Objectives. Objectives. Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

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1 Objectives To review the physiology of and the important aspects of milk composition Essentials of Breastfeeding Kathleen M. Rasmussen, ScD To describe 3 major recommended practices To describe potential benefits of for women and communities Professor Division of Nutritional Sciences Cornell University December 20, 2010 (updated 2017) Objectives To review the physiology of and the important aspects of milk composition To describe 3 major recommended practices To describe potential benefits of for women and communities We will begin with some basic information about the process. OXYTOCIN Mammary Gland Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

2 Neural arc Suckling Prolactin release?? Prolactin (in blood)?? Mammary Gland Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

3 OXYTOCIN OXYTOCIN OXYTOCIN OXYTOCIN Oxytocin (in blood) Uterus The let-down reflex is required! These help reflex These hinder reflex OXYTOCIN Thinks lovingly of baby Sight & sounds of baby Touches baby Confidence Feeing relaxed, calm Worry Stress Pain Doubt Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

4 Inhibitor in breast milk: supply and demand FIL Inhibitor in breast milk: supply and demand If the breast remains full of milk, secretion stops because of an inhibitor in the breast. FIL Knight CH, et al. Rev Reprod 1998;3: Knight CH, et al. Rev Reprod 1998;3: Inhibitor in breast milk: supply and demand If the breast remains full of milk, secretion stops because of an inhibitor in the breast. FIL Breast milk is an exceptional food Bioactive Components of Human Milk Nutrients Protective Agents If mother and infant are separated, milk removal must be continued to maintain its production. Adaptive Immune System Humoral (siga, other Igs) Cell-mediated (macrophages, white cells, lymphocytes) Non-specific Immune System Prebiotics Multifunctional milk components Cell surface receptor homologs Immunomodulatory agents Knight CH, et al. Rev Reprod 1998;3: Adapted from: Newburg DS. J Nutr 2005;135:1308 Breast milk is an exceptional food Bioactive Components of Human Milk Breast milk is an exceptional food Bioactive Components of Human Milk Nutrients Protective Agents Nutrients Protective Agents Adaptive Immune System Non-specific Immune System Adaptive Immune System Non-specific Immune System Humoral (siga, other Igs) Cell-mediated (macrophages, white cells, lymphocytes) Prebiotics Multifunctional milk components Cell surface receptor homologs Immunomodulatory agents Humoral (siga, other Igs) Cell-mediated (macrophages, white cells, lymphocytes) Prebiotics Multifunctional milk components Cell surface receptor homologs Immunomodulatory agents Adapted from: Newburg DS. J Nutr 2005;135:1308 Adapted from: Newburg DS. J Nutr 2005;135:1308 Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

5 Breast milk is an exceptional food Bioactive Components of Human Milk Breast milk is an exceptional food Bioactive Components of Human Milk Nutrients Protective Agents Nutrients Protective Agents Adaptive Immune System Non-specific Immune System Adaptive Immune System Non-specific Immune System Humoral (siga, other Igs) Cell-mediated (macrophages, white cells, lymphocytes) Prebiotics Multifunctional milk components Cell surface receptor homologs Immunomodulatory agents Humoral (siga, other Igs) Cell-mediated (macrophages, white cells, lymphocytes) Prebiotics Multifunctional milk components Cell surface receptor homologs Immunomodulatory agents Adapted from: Newburg DS. J Nutr 2005;135:1308 Adapted from: Newburg DS. J Nutr 2005;135:1308 Breast milk protects against infection Enteromammary Circulation Breast milk protects against infection Enteromammary Circulation Newburg DS. J Nutr 2005;135:1308 Newburg DS. J Nutr 2005;135:1308 Breast milk protects against infection Enteromammary Circulation Breast milk protects against infection Enteromammary Circulation Newburg DS. J Nutr 2005;135:1308 Newburg DS. J Nutr 2005;135:1308 Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

6 Breast milk protects against infection Enteromammary Circulation Breast milk protects against infection Enteromammary Circulation Newburg DS. J Nutr 2005;135:1308 Newburg DS. J Nutr 2005;135:1308 Breast milk protects against infection Enteromammary Circulation Breast milk protects against infection Enteromammary Circulation Newburg DS. J Nutr 2005;135:1308 Newburg DS. J Nutr 2005;135:1308 Breast milk helps to develop and sustain the infant s gut microbiome Individualized components of breast milk: Bacteria from the mother s skin and the microbiome of her milk Common problems with artificial feeding Carbohydrates that support the development of a healthy gut microbiome in her infant Guran T. Nature s first functional food. Science 2014;345:747-9 Victora CG, et al. Breastfeeding in the 21 st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016;387: Verduci E, et al. Epigenetic effects of human breast milk. Nutrients 2014;6: Mayer-Davis EJ, et al. Breast-feeding and risk for childhood obesity: does maternal diabetes or obesity status matter? Diabetes Care 2006;29: Preparation with contaminated water Infection Bottles difficult to clean Infant drinks from contaminated bottle Infection Formula is expensive Dilute preparation Inadequate nutrition Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

7 Recommended practices Immediate skin-to-skin contact and early initiation of (within first hour after delivery) Breastfeed exclusively for 6 months Continue to 24 months and beyond Suboptimum and deaths of children <5 Fetal growth restriction (<1 month) 11.8% Stunting (1 to 59 months) 14.7% Underweight (1 to 59 months) 14.4% Wasting (1 to 59 months) 12.6% Zinc deficiency (12 to 59 months) 1.7% Vitamin A deficiency (6 to 59 months) 2.3% Suboptimum (0 to 23 months) 11.6% Joint effects of fetal growth restriction and suboptimum in neonates 19.4% Joint effects of fetal growth restriction, 44.7% suboptimum, stunting, wasting, and vitamin A and zinc deficiencies (<5years) 0% 10% 20% 30% 40% 50% 60% Proportion of total deaths of children <5 years Black RE, et al, Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013;382: Recommended practice: Initiate early Nilsson L, Hamberger L. A Child Is Born. New York: Dell Publishing,1993 What is colostrum? First milk produced Higher nutrient density than mature milk Protein, fat, vitamin A Rich in antibodies, growth factors Amount of colostrum produced matches the newborn s stomach capacity Effect of regimen on the continuation of lactation Treatment group Early/2 hour* (n = 29) Early/4 hour Late/2 hour* Late/4 hour (n = 28) Timing of lactogenesis (% < 48 hours) Proportion still (%) 6 weeks 12 weeks *Significantly different from the corresponding 4-hour group Salariya EM, et al. Lancet 1978;ii: Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

8 Effect of regimen on the continuation of lactation Effect of regimen on the continuation of lactation Treatment group Early/2 hour* (n = 29) Early/4 hour Late/2 hour* Late/4 hour (n = 28) Timing of lactogenesis (% < 48 hours) Proportion still (%) 6 weeks 12 weeks Treatment group Early/2 hour* (n = 29) Early/4 hour Late/2 hour* Late/4 hour (n = 28) Timing of lactogenesis (% < 48 hours) Proportion still (%) 6 weeks 12 weeks *Significantly different from the corresponding 4-hour group Salariya EM, et al. Lancet 1978;ii: *Significantly different from the corresponding 4-hour group Salariya EM, et al. Lancet 1978;ii: Effect of regimen on the continuation of lactation Effect of regimen on the continuation of lactation Treatment group Early/2 hour* (n = 29) Early/4 hour Late/2 hour* Late/4 hour (n = 28) Timing of lactogenesis (% < 48 hours) Proportion still (%) 6 weeks 12 weeks Treatment group Early/2 hour* (n = 29) Early/4 hour Late/2 hour* Late/4 hour (n = 28) Timing of lactogenesis (% < 48 hours) Proportion still (%) 6 weeks 12 weeks *Significantly different from the corresponding 4-hour group Salariya EM, et al. Lancet 1978;ii: *Significantly different from the corresponding 4-hour group Salariya EM, et al. Lancet 1978;ii: Effect of regimen on the continuation of lactation Effect of regimen on the continuation of lactation Treatment group Early/2 hour* (n = 29) Early/4 hour Late/2 hour* Late/4 hour (n = 28) Timing of lactogenesis (% < 48 hours) Proportion still (%) 6 weeks 12 weeks Treatment group Early/2 hour* (n = 29) Early/4 hour Late/2 hour* Late/4 hour (n = 28) Timing of lactogenesis (% < 48 hours) Proportion still (%) 6 weeks 12 weeks *Significantly different from the corresponding 4-hour group Salariya EM, et al. Lancet 1978;ii: *Significantly different from the corresponding 4-hour group Salariya EM, et al. Lancet 1978;ii: Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

9 Early initiation saves lives Early initiation saves lives 20% of neonatal deaths Mullany LC, et al. J Nutrition 2008;138: Mullany LC, et al. J Nutrition 2008;138: Early initiation saves lives NEOVITA study Compared to infants who were put to the breast within 1 hour of birth, the risk of dying in the first 28 days of life was 41% higher for those infants who were breastfed within 2-23 hours and 79% higher for those infants who initiated after 1 day How does early initiation save lives? Colostrum (first milk) is rich in immune and non-immune components that fight infection and accelerate intestinal maturation Promotion of warmth and protection may reduce risk of death from hypothermia The alternative, prelacteal feeding, may disrupt normal physiologic gut priming NEOVITA Study Group. Timing of initiation, patterns of, and infant survival: prospective analysis of pooled data from three randomised trials. Lancet Glob Health 2016;4:e Edmond KM, et al. Pediatrics 2006;117:e380-6 Beyond saving lives: other benefits of early initiation Earlier onset of ample milk production Longer duration of Improved mother/infant bonding Decreased infant distress Stronger uterine contractions that reduce uterine bleeding Avoid prelacteal feeds: they shorten duration Water-based prelacteal feeds Milk-based prelacteal feeds Exclusive Any 714 Honduran infants, 0-6 months old Pérez-Escamilla R, et al. Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras. J Nutr 1996;126: Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

10 Avoid prelacteal feeds: they shorten duration Avoid prelacteal feeds: they shorten duration Water-based prelacteal feeds 81% reduction Exclusive Water-based prelacteal feeds 81% reduction Exclusive Milk-based prelacteal feeds Any Milk-based prelacteal feeds Any 714 Honduran infants, 0-6 months old Pérez-Escamilla R, et al. Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras. J Nutr 1996;126: Honduran infants, 0-6 months old Pérez-Escamilla R, et al. Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras. J Nutr 1996;126: Avoid prelacteal feeds: they shorten duration Few women initiate early Water-based prelacteal feeds 81% reduction Exclusive Milk-based prelacteal feeds 79% reduction Any 714 Honduran infants, 0-6 months old Percent of newborns put to the breast within one hour of birth, by country and region, 2015 Pérez-Escamilla R, et al. Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras. J Nutr 1996;126: Source: UNICEF Global Databases Why aren t women initiating early? Lack of support in hospital Traditional beliefs Dirty because of color Milk has gone bad (been in the breasts too long) Women who deliver at home don t receive adequate support Prelacteal feeds are given Skilled birth attendants can provide vital support for early initiation we need to seize this opportunity Skilled birth attendant (e.g., doctor, nurse, midwife) Untraditional birth attendant (e.g. traditional) or others (e.g., relatives)t Eastern and South Asia East Asia and CEE/CIS Southern Africa the Pacific West and Middle East and Latin America and Other Central Africa North Africa the Caribbean Percent of newborns put to the breast within one hour of birth by birth delivery attendant, by region, 2015 Source: UNICEF Global Databases Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

11 Skilled birth attendants can provide vital support for early initiation we need to seize this opportunity Skilled birth attendant (e.g., doctor, nurse, midwife) Untraditional birth attendant (e.g. traditional) or others (e.g., relatives)t Recommended practice: Breastfeed exclusively for 6 months Eastern and Southern Africa West and Central Africa Source: UNICEF Global Databases South Asia East Asia and CEE/CIS the Pacific Middle East and Latin America and North Africa the Caribbean Percent of newborns put to the breast within one hour of birth by birth delivery attendant, by region, 2015 Other Any woman can breastfeed Exclusive saves lives Relative risk compared to exclusive for 0-5 months Diarrhoea mortality Pneumonia mortality Diarrhoea incidence Pneumonia incidence All cause mortality Predominant Partial Not Source: UNICEF Black RE, et al. Lancet 2008;371: Sankar MJ, et al. Optimal practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr 2015;104:3-13 Exclusive saves lives Relative risk compared to exclusive for 0-5 months Exclusive Diarrhoea mortality Pneumonia mortality Diarrhoea incidence Pneumonia incidence All cause mortality Predominant Partial Not Black RE, et al. Lancet 2008;371: Sankar MJ, et al. Optimal practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr 2015;104:3-13 Exclusively breastfed children grow just as well Weight-for-age z-scores from 0 to 6 months: breastfed infants, USA v. Honduras. Cohen RJ, et al. Lancet 1994;334: Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

12 Exclusively breastfed children grow just as well Exclusively breastfed children grow just as well Weight-for-age z-scores from 0 to 6 months: breastfed infants, USA v. Honduras. Cohen RJ, et al. Lancet 1994;334: Weight-for-age z-scores from 0 to 6 months: breastfed infants, USA v. Honduras. Cohen RJ, et al. Lancet 1994;334: Exclusively breastfed children grow just as well Exclusively breastfed children grow just as well Weight-for-age z-scores from 0 to 6 months: breastfed infants, USA v. Honduras. Cohen RJ, et al. Lancet 1994;334: Weight-for-age z-scores from 0 to 6 months: breastfed infants, USA v. Honduras. Cohen RJ, et al. Lancet 1994;334: Exclusively breastfed children grow just as well Exclusively breastfed children grow just as well Weight-for-age z-scores from 0 to 6 months: breastfed infants, USA v. Honduras. Cohen RJ, et al. Lancet 1994;334: Weight-for-age z-scores from 0 to 6 months: breastfed infants, USA v. Honduras. Cohen RJ, et al. Lancet 1994;334: Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

13 Exclusively breastfed children grow just as well Weight-for-age z-scores from 0 to 6 months: breastfed infants, USA v. Honduras. Cohen RJ, et al. Lancet 1994;334: Early child development Emotional bonding Close, loving relationship between mother and baby Mother is more emotionally satisfied Baby cries less Baby may be more emotionally secure Cognitive development Children perform better on intelligence tests Source: UNICEF Few women breastfeed exclusively for 6 months Percent of infants 0 5 months of age exclusively breastfed, by country and region, 2015 Why don t women exclusively breastfeed for 6 months? Cultural and social myths Not enough milk! Breastfeeding is perceived to be difficult Lack of social support Lack of adequate maternity leave Lack of workplace support Widespread marketing of breast milk substitutes Obesity Source: UNICEF Global Databases Recommended practice: Continue to breastfeed for 24 months and beyond Breast milk is an important source of nutrients Martine Korpel and her son Quinten (2 years) Argos Fotoburo Savage King F, Burgess A. Nutrition for Developing Countries. New York: Oxford University Press,1993 Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

14 Breast milk provides energy Breast milk provides energy Estimated energy requirements (kcal/day) months 9-11 months months Total energy Energy from breastmilk Energy from complementary food Estimated energy requirements (kcal/day) months 9-11 months months Total energy Energy from breastmilk Energy from complementary food Dewey KG, Brown K. Food Nutr Bull 2003;24:5-28 Dewey KG, Brown K. Food Nutr Bull 2003;24:5-28 Breast milk provides fat Breast milk provides fat Recommended % of total dietary energy from fat Level of breast milk intake Energy (%) needed from fat in complementary foods, by level of breast milk intake 6-8 months 9-11 months months Recommended % of total dietary energy from fat Level of breast milk intake Energy (%) needed from fat in complementary foods, by level of breast milk intake 6-8 months 9-11 months months 35 Low Medium High Joint FAO/WHO Expert Consultation on Fats and Fatty Acids in Human Nutrition. Interim Summary of Conclusions and Dietary Recommendations on Total Fat and Fatty Acids Low Medium High Joint FAO/WHO Expert Consultation on Fats and Fatty Acids in Human Nutrition. Interim Summary of Conclusions and Dietary Recommendations on Total Fat and Fatty Acids Recommended % of total dietary energy from fat Breast milk provides fat Level of breast milk intake Energy (%) needed from fat in complementary foods, by level of breast milk intake 6-8 months 9-11 months months 35 Low Medium High Joint FAO/WHO Expert Consultation on Fats and Fatty Acids in Human Nutrition. Interim Summary of Conclusions and Dietary Recommendations on Total Fat and Fatty Acids Continued and growth Good growth after infancy depends on, intake of complementary foods and illness in a complex manner Women continue to breastfeed children who are perceived to be too small, especially when they are ill or consume too little complementary food In contrast, women wean children who are growing well, consume adequate amounts of complementary foods and are not ill Marquis GS, et al. Int J Epidemiol 1997;26: Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

15 Globally, less than half of children are still breastfed at 2 years Percent of children months of age who are breastfed, by country and region, 2015 Why don t women breastfeed to 24 months? Conflict with work Cultural beliefs Nursing during another pregnancy Loss of milk s nutritional value Family and peer pressure to stop, especially after 12 months Source: UNICEF Global Databases Benefits of for the mother, family, and community Benefits of for the mother Lazarov M. Zero to Three. 2000;21:15 Delays the return of fertility More rapid return to prepregnancy weight; lower postpartum weight retention Lowers risk of postpartum depression Lowers risk of pre-menopausal breast cancer and ovarian cancer May reduce the risk of hip fracture Benefits of for the family and community Decreases absence in the workplace because of decreased family illness Lowers expenditures for food and health care Provides a safe food in emergency and disaster situations Supports the environment, reducing use of fuels, pharmaceuticals, plastic, and waste from the dairy industry Recommended practices Immediate skin-to-skin contact and early initiation of (within first hour after delivery) Breastfeed exclusively for 6 months Continue to 24 months and beyond Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University

16 Thank you! Art Media Co., Ltd. (Thailand) This training course was jointly developed by the Infant and Young Child Feeding Unit, Nutrition Section, UNICEF Headquarters, and Cornell NutritionWorks, Division of Nutritional Sciences, Cornell University. Copyright 2017 Essentials of Breastfeeding. E Course on Programming for IYCF. UNICEF and Cornell University