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

Breast feeding vary substantialy, but the vast majority of infants worldwide are breast-fed

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

In United States, The cultural context of breastfeeding 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

Provisional rates of any and exclusive breastfeeding by age among children born in 2009, National Immunization Surveya,b

Interviews with caregivers of children born in 2009 will continue through December 2012. Provisional rates for children born in 2009 will be updated with final estimates once data becomes available in August 2013. See survey methods for details on study design. bExclusive breastfeeding is defined as ONLY breast milk NO solids, no water, and no other liquids.

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 month ( 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 mother 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)

10 LANGKAH MENUJU KEBERHASILAN MENYUSUI Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, suatu pernyataan bersama WHO dan UNICEF 1.Sarana Pelayanan Kesehatan (SPK) mempunyai kebijakan Peningkatan Pemberian Air Susu Ibu (PP-ASI) tertulis yang secara rutin dikomunikasikan kepada semua petugas. 2.Melakukan pelatihan bagi petugas dalam hal pengetahuan dan ketrampilan untuk menerapkan kebijakan tersebut. 3.Menjelaskan kepada semua ibu hamil tentang manfaat menyusui dan penatalaksanaannya dimulai sejak masa kehamilan, masa bayi lahir sampai umur 2 tahun, termasuk cara mengatasi kesulitan menyusui. 4.Membantu ibu mulai menyusui bayinya dalam 30 menit setelah melahirkan , yang dilakukan diruang bersalin. Apabila ibu mendapat operasi Caesar, bayi disusui setelah 30 menit ibu sadar. 5.Membantu ibu bagaimana cara menyusui yang benar, dan cara mempertahankan menyusui meski ibu dipisah dari bayi atas indikasi medis.

6.Tidak memberikan makanan atau minuman apapun selain ASI kepada bayi baru lahir.
7.Melaksanakan rawat gabung dengan mengupayakan ibu bersama bayi 24 jam sehari. 8.Membantu ibu menyusui semua bayi semau bayi, tanpa pembatasan terhadap lama dan frekuensi menyusui. 9.Tidak memberikan dot atau kempeng kepada bayi yang diberi ASI.

10.Mengupayakan terbentuknya Kelompok Pendukung ASI (KP-ASI) dan rujuk ibu kepada kelompok tersebut ketika pulang dari Rumah Sakit/ Rumah Bersalin/ Sarana Pelayanan Kesehatan.

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 %

Indonesia
Th 2010 Data Kementerian Kesehatan jumlah bayi di Indonesia sekitar 4,4 juta
69 % bayi Indonesia tdk mendapatASI eksklusif Direktur Jenderal Bina Gizi dan Kesehatan Ibu dan Anak, Kementerian Kesehatan, Slamet Riyadi Yuwono
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

Data Dinkes Jateng

juga menyebutkan bahwa pencapaian sasaran

ASI ekslusif dari tahun 2007 terus mengalami peningkatan yakni dari 27,35 persen (2007); 28,82 persen (2008), 40,06 persen (2009), dan 52,3 persen (2010).

SOCIOCULTURAL DETERMINANTS OF BREAST FEEDING IN THE UNITED STATES

The major determinants of breast-feeding in the

United States, include :

Age : Younger mother breast-feeding much less

frequently than older mothers (tend to breast-feed for longer periodes) Parity : Multiparious and Primiparious women initiate breast-feeding at similiar rates Geographics differences : Women from western states are much more likely to breast-fed than women from Souther or Eastern states Marital status : Unmarried women are much less likely to breast-feeding than mmarried women

 Education : At least one year of college-level

education is a strong postive predictor of breastfeeding Income : Poverty is associated with decreased rates of breast-feeding. Women from households with the lowest family income are only half as likely to nurse their infants as those with family incomes more than $25,00/year. Employment : Maternal employment outside the home influences breast-feeding mothers working full time are less likely to initiate breast-feeding and much less likely to breast-feeding at six months compared with women working part time or not working

Sociocultural Determinants ofBreast Feeding in US

Age Parity Geographi cs differences Marital status Educatio n Younger mother breast-feeding much less frequently than older mothers 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

Income
Employm ent

mothers working full time are less

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 impoverished 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 health-

 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 these enviroments, bottle feeding can be a dangerous source of infection more susceptible to infectious diarrheal illness in 1981 documented the high cost to infant health 1 milion infants deaths were attributable to contaminated infant formula WHO/UNICEF approved the International Code for marketing of breast Milk substitutes Breast-feeding is the most important form of contraception in many highly populated developing countries. Anovulation during breast-feeding contributes to child spacing by providing a period during which the mother can recover from her previous pregnancy before beginning a

 1978 guidelines endorsing breast feeding by

american Academy of Pediatrics and The Canadian Pediatric Society Many developing country have taken firm step to discourage use of breast milk substitutes In the mid 1970s Papua New Guinea enacted low forbidding the advertisement of leading bottles and formulas and made both available only by prescription In1989 WHO reported on rate of breast feeding in 15 developing countries in Asia, Africa and Latin America To reaffirm the impotance of breast feeding WHO and UNICEF issued the Innocenti Declaration in1990 This report put forth major goals designed to protect, promote, and support beast feeding around the world

MATERNAL EMPLOYMENT AND BREASTFEEDING

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 However depending on the life situation and type of job, breast-feeding while working can be a challenge The mother can continue to breast-fed when she is home but have her infant consume formula when she is away at work When the mother is away, the infant can be fed stored milk-milk that is expressed from the breast and frozen for that purpose Less commonly, she can have the baby brought to her at work for feedings or she can return home througouht the

 The Family and Medical Leave Act (FMLA),

makes it easier for a new mother to breast-feed her infant during early pregnancy. The FMLA says that workers at large firms have a right to take up to 12 weeks of unpaid leave to care for a new baby or a close family member with a serious health condition. When possible, the working mother should have a minimum of four to six weeks at home with her baby after birth. This period allows the mother and infant to develop a close attachment and enables the mother who chooses to breast-feed time to fully establish lactation.

The Baby Friendly Ten Steps to Successful Breastfeeding

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
1.

A STEPBY- STEP APPROACH TO BREASTFEEDING

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 INVERSION

EARLY BREAST-FEEDING
THE POSTPARTUM ENVIRONMENT INITIATING BREAST- FEEDING

THE FIRST FEEDINGS

ADVANTAGES OF EARLY FEEDINGS

THE FIRST TWO MONTHS OF BREASTFEEDING

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

MATERNALINFANT 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 maternalinfant 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 New mothers struggling with sore nipples or breast engorgement need to be reassured that frequent feedings are not a sign of insufficient milk and infant hunger, but the normal breast feeding pattern
STOOLING PATERNS OF THE BREASTFEEDING

INFANT
Stooling begin shortly after birth and during the first several days,

meconium is passed and the stool appears black and tarry. With each successive feeding , the stool lightens in color and becomes more liquid 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 that many

BREASTFEEDING FROM TWO TO SIX MONTH

FEEDING PATTERNS

APPETITE SPURTS
POTENTIAL PROBLEM FOODS IN THE

MOTHERS DIET

BREASTFEEDING SIX MONTHS AND BEYOND

ADDING SOLID FOODS

TEETHING
PSYCHOLOGICAL BENEFITS OF NURSING

WEANING
HOW LONG SHOULD A MOTHER BREAST FEED

? THE PROCESS OF WEANING MATERNAL HEALTH DURING WEANING WEANING AND INFANT HEALTH IN THE DEVELOPING WORD

RELACTATION AND INDUCED LACTATION

EXTRACTION AND STORAGE OF BREAST MILK

MANUAL EXPRESSION OF MILK

BREAST PUMPS
MILK STORAGE

MATERNAL CONCERNS DURING BREASTFEEDING

INSUFFICIENT MILK AND FAILURE TO

THRIVE TOO MUCH MILK BREAST PROBLEM

Engorgement Leaking Nipple soreness Plugged Milk Ducts

Mastitis and Ereast Abscesses

Breast-Feeding in Special Situations

Casarean Birth Breast feeding twins Breast feeding after Breast surgery Maternal Disorders
Diabetes Mellitus

Chronic diseases
Maternal infections

Infant Disorders
Respiratory infections
Cleft lip and palate Breast milk Jaundice Metabolic Disorders

Breast-Feeding and The Human Immunodeficiency Virus

Mothers infected with the human immunodeficiency

virus (HIV) can pass the virus to their infants during breast feeding HIV has been isolated 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, a policy widely adopted by the other industrialzed countries A recent study in Africa found that HIV positive mothers deficient vitamin A are more likely to transmit

Breast Fedding and Infant Health

Human breast milk, is specific :

evolved to meet the unique nutritional

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

 Protein in Human Milk

Mature human milk contains much less protein(0.8 g

versus 3.5 g / 100 ml) than cows milk A major difference is the concentrations of the whey and casein protein 80% of the protein in cows milk are casein proteins, 40% of human milk protein is casein During digestion in the infants gastrointestinal tract, whey and casein proteins have distinct characteristics Caseins precipitate into sizable curds in the newborns stomach that are tougher and less readily digestible than the softer, more flocculent clumps formed when they whey protein presipitate Whey proteins are consequently often better toleranted by the newborn

 The protein content of breast milk is considered ideal

for human infants

Human milk proteins are complate and balance Supplying optimal anounts of the essential and

nonessential amino acids Rich in cystine and taurine (taurineis found at levels 30 times that in cows milk) Human milk contains only moderate amounts of phenylalanine, tyrosine and methionine The enzym system that metabolize these amino acids mature late in fetal life (Rassin 1991) Preterm infants over consumption of these amino acid can increase blood level to potentially detrimental levels

 Vitamins, Minerals, and Enzymes in Human Milk

 Protection from Infectious Diseases

ProtectionFromAllergies

Breast feeding, maternal diet and Infant Allergy

Breast feeding and Chronic Diseases of Later Life

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

Obesity

Artherosclerosis

Immune Disorders

Breast Feeding and Infant Mortality

In the developing countries of the world 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 are primarily due to differences in rate of infection between formula fed and breast fed infants(Wray 1991) In US mortality rates are low for both breast fed and formula fed infants it is not clear whether breast feeding still confers a protective effect (Wray 1991)

Levels of Influence in the Social-Ecological Model

Structures, Policies, Systems Local, state, federal policies and laws to regulate/support healthy actions Institutions Rules, regulations, policies & informal structures

Community Social Networks, Norms, Standards

Interpersonal Family, peers, social networks, associations Individual Knowledge, attitudes, beliefs

Thank You