BREAST FEEDING

Anatomy Physiology of The Breast

The breast are compound secreting glands, composed mainly of glandular tissues which is arranged in lobes, approxiamately 20 in number. Each lobe is divide into lubues that consist of alveoli and ducts. The alveoli contain acini cells which produce milk and are surrounded by myo-epithelial cells which contact and propel the milk out. The breast are richly supplied with blood. Small lactiferous ducts, carrying milk from alveoli, unite to form langer ductus: one large duct leaves each lobe and widens to form a lactiferous sinus or ampulla which acts as a temporary reservoir for milk. A lactiferous tubule from each sinus emerges on the surface of the nipple. Each of breast functions independently of the other.

Fig. Lactating breast

Fig. Breast anatomy from front

The nipple, composed of erectile tissues, is covered with epitellium and contains plain muscle fibres which have a sphincter-like action in controlling the flow milk. Surrounding the nipple is an area of pigmented skin called the aerola which contains Montgomery's glands. These produce a sebum-like substance which acts as a lubricant during pregnancy and throughtout breast feeding. Breasts, nipples and aerolae vary considerably in size from one woman to another.

The breast is supplied with blood from internal and external mammay and branches from the intercostal arteries. The veins are arranged in a circular fashion around the nipple.

Lymph drains freely between two breast and into lymph nodes in the axillae and the mediastrum.

During pregnancy, oesterogens and progesterone induce alveolar and ductal growth as well as stimulating the secreting of colustrum. Other hormones are also involved and they govern a complex sequence f events which prepare the breast for lactation. The production of milk is held in abeyance until after delivery, when the levels of prolaction to rise and milk production of prolactin is caused by the baby feeding at the breast, with concentrations highest during night feeds. (prolactin supresses anovulatory untill lactation ceases, although for others this effect is not so prolonged). If breast feeding (or expressing) has to be delayed for a few days, lactation can still be initiated.

Milk release is under neuro-endocrine control. Tactile stimulation of the breast stimulates the poduction of oxytoxin causing contaction of the myopithelial cells. This process is known as 'let-down' or 'milk-ejection' reflex and makes the milk available to the baby. In the early days of lactaion this reflex is unconditioned and is therefore unlikely ti be inhibited by anxiety. Later it becomes a conditioned reflex responding to the baby's cry (or other circumstances associated with the baby or feeding). At this stage it could be inhibited to some extent by anxiety. Milk is transferred to he baby by a combination of the milk ejection reflex and active removal of milk by the action of baby's tongue and jaw. Removal of milk is the most important factor in the maintenance of milk production, because without it prolactin will not be release and the supply will diminish.

Properties and Components of Breast Milk

Human milk varies in its composition with the time of day, with the stage of lactation, in response to maternal nutrition and because of individual variations. Fore-milk, at the begininng of the feed, differs from hind-milk, towards the end of the feed. Samples obtained for research may not represent the milk obtained by the baby because of the methodes used for collection. Comparison with the milks of other animals shows human milk to be unique. It meets all nutritional requirements of the new baby and has many other important properties as well.

Fat provides the baby with more than 50% of his calorific requirements (Helsing and Savage King 1982). The fat content in human milk has diurnal variations, being lowest in he morning and highest in the afternoon. The proportion of fat in the milk increase during the course of the feed, sometimes increasing five times the initial value. It is utilised very rapidly because of the action of the enzyme lipase which is present in the milk in a form which only becomes active i the infant’s prestine. Pancreatic lipase is not plentiful in the newborn baby.

Lactose. There is more lactose in human milk than in any other mammalian milk. It is converted into galactose and glucose by action of the enzyme lactase angd these sugars provide energy to the rapidly growing brain. Lactose enhances the absorption of calcium and also promotes the growth of lactobacilli which increase intestinal acidity, thus stemming the growth of pathogenic organisms.

Protein. Human milk contains less than half the amount of protein contained in cow’s milk but because of its easy digestibility it provides the baby with the ideal quantity. Human milk f orms soft, flocculent curds when acidified in the stomatch. The predominant protein is lactabumin (when protein) and caseinogen is present in lower quantities. This provides a continuous flow of nutrients to the baby. Two amino acids, cystine and taurine, are found in human milk but not in cow’s milk. The first is important for growth and the second for the development of the brain. Colostrum contains nearly there times the amount of protein that is present in imature milk and contains all the ten essential amino acids. It also contains secretory IgA and lactoferrin (see below).

Vitamins, minerals, and trace element

There are four fat soluble vitamins, A, D, E, and K :

• Vitamin A. Mature human milk contains 280 international units (IU) of vitamin A and colostrum contains twice that amount. Cow’s milk contains only 180 IU.
• Vitamin D. It is now believed that both water-soluble and fat-soluble vitamin D are present in human milk. Provided that the mother’s diet is adequate and that the baby can be exposed to the sun, supplementation with vitamin D is not necessary. Dark-skinned babies ae he exceptions.
• Vitamin E. Human colostrum is rich in vitamin E and the levels in mature human milk are higher than in cow’s milk. It’s main function is to prevent haemolytic anaemia but it also helps to protect the lungs and retina from oxidant induced injury.
• Vitamin K. This vitamin is essential for the synthesis of blood-clotting factors. It is present in human milk and absorbeb efficiently. Recent research suggests that the breast-fed baby may receive more vitamin K than has previously been demonstrated because it has been discovered that levels are higher in colostrum and, in the early days. In the high fat hind-milk (Kries et al 1987). Later, levels depend on maternal dietary intake. Babies who are at risk of haemorrhage, such as the preterm and those delivered precipatately or instrumentaly, usually receive a prophlactic dose, usually by intramuscular injection. May paediatricians consider that all other babies should receive an oral dose soon after birth. After a few days the baby’s gut flora will synthesise vitamin K. Colonisation of the gut may be aided by encouraging the mother not to wash her breasts, or otherwise clean them before a feed.
• Vitamin B complex. All of the B vitamins are present at levels which are believed to provide the baby with his necessary daily requirements.
• Vitamin C. Human milk contains 43 mg/100 ml in fresh cow milk. The amount in the mother in the mother’s milk reflects the dietary intake and it is advisable for her to increase her intake during lactation. Vitamin C is essential for collagen synthesis.
• Iron. Normal full-term babies are usually born with ahigh haemoglobin breakdown is utisilied again. They also have ample iron stores which last from 4-6 months. Human milk and cow’s milk contain small quatities of iron (0.5-1 mg/1). 49 % of the amount available in human milk is utilisied, whereas only 4% is absorbeb from cow’s milk (Saarinen and Siimes 1977). The difference is due to the high levels of vitamin C and lactose in human milk which facilities absorption. Babies who are fed cow’s milk may become anaemic because of microhaemorrhages of the bowel. Preterm babies do not have good iron stores and may need supplementation with oral iron.
• Zinc. This trace mineral is esssential to humans. A deficiency may result in failure to thrive and typical skin lesions. Althought there is more zinc present in cow’s milk than a human milk, the bio-availability is greater in human milk.
• Other minerals. Human milk has significantly lower levels of calcium, phosphorus, sodium and potassium than cow’s milk. Breast milk threfore impose a lower solute load on the neonatal kidney than does unmodified cow’s milk. If a baby is fed on ‘doorstep’ milk, he will become dehydrated due to hypernatremia (excess sodium). The breast-fed baby does not ingest an overload of salts and is therefore unlikely to need additionaly water under most conditions (Almroth 1978, golderg and Adams 1983, Sachdev et al 1991).

Other important properties

Anti-infective factors. During the first 10 days there are more white cells per ml than there are in blood.

Macrophages and neurotrophills are amongst the most common leucocytes in human milk and they surround and destroy harmful bacteria by lymphocytes in human milk.

Immunoglobulins IgA, IgG, IgM, and IgD are all found in human milk. Of these the most important is IgA, which appears to be both synthesised and stored in the breast. It ‘paints’ the intestinal epithelium and protects the mucosal surfaces against entry of pathogenic bacteria and entero viruses. It affords protection against Eschericia coli, salmonellae, shigellae, streptococci, staphylococci, pneumococci, poloivirus and rotaviruses.

Lysozyme is present in breast milk in concentration 5000 times greater than in cow’s milk. It is a well known general anti-infectifve agent and its actifity appears to increase during lactation.

Lactoferin is abudant inhuman milk but is not present in cow’s milk. It effects the absorption of enteric iron, thus epreveting pathogenic E. coli from obtaining the iron they need for survival.

The bifidus factor in human milk promotes the growth of Gram-positive bacilli in the gut flora, particulary Lactobacillus bifidus, which discourages the multipliction of pathogens. Babies who are fed on cow’s milk formula have Gram-negative (potentially pathogenic) bacilli in thier gut flora.

Anti-allergic factors. Allergic problems occur lessfrequanly in breast fed babies than in bottle-fed babies. This may be because the infant’s intestinal mucosa is permeable to proteins before the age of 6-9 months and roteins in cow’s milk can act as allergens.

Occasionally a baby may become allergic to substance in his mother’s milk which come from her diet. This is rare and can be circumvented by the mother avoiding the foods which cause the trouble so that she may continue to breast feed.

The advantages of breast feeding

1. Neonatal Advantages

In addition to the flexibility of the composition of breast milk to suit the needs of the growing child (Department of Health and Social Security 1988), it has other benefits. Breast-fed babies are less liely to be overweight than bottle-fed infants in the days of unmodified milks (Hall 1975). It thought, however, that breast feeding has a protective effect against the occurrence of obesity in adolensence (Kramer and Moroz 1981). Also, unlike artifical feeds, breast milk cannot be too concentrated, nor can anything be added to it.

Infections, especially of the gastrointestinal tract, are less common in breast-fed infants (victoria et al. 1987). They are protected from these in many ways. White cells in the milk, such as neutrophils and macrophages, destroy harmful bacteria in the gut; growth of pathogens is inhibited by the acid environtment of the gut and by the growth of gram-positive organisms, such as lactobacilli (Lucas 1983).

Lactoferrin binds to enteric iron, making it unavailable for the growth of E. coli, and breast milk contains immunoglobulins (mainly immunoalglobulin (IgA) which prevent passage of enteroviruses and pathogens through the gastric mucosa (Bullen et al. 1972); goldman and Smith 1973).

Delaying the introduction into the diet of foreign proteins by breast feeding has been shown to reduce, rather than totally protect against, the incidence of allergies in infancy.

2. Maternal Advantages

Breast feeding helps the mother to use the fat stores laid down in pregnacy in preparation for feeding, altought lacation women become more energy-efficient and do not need to increase their dietary intake as much as was previously thought (illingworth et al. 1986) . Prolonged and regular feeding (especilly during the night) delays the return of ovulation (Howie et al 1982). In the developig world, this is an important aid to birth spacing. Breast feeding requires no preparation or the purchase of any equiptment. It can cause less disruption during the night or when travelling. Society’a attidutes to breast feeding, especially in public, may create some difficulties (Newson and newson 1965) although, in practice, discrete feeding can usually be accomplished. If nursing mothers continue to be isolated from the rest of society, there will be little chance of breast feeding becoming an acceptable public activity (Melthosh 1985). Many women find breast feeding to be a very pleasurable activity, which promotes a feeling of closenes and intimacy between the mother and child (Messenger 1982). Some mothers also experience an increase in libido (and may on occasion even reach orgasm) during feeding, which may give rise to embarrasement especially if unexpected (master and johnson 1966).

3. The Advantages of Breast Feeding For father

Fathers are able to enjoy a healthy baby and wife. They can appreciate the impact on the family budget with lower health care costs, fewer sick days, and lack of need to buy formula milk.

The Techniques of Breast Feeding

*Positioning The Mother

There are two main positions for the mother to adopt while she is breast feeding. The first is lying on her side and this may be approciate at different times during her lactation.

Fig. Lying down position

If she has had a caesarean section, or if her perineum is very painful, this may be the only position she can tolerate in the first few days sfter birth. She will need assistance in placing the baby at the breast because it will be difficult for her to manipulate him skilfully. When feeding from the lower breast it may be helpful to raise her body slightly by tucking the end of a pillow under her ribs. Later she and her baby have learned how to breast feed, either during the day because she finds it more comfortable and restful or at night because it is more convinient.

The second position is sitting up in early days it is particulary important that the mother’s back is upright and at a right angle to her lap bed with her legs streched out in front of her (though she might be able to achive it sitting cross-legged) or if she is sitting in a chair with a deep backward-sloping seat and sloping back.

Both lying on her side and sitting correctly on a chair (with her back and feet supported) enhance the shape of the breast and also allow ample room in which to manoeuvre the baby.

*Positioning The Baby’s Body

The baby’s body should be turned towards the mother’s body. The baby’s mouth should be opposite the nipple and the neck should be slightly extended.

Fig. Position The Baby’s body

*Positioning (or attaching or lacthing) The Baby’s Mouth onto the Breast

The baby should be supported acros his shoulders, so that the slight extension of the neck can be maintained. The head may be supported by the extended fingers of the supporting hand or on the mother’s forearm. it may be helpful to wrap the baby firmly in a small sheet so that his hands are by his sides. If the baby’s mouth is moved gently but persistently against his mouth wide. this is termed the rooting reflex. Mothers may find the suggestion that they should try to stroke the top lip against the nipple helpful (Prechtl 1985).

As his mouth gapes, he is moved quickly to the breast. The aim is to osition the bottom lip at least 0,5 inchi (1,5 cm) away from the base of the nipple. This allows the baby to draw some of the breast tissue into his mouth with his tongue and lower jaw. If correctly positioned, the baby will have formed a teat from the breast and the nipple. The lactiferous sinuses will now be within the baby’s mouth (woolridge 1986).

Fig. lacting The Baby’s Mouth onto the Breast

The nipple will extend back as far as the soft palte and make contact with it. It is this contact which triggers the sucking reflex. the baby’s lower jaw closes on the breast tissues, suction is exterted so that the nipple is held well within the mouth and the tongue applies rhythmical cycles of compression so that milk is stripped from the ducts. Although the mother may be startled by the physical sensation, she should not experience pain. Some women experience feelings of sexual arousal or even orgasm due to the stimulation of the nipple, though this is probably rare.

Care of breasts

The breast should be washed daily with clean water or mild soap. A well-fitting brassiere provide needed support. During the early postpartum period a tight binder, ice pack, and mild analgesic may be necessary to relieve discomfort caused by pressure if the milk comes in. Nipple and breast stimulation should be avoided. When showering, women should stand so that the shower sprays their back and not their breast. Medication to suppress lactation may be prescibred. Note, as of August 1994, bromocriptine (parlodel) was voluntarily withdrawn by the manufacturer as an indication for lactation suppression due to reports f serious advers effects.

REFERENCES

Bennet, V. Ruth. Myles Text Book fot Midwives. 1993. British : Britishchurchill livingstone

Bobak. Maternity Nursing. 1995. Missouri : Mosby-year book

Johnson, martin H. Essential Reproduction. 2000. Australia: Blackwell science

Ruth, johnson. Skills For Midwifery Practice. 2000. British : Britishchurchill livingstone

Silvertone, Louise. The Art and Science of Midwifery. 1993. British : Redwood books

_________. Healthy Mother and Healthy Newborn Care. 1998. _____ : ______

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