Week 7: Infant feeding

Question 1

Explain Baby friendly health initative (BFHI)

Answer 1

Role: to protect, promote and support breastfeeding.

Does this by providing a frame work for any healthcare system to operate within the Ten steps for successful breastfeeding.
- these standards ensure mother are provided with contemporary and approprite support in the the antenatal and post natal period.

In a Baby Friendly accredited facility, breastfeeding is
encouraged, supported and promoted. Breastfed babies are not given breastmilk substitutes (infant formula), dummies or teats unless medically indicated or it is the parents’ informed
choice.

Question 2

What are the ten steps to successful breast feeding?

Answer 2

1. 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. Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognise when their babies are ready to breastfeed, offering help if needed.
5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants
6. Give newborn infants no food or drink other than
   breastmilk, 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 artificial teats or dummies to breastfeeding
   infants
10. Foster the establishment of breastfeeding support and
    refer mothers on discharge from the facility.

Question 3

Summaries the main points of the international code

Answer 3

• No advertising of breast-milk substitutes and other products to the public
• No donations of breast-milk substitutes and supplies to maternity hospitals
• No free samples to mothers
• No promotion in the health services
• No company personnel to advise mothers
• No gifts or personal samples to health workers
• No use of space, equipment or education materials
sponsored or produced by companies when teaching
mothers about infant feeding.
• No pictures of infants, or other pictures idealizing
artificial feeding on the labels of the products.
• Information to health workers should be scientific and factual.
• Information on artificial feeding, including that on
labels, should explain the benefits of breastfeeding
and the costs and dangers associated with artificial
feeding.
• Unsuitable products, such as sweetened condensed
milk, should not be promoted for babies.

Question 4

What are the three components of the breast?

Answer 4

• skin
• subcutaneous tissue
• corpus mammae (body of the breast)
  - parenchyma – glandular (secretory) tissue
  - Stroma- adipose tissue, blood and lymph vessels and nerve tissue

These are supported by Cooper’s ligaments (fibrous connective tissue)

Question 5

Explain the compartments within the breast

Answer 5

Alveoli- (10-100) tiny little pockets. Role= milk synthesising and secretion.
- Myoepithelial cells contract to eject milk from the alveolus into the lactiferous ducts

Lobules- (15-20)= clusters of alveoli that are surrounded by fat

Lactiferous ducts- (4-18) milk transport ducts which converge with the nipple

Papilla mamme- Nipple is rich innervated with sensory nerve endings. When baby succles this sends signals to the alveoli to produce and secrete milk

Areola mammae- Areola is pigmented with approx. 18

Montgomery’s tubercles (sebaceous and lactiferous
glands) that secrete a lubricatation to protect the nipple

Areola and also provide a scent to attract the baby

Question 6

Explain the anatomy of the breast

Answer 6

The alveoli are surrounding a ductule. This is then further surrounded my myoepithelial cells that contract when the alveoli produce milk, pushing it into the ductus. This travels down the Lactiferous ducts.

Question 7

Explain the blood, lymphatic and nervous supply to the breast.

Answer 7

Blood supply is from

• (60%) Internal mammary artery
• (30%) lateral mammary branch of the lateral thoracic artery

Lymphatic supply

• Rich, extensive lymphatic drainage
• drained is the axillary nodes (75%) & internal mammary nodes

Nerve supply
- innervated by nerves 4th, 5th, & 6th intercostal nerves that innervate the skin, nipples and blood.

Question 8

Describe the changes in breast milk

Answer 8

Colostrum

• think yellow from 16th weeks of pregnancy- 3rd-14th day after birth (14th day= extreme)
• high density and low volume
• contains high level of anti-infective properties and nutrients
• some women don’t get it
• around the 3rd day women see a change in her milk

Transitional milk
- from colostrum to mature milk

Mature milk

• from aprox comes approx 14 days
• gradually changes from foremilk (lower in fat) at the beginning to hind milk (higher in fat) towards the end

Question 9

What are some of the unique properties of breast milk?

Answer 9

Proteins – Casein 40% and Whey 60%. These are easily digested and contain anti-infective properties
- it is the balance of these concentrations that makes them easily digestible. These ratios are very different in cows.

Carbohydrates – Lactose is the main carbohydrate

Fats – Lipids are mainly triglycerides 98-99% and are
easily digestible

In addition, breast milk contains; electrolytes, minerals, trace elements, vitamins, enzymes, hormones, anti-infective factors and anti-allergic properties

Question 10

What are the actions of the anti-infective

properties?

Answer 10

Lactoferrin – inhibits iron dependent bacteria
in the gut

Secretory IgA – protects against virus and
bacteria

Lysozymes – protects against Ecoli

Bifidus factor – supports growth of lactobacillis

Question 11

How does the breast milk supply establish?

Answer 11

Embryogenesis – Embryonic development in utero

Mammogenesis – (2 phases) growth and development of the mammary glands in
response to hormones during puberty and in pregnancy

Lactogenensis – (3 phases) the initiation and
production of milk and is the transition from pregnancy to lactation

Question 12

Further explain Embryogenesis and its role in establishing the supply of milk

Answer 12

• 4th week embryonic period (of mother of baby?) the primitive milk streak develops from axilla to groin (2.5 mm long)
• Further development results in the breast structures
• From 32 – 40 weeks of gestation, lobular-alveolar
structures containing colostrum develop
• Following birth the neonate may secrete colostrum
known as witch’s milk

Question 13

Further explain Mammogenesis and its role in establishing the supply of milk

Answer 13

=the growth and development of the mammary glands.

• This occurs in two phases as the glands respond first to the hormones of puberty and then later to the hormones of pregnancy.
• Puberty - Oestrogen is the hormone responsible at puberty where the primary and secondary ducts grow and divide and form terminal end buds (budding)

• Pregnancy – early pregnancy placental lactogen, prolactin and
chorionic gonadotrophin promote growth and oestrogen develops the duct system

Question 14

Explain lactogenisis

Answer 14

= the initiation and production of milk.

Lactation is the physiological completion of the reproductive cycle.

The process can be divided into three stages during which human milk varies in components, appearance and volume:

Lactogenesis I – Breast size increases and there is initiation of milk synthesis from mid to late pregnancy

Lactogenesis II – (approx. D2 – 8 ) The onset of copious milk production is triggered by a rapid drop in progesterone following expulsion of the placenta. Together with milk removal, lactation is established.

Lactogenesis III (Galactopoiesis) – (D8-9) the maintenance of abundant milk production (autocrine system – supply/demand)

Question 15

What hormone is key in milk supply before t becomes a mechanical action?

Answer 15

Prolactin

Question 16

Explain the supply and demand of breast milk and a midwife’s role in maintaining this.

Answer 16

• Milk removal stimulates production
• amount removed at each feed, stimulates the amount that is reproduced.
• milk removal must be continued between separation or periods where breastfeeding is not possible to maintain supply.

Midwifes role= facilitate milk removal

Practice note:
• Breast size does not reflect milk storage capacity
• Storage capacity does vary with breasts
• If the breasts remain full prolactin receptors will not function
and milk production will be inhibited
• Therefore frequent emptying is important to maintain the
milk supply

Question 17

Explain let down

Answer 17

Milk ejection reflex

• contraction of myoepithelial cells surrounding alveoli that sends milk though the ductule.
• in response to nipple stimulation and sometimes psychological influences.

Question 18

What is the role of the pituitary gland in breastfeeding?

Answer 18

Production of milk

• baby suckles
• impulses are sent via nerves to the anterior pituitary
• this raises prolactin levels in blood
• this causes the mammory glands to produce more milk

Release of milk

• baby suckles
• impulse reaches posterior pituitary gland
• raises oxytocin in blood
• this causes milk ejection

Anterior pit= prolactin= production of milk
Posterior pit= oxytocin= ejection

Question 19

Why breastfeed in the first 24hrs?

Answer 19

• infant is alert and has suckling state awareness

Skin on skin and early feeding causes;
- encourages baby to feed
- encourages prolactin
Provides colostrum – immunological advantages
- Lactation is accelerated
- Prolactin is high in the first 2 hours
- Helps reduce the incidence of engorgement (when milk comes in and congestion occurs and can prevent the flow of milk)
- Reduces weight loss for the baby (expect baby to lose 10%)

Question 20

What are some maternal benefits of early feeding?

Answer 20

• Release of Oxytocin encourages contractions –
involution of the uterus to close off all the bleeding points (EARLY feeding is extra important)
• Mothers will BF for a longer duration
• Breast engorgement is minimized
• Attachment and bonding
• BF accelerates the baby’s adaptation to extrauterine
life, reduces crying, and increases the baby’s blood
glucose and temperature
• Peristalsis (get movements) is stimulated – Reduces jaundice= meconium has high bilirubin levels so if baby doesn’t eat the bilirubin isn’t moved out.

Question 21

What are some benefits of early feeding for baby?

Answer 21

Skin to skin

• Maintains baby’s body temperature
• Regulates the baby’s heart rate
• Allows metabolism of the baby’s brown fat to keep warm
• Releases normal amounts of growth hormone

With demand Feeding: women may need to wake baby during the initial
deep sleep period 2 - 20 hours after it is born

Rooming in: mother learns to;

• identify hunger cues
• avoids
• delaying hunger gratification
• provides unrestricted access

Question 22

Explain a babys alertness post bith

Answer 22

Alert= birth- 2hrs
(encourage breast feeding within the first hour of birth)
Light and deep sleep= 2- 20 hrs
Increasing wakefulness= 20-24 hrs
(often includes cluster feeding episodes over 2 – 3 hours followed by deep sleep of 4 -5 hours)

Question 23

What is the expected in put and out put of a baby with in the first 48hrs?

Answer 23

First 24 hours
• Approximately ½ teaspoon colostrum at each feed
• Approximately one meconium bowel action
• Approximately one wet nappy

24 – 48 hours
• Approximately one teaspoon of colostrum
• Approximately two meconium bowel actions
• Approximately two wet nappies

Question 24

What can we do to help a woman breastfeed?

Answer 24

• Confidence holding, feeding and settling her baby
• Hunger cues (point them out as we see them)
• Positioning and attaching baby at the breast
• Signs of optimal attachment
• Recognition of an adequate feed
• How to achieve optimal attachment if baby unable to self-latch
• Demand and supply principle
• How long to feed for: watch the baby not the clock, empty the first breast before offering the second side – falls asleep, flutter sucking or comes off.
• talk about ability to manage full breasts when the milk “comes in” – usually after discharge home
• Available supports / resources

Question 25

Explain the hands-off technique?

Answer 25

HOT
About not taking over and talking the women though how to breast feed her baby

Talk her though it
Show with fake breast and baby of how she can do it

• respects the womans dignity and autonomy
• empowers the woman
• boosts confidence
• equips woman with appropriate skills
• less back injuries for midwives

Question 26

What are the hunger cues?

Answer 26

Early cues

• stiring
• mouth opens
• turning head seeking/rooting= mouth open and seeking breast
• this is when we want to feed

Mid cues

• streahing
• increasing physical movement
• hands to mouth

late cues

• crying
• agitated body movements
• colour turning red

Question 27

When should feeding be initiated?

Answer 27

When it is in the early stage.

It will need calming before it feeds.

Question 28

How can we assess feeding?

Answer 28

Normal feeding pattern: 8 -12
feeds in 24hours (could be clustering or not)

Assessment of a good feed

• Feel the breast before and after the feed
• Watch the baby suck/swallow (suck, suck, swallow or suck =, swallow, suck swallow)
• Assess let down (tingling coming down breast)
• Observe nipple shape after the feed (if pinched up they haven’t had a good latch and been on the hard pallet)
• What goes in one end comes out the other (poo chart)

Demonstrate breaking the latch

Question 29

Why is a good attachment so important

Answer 29

It is critical as it gets breast feeding right

It maintains supply as if the breast isn’t not drained, it wont refill.

Question 30

What are some good positions for mother and baby when breastfeeding?

Answer 30

Mothers position
- Comfortable back and feet support (no matter what position)
- Feet supported if sitting out
Baby’s position
- Unwrapped so it can be very close to woman
- Chest to Chest
-  Nose to nipple
- Chin tucked in
- Supported shoulders

Encourage skin to skin!

Question 31

What is the precursor for a good attachment?

Answer 31

• nose in line with nipple
• chin tucked
• bottom lip to base of areola

Question 32

What are some signs of a good latch?

Answer 32

• No Pain
• Large mouthful of breast taken
• Baby’s mouth should not
slide up and down the breast
• No gap b/w baby’s cheeks/chin and breast
• Cheeks rounded on baby and not dimpling in
• No clicking (means tongue has space in mouth)
• Nipple should be round post feed

Question 33

What can be done when a woman is struggling to breastfeed?

Answer 33

• Offer HOT help – use tools
• If hands on is required – Ask permission
• Don’t continue to try if the mother or baby is upset
• Express – offer this to the baby as it may stimulate the baby to feed
• Try again next feed – offer 3 hourly if unsuccessful
• If baby shows no interest and/or there is a concern I.e.
hypoglycaemia, sepsis or dehydration – Paediatric review

Question 34

What should be done about razed, cracked or blistered nipples?

Answer 34

Crackled nipples are a common problem in the first weeks to feeding

Midwives should
• Assess the cause (most likely attachment)
• Ensure attachment is correct
• Breast feed from least painful breast first as baby will be most riugh when most hungry
• If nipple is too painful, express and offer express breast milk (EBM)
• Lubricate the nipple with breast milk ac and pc
• May apply a pure lanolin cream

Question 35

Explain breast engorgement and why it is a problem?

Answer 35

Fullness of the breast can occur on day 3 - 4 and
engorgement

May occur due to infrequent or inadequate feeding

Sings and symptoms Breasts may be:
• heavy and firm
• hot
• lumpy= milk backing up into the lobules
• Dripping breast milk

Question 36

How do we manage the engorgement of the breast?

Answer 36

• Unrestricted access to the breast
• Breastfeed frequently (wake baby up to feed)
• Ensure attachment is correct
• Hand express to soften the areola if the baby is
having difficulty attaching
• Massage breast towards the nipple whilst feeding
• Cold packs or cold washed cabbage leaves applied pc (reduces blood flow and flow of milk)
• Analgesia if required

Question 37

Explain the use of medications and breastfedding.

Answer 37

• Most medications will pass through breast milk

Factors impacting are;

• maternal plasma (blood) levels of the medication
• molecular weight
• oral bioavailability
• protein binding

The first few days of BF the alveolar epithelia structure of the breast is quite open and porous= medications pass easily (but remeber baby is only have small amounts)

Many medications are not harmful to the baby if only required short term and therefore it is better to continue breastfeed

In some cases breastfeeding should be avoided as the mother
requires medication that may harm the baby e.g. anticancer drugs,
lithium, oral retinoids, amiodarone and gold salts.

Certain medications used for diagnostic procedures may be harmful and may be advised to express and discard the breastmilk

Question 38

Explain the DR Hale’s risk categories

Answer 38

L1 Safest Drug
L2 Safer Drug
L3 Moderately Safe
L4 Possibly Hazardous
L5 Contraindicated

Question 39

Why do we express?

Answer 39

To collect breast milk
– Separation when baby is premature or ill
– Mother is ill
– Returning to work
– To store

Relieve breast fullness

Build up milk supply

To drain the breasts when a decision has been made
not to feed

Question 40

What are the advantages and disadvantages of expressing?

Answer 40

Advantages
• Gentle to the nipple
• Minimal equipment required
• Some women find it difficult to let down with a
manual pump

Disadvantages
• Breast tissue may become tender if technique rough
• May be hard work with long term expressing

Question 41

Explain pump expressing

Answer 41

• A pump does not suck or pull milk out of the breast
• It reduces resistance to milk outflow from the alveoli
allowing the internal pressure of the breast to push out the milk
• The milk ejection reflex produces an initial rise in the
intramammary pressure. The pulsatile nature of oxytocin release and its short half life maintains
ductal pressure over time.

Question 42

What are the advantages and disadvantages of expressing using a pump

Answer 42

Advantages
• Higher milk volume then hand expressing
• Double pump – Shorter time
• Removes milk quickly
• Promotes physiologic prolactin cycling
• Milk has high energy content
• Easily controlled vacuum
• Easy to use

Disadvantages
• Pumps differ in efficiency
• Nipple damage
• Pain
• Difficult let down

Question 43

What are some techniques that can encourage expression?

Answer 43

• Moist heat
• Relaxation techniques
• Double pump – Reduces pumping time. Higher rise of
prolactin. Causing slightly higher fat content.
• Breast Massage
• Switch sides frequently – multiple let downs
• Frequent expressing if small amounts obtained
• Breast Compression

Question 44

What are some key principles of cleaning expressing equipment?

Answer 44

• For regular expressing rinse with cold water and store
in fridge
• Clean equipment with warm soapy water for single
use expressing or once in 24 hours for regular
expressing
• Containers and breast pump parts used to collect or
store breastmilk will need to be cleaned before use
(sterile expressed breastmilk bags or new plastic bags
are an exception)

Question 45

Explain storage of breast milk;

• how long can breast milk be kept at room temp?
• In the freezer?
• if previously frosen then thawed?

Answer 45

• how long can breast milk be kept at room temp?
  6-8hrs
• In the freezer?
  3 months
• if previously frozen then thawed?
  4hrs or refrigerated for 24hrs
• once baby has feed from it, it must be used in that feed or discarded

Question 46

Describe cup feeding

Answer 46

At times a baby may need breast milk supplementation

• BFHI recommend within the 10 steps:
– 9. Give no artificial teats or dummies to breastfeeding infants (can cause confusion to infant suck)

Question 47

What do you did when approaching weaning?

Answer 47

Can be baby lead or maternal lead

• Demand and supply results in a reduced milk supply
and breast involution (if baby or mother takes less milk off)

• alveolar epithelium undergoes apoptosis [programmed
cell death] and remodelling & glands revert to a near
pre-pregnant state

• Rapid weaning is not recommended; however if this is needed the woman can express for comfort

Question 48

Explain breast development

Answer 48

Breast development begins during the embryonic period, then has a period of latency until puberty when hormonal changes facilitate the budding of the breast. A further resting period occurs until pregnancy when the duct system further matures. Full maturation occurs with lactation.

Question 49

What occurs in the breasts in the first trimesta?

Answer 49

rapid growth in the duct, lobes and alveolar system. It is characterised by growth and branching from the terminal portion of the duct system into the adipose tissue, which seems to diminish. Rate of hyperplasia levels off by the end of the first trimester. Towards the end of pregnancy any enlargement is the result of the parenchymal cell growth rather than proliferation, and distension of the alveoli with early colostrum.

Question 50

What occurs in the breasts in the second trimesta?

Answer 50

interlobular connective tissue is noticeably decreased and alveolar proliferation is extensive. The division and differentiation of epithelial cells and presecretory alveolar cells into secretory milk-releasing cells take place in the third trimester. The lactating gland has a large number of alveoli made up of cuboidal and myoepithelial cells. Lipids form as small droplets within the cells and become larger and are discharged into the lumen. This process depends on the interplay of nervous and endocrine function.

Question 51

What occurs in the breasts in the post natal period?

Answer 51

During the postnatal period if the breast is not drained, a number of functional, hormonal and anatomical changes will occur to bring about a regression of the mammary gland. The glands become distended and production gradually ceases. This is accomplished by lack of stimulation from sucking, and results in engorgement and compression causing diminished blood flow, which leads to decreased oxytocin. Alveoli become distended and epithelium flattened, and the remaining milk is reabsorbed. The alveoli gradually collapse and connective tissue increases, while glands gradually recede to resting state without fully involuting. Fat may increase, perhaps never to the same levels. It is not clear if slow weaning has the same effects.

Breast development continues after pregnancy with the breast maturing through lactation. Finally, the breast, like the uterus, involutes with weaning.

Question 52

What is the relationship between breast feeding and the mothers longer term health?

Answer 52

Women who breastfeed longer have less risk of certain breast cancers, ovarian cancer and endometrial cancer. It is possible they are also less likely to become diabetic.

Question 53

What is the benefits to baby in?later life of breastfeeding

Answer 53

Babies of breastfeeding women are more likely to acquire language skills early, have fewer ear infections, GI tract infections, respiratory illness, middle ear infections, type 1 diabetes, childhood leukaemia and possibly an enhanced cognitive development.

Question 54

What are some dot point principals of breast feeding?

Answer 54

1. Should women routinely express breastmilk during the day to avoid feeding at night?
   - No as this will affect her milk supply. Remember it is the supply and demand principle. Also when a woman breast feeds her levels of prolactin are increased and this also carries a role for ongoing maintenance of breast milk supply. By routinely avoiding breast feeding during the night her prolactin levels will be affected and this will impact on her milk supply.
2. How many days can breastmilk be stored in a refrigerator? In a freezer?
   - 3 – 5 days in the fridge 2 weeks in a freezer within a fridge that has an internal door 3 months in a freezer with a separate door in a fridge 6-12 months in the deep freezer
3. May we heat breastmilk more than once? May we heat it in a microwave?
   - Breast milk should not be reheated more than once and it should not be microwaved. Microwaving destroys some of the beneficial constituents/properties.

Question 55

Explain the steps of correct infant feeeding

Answer 55

Read the instructions on each can of formula carefully - It is important to make up the right strength of formula
Incorrect dilution of formula can make the baby unwell
Different brands may use different quantities of water to powder ration and scoop sizes can vary therefore, check the quantity of water and number of scoops of formula required using the feeding table on each new can and use only the scoop enclosed with each individual can
Empty kettle and refill it with tap water - bottled water is not sterile so should also be boiled
Kettles without an automatic shut off should be allowed to boil for 30 seconds - Allow water to cool slightly but no less than 70 degC
Thoroughly clean work surface - It may be simpler to use a tray that is easy to clean and kept for baby’s things only
Wash hands before preparing formula
Pour the amount boiled water (70 degC) needed into a sterilised feeding bottle (always add water before the powder)
Check the level of water in the bottle at eye level for accuracy
Shake the can to make sure the powder isn’t packed down
Follow the instructions on the can for measuring out the milk powder using the special scoop
Fill the scoop with milk powder and level off with the back of a clean knife - DO NOT ‘PACK’ THE SCOOP
Add the required amount of milk powder to the bottle
Cap the bottle and shake until the powder dissolves
Cool rapidly in cold water to the desired temperature to feed the baby
Formula should not be pre-prepared and refrigerated. It should only be made when required to avoid growth of bacteria that may be harmful to the infant
DO NOT heat formula in a microwave
Cans of formula should be:
Stored in a cool, dry place (opened and unopened cans)
Kept closed with the plastic cover after opening
Used within four weeks from opening
Discarded after the use-by date

Question 56

What are the artifical feeding requirements of a baby in the first 5 days?

Answer 56

Nutritional requirements are increased each day until 150ml/kg/d

Day 1 – 30ml/kg/d
Day 2 – 60ml/kg/d
Day 3 – 90ml/kg/d
Day 4 – 120ml/kg/d
Day 5 – 150ml/kg/d
Feed volume is divided into 6 (4hourly) or 8 (3 hourly) feeds per day.
For example, day one, a baby weighing 3624g would require: 30ml x 3.624 divided by 6 = 18mls every 4 hours OR 30ml x 3.624 divided by 8 = 14mls every 3 hours

Question 57

What are requirements for discharge of a women and baby from post natal care?

Answer 57

The woman:

• Ensure you have witnessed at least one full feed per shift and have been able to educate and assist the woman in real time
• Ensure the woman and her support network feel confident and competent with their intended feeding
• Breastfeeding mothers - teach how to hand express and how to feed EBM prior to discharge. This is so that if baby is having great difficulty latching, the mother has a means to feed the baby and continue stimulating the breast, prior to the home visiting midwife. (There is no need for a BF of a well baby to have a tin of formula as a back-up unless she absolutely wishes to. Even one supplementary formula feed can affect milk supply and the baby’s gut significantly).

The baby:

• Has a full examination of feeding including mouth, tongue, latch, swallow, tone, skin colour and output.
• Referral to Lactation Consultant if needed.