Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Monoclonal antibody wikipedia , lookup
Immune system wikipedia , lookup
Adaptive immune system wikipedia , lookup
Polyclonal B cell response wikipedia , lookup
Neonatal infection wikipedia , lookup
Adoptive cell transfer wikipedia , lookup
Immunosuppressive drug wikipedia , lookup
Hygiene hypothesis wikipedia , lookup
Cancer immunotherapy wikipedia , lookup
Sjögren syndrome wikipedia , lookup
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.