Lactation

Question 1

How does breastfeeding associated with IQ?

Answer 1

Observational studies suggest that breastfeeding reduced risk for low IQ
Mechanism not known but could be:
- Nutritional content of human milk (omega-3 fatty acids, other lipids)
- Parent-child interaction
- Confounding effects

Question 2

What is the WHO, Health Canada, and Dietitians of Canada breastfeeding recommendations?

Answer 2

Exclusive breastfeeding is recommended for the first 6 months of life for healthy term infants, as breast milk is the best food for optimal growth. Breastfeeding may continue for up to 2 years and beyond.

Question 3

What are benefits of breastfeeing for infant?

Answer 3

Optimal nutrition - proper quantity + quality of nutrient
- bioavailable minerals
- easily digestible fats + proteins
Changing/adapting - age of the baby and nursing parent eats, illnesses
- may inc. acceptance of new foods
Immunological benefits - antibodies
- protection from acute + chronic diseases - allergies
- dec. infant mortality
Bonding
May improve cognitive development

Question 4

What might be a confounder in the relationship between breastfeeding and IQ?

Answer 4

Socioeconomic status
Education
Availability of parent

Question 5

What are benefits of breastfeeding for mother/parent?

Answer 5

Bonding - emotional benefits
Promotes involution of uterus (oxytocin)
Suppress ovulation
Dec. risk of chronic disease - breast cancer
Convenience - once established
Generally less expensive
Dec. risk of postpartum depression

Question 6

What is postpartum depression?

Answer 6

Mood disorder that occurs within 1 year after childbirth
- Different than the “baby blues” - really sad/mood dropped; overwhelmed + inadequate

Edinburgh Postnatal Depression Scale
- Scores: 0-30
- Score of 13 or more indicates probable major depression

To be considered postpartum depression, symptoms must be present everyday for at least 2 weeks

Question 7

Who are at higher risk of postpartum depression?

Answer 7

Unknown etiology but genetics, changing hormones, psychological, and social life stressors may play a role

Risk:
- history of depression
- higher stress during pregnancy/high risk pregnancy
- lack of support after birth
- lifestyles - poor diet, lack of sleep, lack of exercise

Question 8

What influences Breast Feeding Initiation and Continuation?

Answer 8

Work
Painful - lactation problems
Lack of guidance
Mental health
Lack of family support
Choice - inconvenience/fatigue
Social dynamics - embarrassment
Not enough breast milk
Diffculty with breastfeeding
Health or medical conditions parent/baby

Question 9

Which of the following can reduce the likelihood of successful
breastfeeding? [Select all that apply]
A. Small breast size
B. Breast reduction surgery
C. Breast implants
D. Infrequent breastfeeding
E. Skin to skin contact after birth

Answer 9

D. Infrequent breastfeeding
Percecived low supply ↔ infant formula ↔ milk support

Question 10

What are contraindications to breastfeeding?

Answer 10

Infant
* Galactosemia in infant (rare)

Nursing Parent
* Currently undergoing radioactive therapy or chemotherapy
HIV and some other viruses
* Substance abuse (eg. Opioids)
* Some medications and illnesses are temporarily
incompatible with breastfeeding

Question 11

What is the Breastfeeding Paradox?
A. With more frequent and longer durations of feeds, less milk
is produced
B. Nursing is supposed to be easy and “natural”, but is a struggle
for many
C. Those who stand to gain much from the health benefits of
breastfeeding (and can least afford to buy formula) are least
likely to breastfeed
D. The larger the baby, the less milk they need

Answer 11

C. Those who stand to gain much from the health benefits of
breastfeeding (and can least afford to buy formula) are least
likely to breastfeed

Question 12

What are ways that each of these levels (health care systems, the workplace, the community and the family) can support breastfeeding?

Answer 12

Healthcare:
- Education
- Anticipatory guidance
- Lactation consultants - trained staff
- Promoting early contact + early initaition

Worplace
- De-stigmatize
- Dedicated time + space for pumping/feeding
- Maternal leave compensation

Community;
- Reduce stigma
- Normalize
- Breastfeeding rooms

Family:
- Support
- Bring them class of water/food

Question 13

What is anticipatory guidance?

Answer 13

Guidance on breastfeeding provided before birth increases likelhood of breastfeeding after birth

Question 14

What is early initiation?

Answer 14

Early initiation & skin-to-skin after birth increases
likelihood of successful breastfeeding
Early
Effective
Exclusive

Question 15

What are WHO policies to promote breastfeeding?

Answer 15

Baby Friendly Hospital Initiative:
Ten steps to successful breastfeeding
1. Hospital policies
2. Staff competency
3. Antenatal care
4 Care right after birth
5. Support mothers with breastfeeding
6. Supplementing
7. Rooming-in
8. Responsive feeding
9. Bottles, teats. and pacifiers
10. Discharge

Question 16

What are the international code on marketing of breastmilk substitutes?

Answer 16

1.No advertising of breastmilk substitutes.
2.No free samples to mothers.
3.No promotion of products through health care facilities

Health Canada: Regulatory modernization of foods for special
dietary use and infant foods
It is proposed to prohibit the following on the label of all infant formula:
1. Pictures of infants, which may idealize the use of infant formula
2. The terms “humanized”, “maternalized”, “human milk
oligosaccharide”, “human milk identical oligosaccharide” or similar
3. Statements comparing infant formula or its ingredient(s) to human milk, including comparison of the levels of a nutrient in infant formula to the level of the same nutrient in human milk

Question 17

When are female breasts considered fully developed?
A. In childhood
B. In later adolescence or early adulthood
C. In pregnancy
D. After pregnancy
E. In menopause

Answer 17

D. After pregnancy

Question 18

What are the endocrinology of breastfeeding?

Answer 18

During pregnancy:
* Estrogen, progesterone and placental lactogen prepare breast
* Prolactin is secreted towards end of pregnancy
After delivery of the placenta:
* Pregnancy hormones drop rapidly
* Prolactin and oxytocin production increase
During breastfeeding
* Prolactin promotes milk synthesis
* Oxytocin promotes “let-down” - ejection of milk from milk
ducts to nipple

Question 19

What is the mechanism of the letdown reflex?

Answer 19

1. Suckling stimulates nerves in nipple
2. Nerves send message to hypothalamus
3. Hypothalamus seds message to pituitary gland
4. Pituitary gland releases prolactin, which stimulates milk production, and oxytocin, which stimulates milk release

Question 20

Which of the following correctly matches prolactin and
oxytocin to their endocrine gland?
A. Prolactin & oxytocin – anterior pituitary
B. Prolactin & oxytocin – posterior pituitary
C. Prolactin – anterior pituitary; Oxytocin – posterior pituitary
D. Oxytocin – anterior pituitary; Prolactin – posterior pituitary
E. It depends

Answer 20

C. Prolactin – anterior pituitary; Oxytocin – posterior pituitary

Question 21

What is breastfeeding: supply & demand?

Answer 21

• Increased suckling (removal of milk from the breast) stimulates ↑ milk production
• Feeding or pumping frequently promotes good milk supply
• Early and frequent breastfeeding is essential for establishment of breastfeeding

Question 22

You need to have been pregnant to produce milk (lactate).
A. True
B. False

Answer 22

B. False

Question 23

What is the composition of mature human milk?

Answer 23

Per 100 mL of human milk:
Energy ~ 70 kcal % energy
Protein 1.2 g ~7%
Fat 4.0 g ~51%
Carbohydrate (lactose) 7.4 g ~42%
Minerals in lower concentrations to reduce solute load
Forms that are well-absorbed
Adequate amounts of all vitamins, except vitamin D and vitamin K
Non-nutritive substances: Sphingo/glycolipids, oligosaccharides,
immunoglobulins, lactoferrin, lysozyme, peptides & amino acids, acids, microRNA, microbiota

Question 24

What is the unique composition of milk?

Answer 24

Isotonic with plasma - breastfed infants do not require additional water
Contains micro and macronutrients, nucleotides, white blood cells, enzymes. hormones, and immunoglobulins
Changes with infant age and stage of feeding to meet infant needs

Question 25

What is the composition of proteins in human milk?

Answer 25

**Casein (~20-30%)** * Aggregates to form milk’s white appearance * Promotes absorption of calcium **Whey (70-80%)** * Soluble proteins * Most abundant = lactalbumin * Includes: * Immunoglobulins (IgA) * Lysozyme (antibacterial) * Lactoferrin (carries iron and promotes iron absorption)

Question 26

What is the non-protein composition in human milk?

Answer 26

Non-protein nitrogen - ~25% of nitrogen in mature milk - peptides (hormone, growth factors), free amino acids, urea, carnitiine (FA metabolism), choline - Taurine - neural development + fat digestion

Question 27

What is fat compositon in human milk?

Answer 27

Fatty acid composition reflects maternal diet and fat stores - 16:0 → 18 → 20 → 20:1 **Medium chain fatty acids** * Synthesized in mammary gland, 6-14 carbons * Improved absorption and may be important for gut health* *More easily digested:* ** Lipases *** Palmitate (16:0) in sn-2 position** Triacylglyceride - Huamn milk - 16:0 in the middle to prevent Ca2+ soap - human milk makes fatty acid (FA and monoglyceride b/c 16:0 is in the middle)

Question 28

Human milk is rich in long-chain omega-3 fatty acids A. True B. False C. It depends

Answer 28

C. It depends

Question 29

How is human milk fat globule transported?

Answer 29

Mammary alveolus → milk fat globule secreted → triacylglycerols inside and surrounded by properties that benefit the brain and immune development

Question 30

How is carbohydrates in human milk?

Answer 30

Lactose Human milk oligosaccharides - promotes growth of beneficical gut bacteria and protect gut health -E.g. Bifidus factor

Question 31

Which of the following is correct? A. Breastmilk contains much more iron than infant formula, and iron is much better absorbed from breast milk B. Breastmilk contains much more iron than infant formula, but iron is much better absorbed from infant formula C. Breastmilk contains much less iron than infant formula, but iron is much better absorbed from breast milk D. Breastmilk contains much less iron than infant formula, and iron is much better absorbed from infant formula

Answer 31

C. Breastmilk contains much less iron than infant formula, but iron is much better absorbed from breast milk ~50% iron in BM ~10% iron in Formula

Question 32

What are the immunological components of breastmilk?

Answer 32

WBC Antibodies HMO - prebiotics Probiotics - microbiotia Lactoferrin Lysozyme Lactoperoxide miRNA → immune system, immune tolerance; bind to RNA controls expression/not

Question 33

What is the human milk microbiome?

Answer 33

**Retrograde flow** - Breast skin microbiota - Infant oral microbiota → baby saliva going into mammary gland and lymphatic; makes antibodies for any infection the infants passes to to the mother **Entero-mammary pathways** - Enterocytes → DC from maternal gut

Question 34

What can alter the composition of human milk?

Answer 34

*"Breastmilk can be considered a "live tissue" whose composition varies between women and changes over the course of lactation"* * Maternal genetics & microbiome * Age of infant (stage of lactation) * Length of feed * Maternal diet * Infection * Exposure to medications, alcohol, and other substances

Question 35

What is colostrum?

Answer 35

Liquid Gold → MUCH less volume produced; inc. protein and antibodies * Yellowy, viscous fluid, secreted in small amounts at start of lactation * More protein and less lactose than mature milk Benefits – Establishing** bacterial flora** – Passage of **meconium** – High antibody content

Question 36

What is the influence of diet on milk compostion?

Answer 36

Protein & Carbohydrates → generally no effect Fat → maternal diet has influences FA composition; generally minimal effect on total fat Vitamins → Yes; diet/stores Minerals → generally no effect Flavors → maternal diet influences the taste of the milk; mint, garlic, onions, etc.

Question 37

Anne and Kristy are both breastfeeding 3-month-old babies. Anne’s diet has more iron and vitamin B12 than Kristy’s diet. Which of the following is correct regarding the composition of their breast milk? A. Anne’s milk will contain more iron than Kristy’s milk B. Anne's milk will contain more vitmain B12 than Kristy's milk C. Anne’s milk will contain more iron and vitamin B12 than Kristy’s milk D. These differences in dietary intake will not contribute to any differences in breast milk composition between Anne and Kristy

Answer 37

B. Anne's milk will contain more vitmain B12 than Kristy's milk iron has minimal effect b/c fetal hemoglobin stores and mother not mentrating

Question 38

What are contaminants in human milk?

Answer 38

**Drugs**: - Transfer through breast milk and infant metabolism varies significantly with different types of drugs - Most prescription and OTC medications are considered safe in recommended doses - To check medication safety in lactation: LactMed Database **Effects of illicit drug use on the breastfed infant can range from lethargy, poor feeding, and seizures to death** **Caffeine:** Up to **300mg of caffeine per day** is considered safe while breastfeeding * 2-3 cups coffee/day Energy drink use should be discouraged * Large amounts of caffeine * Added herbal ingredients and vitamins Infants who react to caffeine may be unusually irritable, fussy, wakeful, or have difficulty staying asleep **Alcohol:** - Alcohol freely diffuses into milk - Can reduce milk production, interfere with infant sleep, and interfere with cognitive development **no alcohol use is safest for the baby. Consuming a standard drink on occasion can be okay, as long as it is planned. It takes about two hours for the alcohol contained in a standard drink to be eliminated from the body and leave the breastmilk**

Question 39

Cannabinoids such as THC are lipid soluble, this means they will enter milk by: A. Passive diffusion B. Facilitated transport C. Active transport D. Exocytosis

Answer 39

A. Passive diffusion

Question 40

What are the environmental contaminants in human milk?

Answer 40

**Metals** * Lead (Pb), cadmium (Cd), mercury (Hg), and arsenic (As) **Persistent Organic Pollutants (POPs)** * Polychlorinated biphenyls (PCBs) * Pesticides * Phthalates * Bisphenol A ** Benefits of breastfeeding outweigh potential risks of contaminants

Question 41

What are the nutrition recommendation for lactations?

Answer 41

Factors to consider: 1. Nutrients (and energy) secreted into milk 2. Maternal stores deposited during pregnancy 3. Contaminants and exposures that influence milk

Question 42

What is the energy needs in lactation? EER formula?

Answer 42

EER = non-pregnant EER + energy for milk production – energy mobilized from fat stores 0-6 months postpartum EER = non-pregnant EER + 400 kcal 6-12 months postpartum EER = non-pregnant EER + 380 kcal

Question 43

What is the energy recommendations for a lactating person?

Answer 43

Lactating persons should consume **~300-400 kcal/day** above pre-pregnancy needs * Do NOT restrict energy Weight loss should be gradual * Energy restriction can decrease the volume of milk produced EER is only a guide. Need to monitor maternal and infant weight and health Need to continue with nutrient-dense food choices

Question 44

Is postpartum weight loss a "benefit" of breastfeeding?

Answer 44

Exclusive breastfeeding has been associated with slightly more weight loss postpartum, but this finding has been inconsistent in the research Should not emphasize weight loss as a benefit of breastfeeding * Concern: Quitting early if weight loss ideals are not achieved

Question 45

What are the macronutrient needs in lactation?

Answer 45

EAR = based on non-pregnant needs + amount in milk **Carbs: ** - EAR for lactation: 160 g/d - RDA for lactation: 210 g/d - RDA for pregnancy: 175 g/d **Protien: ** - EAR for lactation: 1.5 g/kg/d - RDA for lactation: 1.3 g/kg/d - RDA for pregnancy: 1.1 g/kg/d Linoleic acid and alpha-linolenic acid: stays the same or around the same

Question 46

Which nutrient requirements might increase in lactation compared to pregnancy?

Answer 46

Vitamin A, E, C → antioxidants Choline Iodine Water increases

Question 47

Would any stay the same or even decrease in lactation to pregnancy?

Answer 47

**Decrease in lactation compared to pregnancy:** - Folate - Iron **Similar increase in pregnancy and lactation:** - niacin - riboflavin - thiamin - vitamin B6, B12 - zinc **No change for pregnancy or lactation** → all bone nutrients - vitamin D → low in milk - vitmain K → low in milk - calcium → inc. absorption - phosphorus → inc. absorption

Question 48

How does this translate into recommendations for foods?

Answer 48

Eat a little more Focus on nutrient dense foods Canada's food guide: - Healthy eating when pregnant and brestfeeding - you need just a little more food each dat to preduce breast milk

Question 49

Should a prenatal multivitamin be continued in lactation? A. Yes B. No C. It depends on the person

Answer 49

B. No

Question 50

What are the recommendations for supplements in breastfeeding individuals?

Answer 50

**Don't eat dairy products**. May need supplemental calcium and vitamin D. **Don't eat animal products.** May need calcium & vitamin D, vit B12, zinc, and iron. **Are at higher risk for nutrient deficiencies** due to poor diet, medications, or chronic conditions But remember that all females who **could become pregnant** should take **400 mcg folic acid daily** - menstration + ovulation returns

Question 51

How Often Should Healthy Newborns be Fed? A. Only once per day in the first few days because they have adequate nutrient stores from pregnancy, increasing frequency of feeds with age of the baby B. ~ 3 meals and 2 snacks to get them into a healthy routine C. Regularly every ~ 3-4 hours or ~6 times per day D. On demand, about every 2-3 hours or as often as baby wants to feed, > 10 times per day

Answer 51

D. On demand, about every 2-3 hours or as often as baby wants to feed, > 10 times per day

Question 52

What are the hunger cues?

Answer 52

**Early cues** - "I'm hungry" - Stirring, mouth opening, turning head;seeking/rooting **Mid cues **- "I'm really hungry" - stretching, increasing physical movement, hand in mouth **Late cues** - "Calm me, then feed me" - Crying, agitated body movements, colour turning red - late feeding cue occurs after other cures have been missed

Question 53

What are breastfeeding positions?

Answer 53

Cradle, Cross-Cradle, Clutch ("football hold"), Side-lying position - Parent in comfortable and supported position - Baby’s head supported but free to move - “Tummy to mummy” - Support bottom for to help baby feel secure

Question 54

What is a good latch?

Answer 54

* Baby attaches with wide open mouth, chin first then mouth * Lips flange; nipple hitting the soft palete * About 2-3 cm of breast tissue in mouth * Listen and look for signs of swallowing

Question 55

How can you tell if the infant is getting enough breast milk? A. The baby falls asleep at the breast every time she eats B. Breast size shrinks by about the amount you expect the baby to eat to be full C. By weighing the baby before and after each feed to make sure they have gained the required amount of weight D. Based on overall feeding frequency, wet and soiled diapers and appropriate weight gain

Answer 55

D. Based on overall feeding frequency, wet and soiled diapers and appropriate weight gain

Question 56

What are the signs of getting enough milk?

Answer 56

**1. Wet Diapers** Day 1: 1 wet diaper Day 2: 2 Day 3: 3 Day 4: 4 Day 5: 5 Day 6 and beyond: 6 + **2. Bowel movements:** - 1-3 per day increasing to 3-5+ per day - Transitions from meconium (thick, black) to yellow and soft **3. Weight gain ** - Loss up to 7% in first 5 days - Growth after day 5 **4. Alert and responsive ** - stare; quiet play

Question 57

Should I breastfeed?

Answer 57

**"Allergy" to breast milk** - true allergy very rare - might be a reaction to flavour/component in milk - try removing food (garlic) for a few days **Infant "Not Getting Enough Milk"** - feed more - supplements w/ formula but continure to express milk **Sick Infant** - defining breastfeed **Sick Nursing Parent** - defining breastfeed **Medications**- Most are safe

Question 58

How long should breastfeeding continue?

Answer 58

− For optimal infant health, Health Canada recommends exclusive breastfeeding for six months, with continued feeding for up to two years and beyond − In many parts of the world, breastfeeding routinely continues for two to three years − Many in Canada, however, currently wean their infant within the first year