Breastfeeding
AMERICAN ACADEMY OF PEDIATRICS Section on breastfeeding (Pediatrics 2012)
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AMERICAN ACADEMY OF PEDIATRICS Section on breastfeeding (Pediatrics 2012)
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UNICEF and WHO (1991)
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10 STEPS TO SUCCESSFUL BREASTFEEDING 1. 2. 3. 4. 5.
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10 STEPS TO SUCCESSFUL BREASTFEEDING 6.
7. 8. 9. 10.
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https://www.who.int/teams/nutritionand-food-safety/food-and-nutritionactions-in-health-systems/ten-stepsto-successful-breastfeeding
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RECOMMENDATIONS WHO, AAP SIP, SIN, SICuPP, SIGENP, Ministry of Health (Position Statement 2015)
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Definitions recommended by the WHO and internationally recognized
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Breastfeeding is an interactive process “Mother” system 1.
Hormonal control (PRL/OSS)
2.
Peripheral control (FIL)
Quality
Quantity Duration “Baby” system 1.
Ability to suck
2.
Correct position and latch (effective drainage)
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Pediatr Clin North Am, 2001. Feb;48(1):13-34
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Global distribution of breastfeeding at 12 months Data are from 153 countries between 1995 and 2013
In low-income countries, most infants are still breastfed at 1 year compared with less than 20% in many high-income countries and less than 1% in the UK C. G Victora, MD,. The Lancet. January, 2016 Breastfeeding
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Global distribution of breastfeeding at 12 months Data are from 153 countries between 1995 and 2013
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C. G Victora, MD,. The Lancet. January, 2016 Breastfeeding
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Child-friendly communities for breastfeeding (2007)
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Breastfeeding in Italy
• Low educational and socio-economic status • Lack of support from partners or other family members
• Not feeling up to it, fear of not having enough milk (exhaustion, post-partum stress)
• Desire • Health status • Return to work
but also orientation, culture and advice in prenatal classes, birth centers, NICUs, local health authorities, and pediatrician offices
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Breastfeeding in public • Breastfeeding produces neither noise nor smell, and it does not require too much space; the breast is not visible, but rather “sensed” • Mainly a cultural issue
• Breast is considered as an object related to sexual pleasure • “Principle of good manners”: it is not very elegant • In Italy there are no laws for or against breastfeeding
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Anatomy
1. Cooper’s ligament 2. retromammary fat 3. gland tissue 4. intramammary fat 5. subcutaneous fat
6. main lactiferous duct 7. lactiferous duct
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Anatomy
The alveolus is the basic functional unit (0.12 mm in diameter), consisting of small bags of about 100 lactocytes that synthesize milk. The alveoli are surrounded by myoepithelial cells which have a contractile capability. Groups of 10-100 alveoli form the lobules, which are grouped into lobes. Small ducts drain the alveoli and converge, thus forming larger ducts, until they create a single duct with a diameter of about 2 mm (nevertheless, the diameter is variable, as shown by the US study) that reaches the surface of the nipple. Each lobe drains independently into the nipple. The lobes are 9, but the holes on the nipple are approximately 15 (some holes have a blind end).
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Milk secretion phases
lactogenesis III
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Lactogenesis
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Lactogenesis: PROLACTIN Enters the bloodstream AFTER the feed to stimulate the production of milk for the NEXT feed
3. Prolactin in the bloodstream 2. Sensory impulses from the nipple
1. The baby sucks
Prolactin is secreted in greater quantities during the night It suppresses ovulation
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Lactogenesis: OXYTOCIN Acts BEFORE and DURING the feed, allowing the milk to flow (milk ejection or oxytocin reflex) 3. Circulating oxytocin 2. Sensory impulses from the nipple
1. The baby sucks
Oxytocin stimulates the uterus to contract
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Oxytocin reflex
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Oxytocin reflex
• Thinking about the baby • Listening to their sounds • Looking at them • Feeling comfortable
• Concern • Stress • Pain • Feeling insecure
STIMULATE
HINDER
the oxytocin reflex
the oxytocin reflex
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Peripheral regulation of milk synthesis
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milk stasis
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PHYSIOLOGY
On demand breastfeeding Through suction, the baby regulates the production of prolactin, the oxytocin reflex, and the removal of FIL Suction must be frequent and correct
8-12 feeds a day > > during the “growth spurts” (usually at 3 and 6 weeks, and at 3 months)
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On demand breastfeeding
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Lactation onset is anticipated by 12-24 hours
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Prevention of breast engorgement
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Higher milk production
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Reduction of neonatal jaundice
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On demand breastfeeding
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Whenever the baby looks hungry
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Both day and night
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At intervals managed by the baby
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Feeds without a fixed duration
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Calibration and maintenance
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Duration of breast feeds
Woolridge MW. Early Human Dev 7:269, 1982
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506 babies
Number of feeds
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With exclusive breastfeeding, the number of feeds in 24 hours remains almost constant throughout the first 6 months of life
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Breast milk
• Colostrum 7th month of pregnancy – 3rd/4th day • Transition milk Until the 14th day • Mature milk
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Colostrum
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Breast milk: composition Constituents per 100 ml Calories Lactose g Protein g
Colostrum 1-4 days 58 5,3 2,3 Lactoferrin mg 330 IgA mg 364 Vit A 89 Beta carotene 112 Vit E mcg 1280 Vit B12 mcg 200 Zinc mcg 540
Mature milk > 15 days 70 7,3 0,9 167 142 47 23 315 26 166 Rjordan 4° Ed, 2010
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Breast milk
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Breast milk in preterm infants (<37 weeks)
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Breast milk
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The taste depends on the diet of the mother
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Variations in flavour can help the baby to get used to the flavours of the foods eaten by the family, and to the transition to such foods after 6 months
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Formula milk always tastes the same
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Breast milk: composition
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Breast milk: composition
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Breast milk: composition
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Breast milk: composition
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Breast milk: composition
• Higher quantity in breast milk as compared to other animals’ milks • The quantity is related to the dimensions of the encephalon Riordan J, 2016
Breast milk
% Lactose
6,8
Donkey 6.2
Cow 4.8
Goat Bufal
4.1
Dog
Mouse renna
Rabbit
3.1
2.5
1.7
Lawrence RA, 2016 Breastfeeding
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Breast milk: composition Lactose glucose
galactose
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Riordan J, 2016 G.M. Hendricks, M. Guo, in Manufacturing Technology, 2014
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Breast milk: composition
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The lipid concentration is lower at the Assunzione diof latte di grassi da parte beginning the efeed (foremilk) and at the end ofda it un (hindmilk) di un higher bambino allattato solo seno 18
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16 25 14 20
10 15 8 6
Grassi
Volumi
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10
4 5 2 0
tempo (min.)
0 5
volume (g)
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grassi (g/l)
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Breast milk: composition
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Breast milk: composition
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Entero-Mammary pathway 1. Ingestion of pathogens
How the breastfed baby benefits from the maternal immunological experience
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4. IgA secretion in breast milk
2. Mesenteric activation of the B cells in the Peyer′s patches
3. Migration of plasma cells to the breast
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Breast milk: composition
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Main constituents of breast milk (g/L)
Oligosaccharides (HMOs)
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Nicholas J. Andreas. Early Human Development, 2015 Jantscher-Krenn E, Bode L, Minerva Pediatrica, 2012 Breastfeeding
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Oligosaccharides (HMOs) Macronutrients and HMOs in mature human and bovine milk (approximate values) Human
Bovine
Protein (g/dl)
0,8
3,2
Fat (g/dl)
4,1
3,7
Lactose (g/dl)
7,0
4,8
Oligosaccharides (g/dl)
0,5–1,5
0,005
Number of identified oligosaccharides
200+
∼40
%fucosylated
50–80%
∼1%
%sialylated
10–20%
∼70%
Lars Bode. Human milk oligosaccharides: Every baby needs a sugar mama. Glycobiology, 2012 Breastfeeding
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Oligosaccharides (HMOs)
• Over 200 molecules identified • Resistant to low pH and intestinal enzymes
• Can be found in faeces • A minimum part is absorbed and excreted in urine (approximately 1%)
Lawrence RA, 2016 Bode L. Hearly Human Developmeent, 2015
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Oligosaccharides (HMOs)
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Prebiotic Anti-adhesive/anti-infective Immune modulator Anti-inflammatory Fiber
Lawrence RA, 2016 Bode L. Hearly Human Developmeent, 2015
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Oligosaccharides (HMOs)
They promote the growth of potentially beneficial bacteria, such as Bifidobacterium infantis, thus protecting against the colonization by pathogens
Jantscher-Krenn E, Bode L, Minerva Pediatr, 2012 Bode L. Early Human Development, 2015
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Oligosaccharides (HMOs)
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HMOs reach the colon unaltered Metabolic substrate for bifidobacteria Bifidobacteria are selected, whose genome allows for the synthesis of glycosidases, which metabolize them The metabolism of HMOs produces SCFAs and reduces the faecal pH, thus promoting their growth
HMOs induce the selective growth and development of bifidobacteria
Jantscher-Krenn E, Bode L, Minerva Pediatr, 2012 Bode L. Early Human Development, 2015
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Oligosaccharides (HMOs)
• Many pathogenic bacteria bind to the glycocalyx on the surface of the enterocyte through "lectins" (Glycan binding proteins) • Structurally, HMOs are similar to the surface receptors of the glycocalyx • They bind to lectins and block bacterial adhesion • HMOs also modify the glycosylation mechanisms of intestinal epithelial cells by modifying the expression of the glycocalyx, with an impact on bacterial adhesion, proliferation and colonization
Jantscher-Krenn E, Bode L, Minerva Pediatr, 2012 Bode L. Early Human Development, 2015
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Oligosaccharides (HMOs)
Bode L. Hearly Human Developmeent, 2015 Anna Kulinich, Li Liu, Carbohydrate Research, 2016 Bode, Kunz, et al., 2004 T. Eiwegger, B. et al. Pediatr. Allergy Immunol, 2010 Breastfeeding
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Oligosaccharides (HMOs)
Bode L. Hearly Human Developmeent, 2015 Anna Kulinich, Li Liu, Carbohydrate Research, 2016 Bode, Kunz, et al., 2004 Breastfeeding
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Oligosaccharides (HMOs)
• They reach the colon undigested • They behave like soluble fibers • They make the stool softer, and increase the frequency of evacuations
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Oligosaccharides (HMOs)
HMOs are a potential source of nutrients (sialic acid) for brain development, as they are contained in gangliosides and glycoproteins
Jantscher-Krenn E, Bode L, Minerva Pediatr, 2012
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Oligosaccharides (HMOs)
Jantscher-Krenn E, Zherebtsov M, Nissan C, et al. The human milk oligosaccharides disialyllacto-N-tetraose prevents Necrotizing Enterocolitis in neonatal rats. Gut 2012 Breastfeeding
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Gut, 2018
HMO composition in breast milk from 200 mothers with VLBW infants was analyzed for the first 28 days postpartum
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Gut, 2018
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Breast milk: composition
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Breast milk: composition
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Breast milk: composition
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Benefits
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Breast milk: benefits
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Breast milk: benefits
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Breast milk: benefits • • • • • • • • • • • SM., Fewtrell, Current Pediatrics, 2004 Section on breastfeeding. Peediatrics, 2012 Spiegler J, J Pediatr, 2016 J. Zhou, Pediatrics, 2015 Breastfeeding
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Tham R, Bowatte G, Dharmage SC, et al. Breastfeeding and the risk of dental caries: a systematic review and meta-analysis. Acta Paediatr Suppl 2015
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Horta BL, de Mola CL, Victora CG. Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure, and type-2 diabetes: systematic review and meta-analysis. Acta Paediatr Suppl 2015 Breastfeeding
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JAMA Pediatr, 2015
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Horta BL, de Mola CL, Victora CG. Breastfeeding and intelligence: systematic review and meta-analysis. Acta Paediatr Suppl, 2015 Breastfeeding
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PEDIATRICS, 2012
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2013 Arslanoglu S et al.
Journal of Pediatric Gastroenterology and Nutrition
1. 2. 3. 4.
5.
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Benefits for the mother and the baby
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Benefits for the mother and the baby
• Stabilize the glucose level, reduce crying periods, facilitate cardiorespiratory stability and gastrointestinal adaptation, and promote growth • Stay close to reduce anxiety and stress Depression and stress (salivary cortisol) are lower in the first month in the case of skin-to-skin contact • Encourage mother-child bonding
Lori Feldman-Winter, MD, et al. Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns. Pediatrics, 2016 Breastfeeding
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Benefits for the mother
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Aune et al. (2014)
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Benefits for the mother
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Breast milk: OTHER BENEFITS
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Breastfeeding in the Neonatal Intensive Care Unit (NICU)
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Breastfeeding in the NICU Influencing factors
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Breastfeeding in the NICU Knowledge • • • •
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Breastfeeding in the NICU Methods and techniques promoting breastfeeding • • • • • •
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Kangaroo Mother Care
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Kangaroo Mother Care
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Kangaroo Mother Care
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Kangaroo Mother Care
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Kangaroo Mother Care
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Kangaroo Mother Care (Bogota, Colombia, 1978)
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Kangaroo Mother Care
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2. 3.
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Contraindications to breastfeeding
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Contraindications to breastfeeding
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Breastfeeding and medications
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Breastfeeding and medications: References
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Breastfeeding and medications: References
National Library of Medicine/National Institutes of Health
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Breastfeeding and medications: References
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Breastfeeding and medications: References
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Breastfeeding and medications
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Breastfeeding and SARS-CoV-2
Covid-19 positive women can breastfeed if they wish. They should: Wear a surgical mask covering both nose and mouth Close contact between mother and baby A woman with COVID-19 should be encouraged to breastfeed safely, make skin-to-skin contact with her baby, and keep him/her in her room.
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Wash their hands before touching the baby Frequently clean and disinfect surfaces
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Breastfeeding and SARS-CoV-2
If a woman with COVID-19 is too sick to breastfeed, she can be supported in finding an alternative that allows her to feed her baby with breast milk
Resume breastfeeding
Milk pumping
Donated human milk
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Protecting breastfeeding •
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Human Milk Banks (HMBs)
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Human Milk Banks (HMBs)
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(2019)
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Human Milk Banks (HMBs)
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Human Milk Banks (HMBs)
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Human Milk Banks (HMBs)
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Breastfeeding in emergencies
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Breastfeeding and nutrition in children: what to do in humanitarian emergency situations Bambino Gesù Children’s Hospital summarizes the WHO and IFE recommendations in 10 points
Titolo Presentazione
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Breastfeeding and nutrition in children: what to do in humanitarian emergency situations Bambino Gesù Children’s Hospital summarizes the WHO and IFE recommendations in 10 points
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Breastfeeding is an interactive process “Mother” system
Quality Quantity
1.
Hormonal control (PRL/OSS)
2.
Peripheral control (FIL)
Duration “Baby” system mouth wide open everted lips asymmetric latch (a larger portion of the areola is visible over the mouth)
Breastfeeding
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Ability to suck
2.
Correct position and latch (effective drainage)
the chin touches the breast
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Assessment of the feed
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Challenges to breastfeeding
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Overcoming breastfeeding difficulties
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Breastfeeding: Comfort & independence
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Assessment scheme
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POSITION
LATCH
SUCKING
Baby lying on his side (ear/shoulder/hip)
Mouth wide open
Slow and deep rhythm
Facing the mother and close to her body (embracing him)
Chin touching her breast
Swallowing is audible
Nose facing the nipple
Lower lip turned outward
Round and full cheeks (not sucked or dimpled)
The baby is supported; head slightly backwards
A larger portion of the areola is visible above the baby’s upper lip than below the lower lip
No click
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Breastfeeding positions
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Breastfeeding positions
Baby lying on his side (ear/shoulder/hip) Facing the mother and close to her body (she embraces him) Nose facing the nipple The baby is supported; head slightly backwards
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Breastfeeding positions
Baby lying on his side (ear/shoulder/hip) Facing the mother and close to her body (she embraces him) Nose facing the nipple The baby is supported; head slightly backwards
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Breastfeeding positions
Baby lying on his side, aligned (ear/shoulder/hip) Facing the mother and close to her body (she embraces him) Nose facing the nipple The baby is supported; head slightly backwards
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Breastfeeding positions
Baby lying on his side, aligned (ear/shoulder/hip) Facing the mother and close to her body (she embraces him) Nose facing the nipple The baby is supported; head slightly backwards
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Breastfeeding positions
Classic
Football hold Cross-cradle hold Biological nurturing
Side-lying hold Twins
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Sitting baby
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What differences can you see?
WHO/CDR/93.6 3/9
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What differences can you see?
WHO/CDR/93.6 3/8
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Breastfeeding positions
Area inside the baby’s mouth
Place the base of the hand on the baby’s shoulders. The latching starts with the chin
IRCCS-OPBG
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Breastfeeding positions
The baby’s head is inclined slightly backwards
Area inside the baby’s mouth
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rapidly draw the baby close to the breast
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Push the shoulder blades with the base of the hand
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his chin touches the breast first
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the baby’s body embraces his mother’s
IRCCS-OPBG
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Breastfeeding positions
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The baby’s head is inclined slightly backwards
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His chin rests on the breast
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Hold the baby firmly on the shoulders, not crouched, and keep him close to your body
IRCCS-OPBG
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Breastfeeding positions
THE POSITION OF THE TONGUE IS IMPORTANT
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Mother competent in feeding (“beyond the technique”) • • • • • •
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Breastfeeding positions
Mouth wide open
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Breastfeeding positions
Slow and deep rhythm Swallowing is audible Round and full cheeks (not sucked or dimpled)
No click
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Breastfeeding
Pain during breastfeeding can be a red flag
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Say no to easy feeding bottles
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Feed Assessment
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FACTORS ENCOURAGING BREASTFEEDING IN VERY LOW BIRTH WEIGHT INFANTS Furman L. Pediatrics 2002
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Factors influencing maternal supply
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Breastfeeding
Even a few drops of milk can be valuable to a premature baby, as well as encouraging for the mother
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Manual Pumping
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Manual Pumping
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Manual Pumping
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Types of breast pumps
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Types of breast pumps
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Breast milk collection for “special” babies
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Breast milk collection for “special” babies
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Breast milk storage
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Storage of pumped breast milk
( + 4 °C) 48/72 HOURS SEPARATE FROM OTHER FOODS
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(- 18°C) SEPARATE FROM THE FRIDGE 3/6 MONTHS
( - 20/25 °C) 9/12 MONTHS
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Breast milk storage
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Storage of frozen breast milk
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