk
• treatment: frequent BF, manual milk
expression

D. Poor weight gain - may signifiy that baby is not

taking enough milk

E. Less milk production

• milk production is high if there is complete

emptying
• if baby falls asleep, mother should pump out
excess milk to promote complete
emptying

F. Mastitis
• red, warm, febrile, tender
• inadequate breastfeeding; improper
• underarm position - useful for twins; [Not attachment
sure if this is synonymous with football hold, • incomplete emptying
but football hold is usually used for twins]
• offer her baby the affected breast first, if
not too painful
• causes: S.
aureus, E. coli,
Strep, H.
influenzae,
Klebsiella,
Bacteroides
• treatments:
antibiotics for
10-14 days /
analgesic
• effective
feeding and/or
milk expression

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G. Inadequate milk intake duration
• fretful, dehydrated
• delayed stooling **
• decreased urine output room temp 6 hours
• weight loss >7% of birth weight
• increased hunger
insulated cooler 24 hours 
**No BM for five to seven days is still normal,
according to Dra. As long as baby is feeding well, no
refigerator 8 days
vomiting, no fever; BUT WITH sleeping after feeding,
with diaper changes soaked diaper after 46 hours, no
danger signs, ok pa rin! After five to seven days, baby freezer inside ref 2 weeks
stool is still soft and brown.
freezer part of ref- 3 months
freezer
H. Breastfeeding jaundice:
• insufficient fluid intake separate deep 6 months
• healthy baby with jaundice freeze / standard
• hyperbilirubinemia - B1/unconjugated/ chest freezer
indirect bilirubin that crosses BBB
• declines after 2nd week thawed milk, di na 24 hours
pwede ibalik 
• However, if severe or persistent, may be d/t:
• galactosemia - absolute contraindication to
breastfeeding IX. Absolute contraindications to breastfeeding

• hypothyroidism
• UTI
• hemolysis formula fed infant: rapid weight gain

• newborn screening is not immediately

reported breast fed infant: growth pattern is the norm;

less risk for excess weight gain -> lower CHON

content of breastmilk [lec]
therapy for breastfeeding jaundice: 
*put to phototherapy -> convert bilirubin to soluble one
so excereted
*during phototherapy: milk formula (2 days) VIII. Relative contraindications for breastfeeding

*after phototherapy/2 days: exclusive breastfeeding

A. HIV
*if cupping, not tilted 90 degrees, assisted cupping
• 15-25% by a non-breastfeeding mother
only
• 20-45% by a breastfeeding mother
• lesser risk if exclusively breastfed for first six
months; higher risk if >6months
• therefore, breastfeed exclusively only for 6
VII. Breast milk collection months. After 6 months, stop na!
Take into consideration the ff: • exclusive breastfeeding is recommended for hiv
• mother’s work/illness infected mothers for the first six months of life
• hygiene unless replacement feeding is accetable, feasible,
• breast pumps / manual expression affordable, sustainable and safe for them and their
infants before that time (IN THE STATES)
• THIRD WORLD COUNTRIES: recommend
breastfeeding!
B. TB
C. Varicella-Zoster infection - if lesions are found on
chest, do not breastfeed
D. Herpes Simplex Virus
E. Recurrent CMV infection
F. Hepa B - give vaccine and immunoglobulin, then
mother can breastfeed!
G. Cigarettte smoking
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IX. Absolute contraindications for breastfeeding
MALNUTRITION
A. chemotherapy/ radiation therapy

B. galactosemia
Malnutrition
C. urea cycle enzyme deficiency

• extremes of your growth charts

• Undernutrition
X. Formula feeding

• underweight
• 20kcal/30 mL • stunting
• sterility • wasting
• variable scoop sizes • nutri deficiency
• water used?
• iron deficiency anemia
• associated with 25 IQ points
XI. Milk substitutes: deficiency
• Overnutrition
A. Cow’s milk protein based formulas • public health issue
• higher protein than breastmilk • highest burden of stunting in < 5y.o.
• higher weight gain in infancy • Philipppines ranking 9th
• predominant whey protein (B globulin) • 1 in every 3 childen < 5 y.o. is stunted
• for breast milk, alpha lacta—
Undernutrition
B. Soy formulas • household level food security
• cow’s milk protein free • access to health and sanitation severices
• lactose-free • immunization
• indications: • child caring practices
• galactosemia • weaning - transition from breastmilk to
• hereditary lactase deficiency solid food; very critical; onset of
• vegetarian diet malnutrition
• secondary lactose intolerance • inadequate knowledge: benefits of BFing
• i.e. following acute diarrhea, when • pregnancy
there is the instance of flattening of • 2 years is the normal spacing for
intestinal villa pregnancy
• cow’s milk allergy is not an indication • first 2 years of life
• chances are also high that if with • highest chunk of infant mortality
cow’s milk allergy, there is also soy • folate deficiency
milk allergy present • iron deficiency

C. Protein hydrolysate formula Measurement of nutritional status

• partially hydrolyzed protein
• not for infants with cow’s milk protein allergy
• for high risk of atopic disease - for prevention Z Score/ standard deviation
of atopic disease, NOT A TREATMENT 

a Z score represents a relationship to the
Recommendation for high risk infants of atopic mean in a particular group
disease is still breastfeeding.
A Z score of 0 is equivalent to the mean

D. Extensively hydrolyzed formulas A Z score of +1/-1 means 1 standard

• cow’s milk protein intolerance
• soy protein intolerance
• lactose free (should not primarily be the
indiciation for consumption/prescription)
• medium chain triglycerides
• for those with malabsorption
E. Pre-term milk formulas
• higher protein
• different mixtures of fats and sugars
• concentrated volumes are given because of
small pre-term sizes (they could only tolerate
small volumes, but they need more)
deviation above or below the mean
A. Weight for height (WFH)
• wasting
• a measure of acute malnutrition
• if not feasible, use mid-upper arm
circumference (MUAC)
• y axis = weight; x-axis = height
• weight has a direct effect to Z score
• wasting < -2
• severe wasting < -3

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B. Height for Age (HFA) D. BMI for age

• stunting • above +2 = overweight
• a measure of chronic malnutrition (with added • above +3 = obesity
acute insult) • below -2 = underweight
• assess nutritional status • below -3 = severely underweight 

• a measure of skeletal growth
• a measure of chronic malnutrition Do not use “normal” as interpretation for growth
• stunted < -2 chart; instead, use “no stunting” or “no wasting.”
• severe stuning < -3

C. Weight for Age

• combines stature with current health
conditions
• less clinical significance Outcomes of poor nutrition
• underweight < -2 • prematurity
• severely underweight <-3 • intrauterine growth restriction (IUGR)
• low birth weight
• premature death - most immediate
consequence
• increased risk of death
• cognitive impairment

Stunting, severe wasting, and IUGR


35% of all child mortality globally

2.2 million deaths < 5 y.o.

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Severe acute malnutrition (SAM) • hypothermia
• weight for height Z score < -3 • common in african children
• visible severe wasting
• presence of nutritional edema - kwashiorkor B. Kwashiorkor
(edema is due to nutrition, not cardiac or • puffy cheeks
renal derangements) • loss of SQ fat is masked by edema
• desquamation, atropy, skin lesions
note: no severe chronic malnutrition (crudely • hair changes - depigmentation, rough
put, patay na yung bata bago siya maging chronic) • sad and apathethic disposition
• noma
• pitting edema - d/t hypoproteinemia
8 million development goals • causes
(selected) • poverty
1st - eradicate extreme poverty and • child abuse
•
hunger • lack of basic health education
• precipitating factors
• to halve, between 1990-2015
• pneumonia
• the proportion oif people
who suffer from hunger; • measles
• infecion - catabolic state
• the proportion of people
whose income is less than
$1/day KWASHIORKOR MARASMUS
• 4th - reduce child mortality
• leading cause of death: deficiency of protein in deficiency of protein,
pneumonia, diarrhea diet carbohydrates, and fats
in diet
Key interventions
small grap period early discontinutation of
• exclusive breastfeeding
between successive breastfeeding
• adequate and timely complementary
pregnancies
feeding
• key hygiene behavor wasting of muscles - evident wasting of
• micronutrient interventions not evident muscles; “skin and
• deworming and oral rehydration bones”
• fortifying foods with micronutrients
• malaria treatment / insecticide- edema no edema
treated bednets
skin changes color and no skin changes
Other interventions become scaly
• birthspacing
• immunizations

Risk factors for SAM

Types of SAM • children from low-socioeconomic status

• marasmus (severe wasting)
• loss of soft tissues, and SQ fats
• “skin and bones”
• kwashiorkor (characterized by edema)
• marasmic-kwarshiorkor (severe wasting +
edema)
• with chronic diseases
• institutionalized
• mental retardation, malignancy, ESRD
• genetic.neurologic disease
• prolonged hospitalization

A. Marasmus
• severe protein calorie malnutriton
• non-edematous malnutrition
• initially, there is failure to gain weight and
irritability -> weight loss -> emaciation
• constipated/starvation diarrhea
• distended/flat abdomen with visible intestinal
pattern
• muscle atrophy
• hypotonia
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Clincal signs of malnutrition

SITE SIGNS

FACE moon face (kwashiorkor)

Simian facies (marasmus)

EYE pale conjunctivae, periorbital edema

due to IDA

MOUTH angular stomatitis, spongy bleeding

tongue

TEETH delayed eruption - except 1st tooth to

erupt at the 6-th-8th, but we can wait
until the 13th month. An infant who
still has no tooth at this point cannot
just be considered malnourished if the
child is clinically well

SKIN loose, wrinkled/edematous

MUSCULATURE muscle wasting (buttocks and thighs)

SKELETAL deformities - due to specific nutrient taken from the lecture; flowchart regarding
deficiency
treatment of SAM
ABDOMEN distended, ascites

CARDIOVASCULAR bradycardia, hypotension (cardiac

arrest)

NEUROLOGIC global development delay, impaired

memory, CNS damage

Treatment of SAM
• 3 phases of management
• inital
• rehabilitation
• follow-up
• outpatient setting
• >6 months old; no medical complications
• access to health facilities
• duration of treatment
• at risk of nosocomial infections
• ready to use therapeutic foods (RUTF)
• nutrient and energy-rich foods
• no need to add water
• no need for refigeration
• add two tables
• hospital setting

Complications of malnutrition
• growth problems in children
• joint defomority
• blindness
• organ failure or dysfunction
• unconsciousness and coma

-END-

disclaimer: There is variable content from this
sem’s lecture to the previous ones; those discussed
presently are the only content included in this trans.
Refer to other sources for more info. Thank you! :)
Take note that not all problems are prioritized
during initial treatment; encircled are top three
priorities, if present upon admission.

BAHAGHARI ‘15