Download do not - Medical College of Wisconsin

Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM
Pediatrician, Aurora Health Care
Clinical Assistant Professor
Community and Family Medicine and Pediatrics
Medical College of Wisconsin
www.drjen4kids.com
WORKING TOGETHER TO
SUPPORT BREASTFEEDING
Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM
DISCLOSURE
 I have no relevant financial relationships with the manufacturers(s) of
any commercial products(s) and/or provider of commercial services
discussed in this activity.
 I do not intend to discuss an unapproved/investigative use of a
commercial product/device in my presentation.
WHO IS INTERESTED
CDC: measuring exclusive breastfeeding at 3 and 6 months
Joint Commission: measuring exclusive breastfeeding rates at hospital
discharge
AAP: recommending 6 months of exclusive breastfeeding
White House: recommending breastfeeding as obesity prevention
Surgeon General: Call to Action
Standard of Care
BREASTFEEDING IS NORMAL
Percent of U.S. breastfed children who are
supplemented with infant formula, by birth year
American Academy of Pediatrics recommends
exclusive breastfeeding for about 6 months,
followed by continued breastfeeding as
complementary foods are introduced with
continuation of breastfeeding for 1 year or longer
as mutually desired by mother and infant.
http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm
The rider and the elephant metaphor for changing behavior.
From “Switch” by Dan and Chip Heath.
THE NORMAL NEWBORN
Why breastmilk is not just food
BREASTFEEDING
 Immune system development
 Brain growth and development
 Temperature regulator
 Trust versus Mistrust (Erickson)
 Biologically and physiologically normal
 And, oh, by the way, it is food
THE NORMAL NEWBORN
 Asks us to protect them as they grow out of infancy
 Protect from disease
 Protect from predators
DISEASE PROTECTION
Development of the immune system
WHAT IF THE BREAST WAS REALLY AN
IMMUNE SYSTEM GLAND?
 In embryology, skin glands with protective infection-fighting effects are very common.
 The mammary gland evolved from a mucus-secreting skin gland, which would then help
protect the skin of the newborn, even if the "newborn" was an egg.
WHAT IF THE BREAST WAS REALLY AN
IMMUNE SYSTEM GLAND?
 Mucous secretion xanthine oxidoreductase (XOR) and lysozyme. Those same
protective skin mucus secretions are also found in the mammary cells.
 XOR, as well as being an important part of the innate immune system is also
crucial in milk fat droplet secretion.
 Lysozyme is an anti-microbial but also evolved into alpha -lactalbumin, a
nutritional whey protein special to the lactating breast.
 So both have two roles- one protective, one nutritional. For both though, their
immune system function came first.
WHAT IF THE BREAST WAS REALLY AN
IMMUNE SYSTEM GLAND?
http://capecchi.genetics.utah.edu/PDFs/150Vorbach.pdf
GETTING THE RIGHT BACTERIA
 The newborn gut is sterile
 The gut starts to be colonized from delivery
 Ideally, harmless, strictly anaerobic bacteria increase in number and compete for
food and space
 These “commensal” bacteria are critical for immune system development
Enteric Bacterium Interacting with
Intestinal Microvillus of the
Small intestine
Bacterial-epithelial
“cross-talk”
Forchielli ML and Walker A.
Br J Nutr. 2005 Apr;93
Suppl 1:S41-8.
Newborn Intestinal Immune System
ILF
SPECIFIC ADAPTIVE IMMUNITY:
CLONAL SELECTION THEORY
Precursor cell
B1
B2
B3
B3
Many B3 cells
Antibodies
(Virgin) resting
B cells
Antigen
[anti-idiotype
Antibodies
from mom in
the form of
sIgA ]
How Prebiotics in Human Milk Work
Forchielli ML and Walker A. Br J Nutr. 2005 Apr;93 Suppl 1:S41-8.
Fetus
Flavors in amniotic
fluid
Nursing
Infant
Flavors in
breastmilk
Weaning
Infant
Flavors in
complementary
foods
Childhood
Flavors of
adult foods
Beauchamp, Mennella Early Flavor Learning and its Impact on Later Feeding
Behavior
http://www.danoneenstitusu.org.tr/pdf/proceedings_Iguassu.pdf#page=29
WHAT THE BABY KNOWS
The areola of the breast
contains Montgomery’s
glands; glands which secrete
a substance, the odor of
which is important to the
latching behavior of
newborns.
The composition is similar to
that of amniotic fluid and
both act as “chemosignals”
that help the baby figure out
who mom is and how to
respond to her.
MIRNA
 RNA molecules of about 20-25 nucleotides
 miRNAs are transcribed from DNA but not translated into protein (non-coding
RNA)
DNA to RNA to Protein
Steve Karp
MIRNA IN HUMAN MILK
 Breastfed infants receive approximately
1.3 x 107 copies/liter/day of miRNA
EPIGENETICS AND BREASTFEEDING
 There is clear evidence that prenatal and early postpartum environment
influences the child lifelong
 Breastmilk contains:
 High levels of miRNA in breastmilk in the first six months of lactation
 Other substances which can affect epigenetic regulation mechanisms
 Stems cells
 Suggests that humans can transfer genetic material other than sexual
reproduction
STEM CELLS IN HUMAN MILK
Presence of low numbers of maternal stem cells in the offspring
 Breastmilk is one source of maternal cells as they are transferred from mother to
child though human milk
 Cells of maternal origin may stay in the offspring for years
 miRNA in breast milk may help with stem cell self-renewal and differentiation
BIRTH WEIGHT
Did I see that baby on a treadmill?
Distribution of weight changes from birth to day 3 of life according to formula
supplementation category.
Chantry C J et al. Pediatrics 2011;127:e171-e179
©2011 by American Academy of Pediatrics
Distribution of weight changes from birth to day 7 of life according to formula
supplementation category on day 3.
Chantry C J et al. Pediatrics 2011;127:e171-e179
©2011 by American Academy of Pediatrics
Flaherman et al, Pediatrics, Dec 2014
SYMPTOMS ARE KEY
 Symptomatic blood sugar can show up as irritability, seizures,
lethargy, turning blue, coma, not being able to maintain your
temperature, irregular breathing, among other evil things.
 Now look at that list and see if we want to chalk any or one of those
symptoms up to just a low blood sugar. That baby could be sick.
Really sick. Like "take them to the ICU sick."
SYMPTOMS ARE THE KEY
 Low blood sugar with no symptoms. Not an issue.
 Breastmilk meets the nutritional requirements of healthy, term
infants and those same healthy term exclusively breastfed infants
do not develop symptomatic low blood sugar because they are not
eating.
 Healthy term infants do not need to have their blood sugar
screened.
SYMPTOMS ARE THE KEY
 Low blood sugar with symptoms: Big problem.
 These children have some reason they can’t make up for low blood sugar with
other fuels.
 Those kids should be screened. Because then, the number means something.
2.22
1.94
1.38
2.49
PEDIATRICS Vol. 127 No. 3 March 1, 2011 pp. 575 -579
DO YOU NEED TO BE A BREASTFEEDING
EXPERT?
 You CAN support breastfeeding when there are problems.
 Acknowledge the obstacles.
 Acknowledge the journey
 Just because it was hard, or the course was bumpy, doesn’t make breastfeeding
any less important.
I'm trying to think of a positive experience regarding breastfeeding
with my twins' pediatrician, but all I'm coming up with is neutral ones.
She never discouraged breastfeeding (even when they were older
nurslings!) or raised an eyebrow, but she also wasn't really a
cheerleader. And based on that I recommended her to other nursing
moms... because finding a doc who didn't tell you stupid, untrue things
about human lactation is a good find!
WHAT YOU SHOULD KNOW
 Your limits
 Where to find help
 You encouragement and acknowledgment of obstacles makes a difference
 Most babies lose weight. They should regain their birth weight by 10-14 days
 You can should watch a feeding.
 Supplementation with formula is not a benign intervention. Supplementation does not always
need to be formula.
 Telling a mother to pump is not an easy process. You can help facilitate that process.
 Telling a mother to pump and discard her milk is –wow, just, wow
 Pumping only tells a mother how much she can pump. It is not a good estimate of what the
baby is getting.
 Your workspace should reflect that you are committed to breastfeeding.
WHAT YOU SHOULD KNOW
 Because the oligosaccharides in milk are not meant to leave the gut, they cause increased
stooling. Stool output is not messed up by delivery and is a good indictor of milk transfer.
 The baby should excrete all meconium by day 4 after vaginal deliveries and day 5 after Csections. If that does not happen, the baby needs an evaluation. Infrequent stooling is only
normal in older (>1 month old) babies.
 The minutes a baby spends on each breast is not a helpful measurement
 Babies should go to breast 8-12 times in a 24 hour period. That does not mean every two
to three hours.
 Oxytocin, the hormone responsible for the milk ejection reflex is extremely sensitive to
stress. Like telling a mother the baby needs to feed every two-three hours.
 A baby at the breast is where they want to be. You can help parents understand that.
www.drjen4kids.com
PHYSICIAN PERSONAL
EXPERIENCES
 Dr. MILK
 Mothers Interested in Lactation Knowledge
 Monthly meetings
 Web presence
 Facebook page
Laurie B. Jones and Emily A. Mallin. Breastfeeding Medicine. June 2013, 8(3): 330-332.
PHYSICIAN EDUCATION
Completion of the Wellstart Modules can be used to satisfy the
requirement of 3 or more hours of training for their physicians by
hospitals preparing for a Baby-Friendly assessment.
Plus, they’re free.
www.wellstart.org
www.bfconsortium.org
AAP RESOURCES, AVAILABLE AT AAP.ORG
WWW.AAP.ORG/BREASTFEEDING/CURRICULUM/
The curriculum was supported by a grant from the Health Resources and Services Administration’s Maternal and Child Health Bureau.