2Accreditation and Educational Credit The University of South Carolina School of Medicine-Palmetto Health Continuing Medical Education Organization designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.This CME Activity is planned and presented in accordance with all ACCME Essential Areas and Elements (including the Standards for Commercial Support) and Accreditation Policies.Relevant financial relationships and acknowledgements of commercial support will be disclosed to participants. Faculties are required to disclose off-label/investigative uses of commercial products/devices.
3Supplements, Storage, and Substitutes Section 4Supplements, Storage, and Substitutes
4Objectives Recommend safe milk storage options. Review indications for formula use and available options.Recommend appropriate breastfeeding management as recommended by the American Academy of Pediatrics
6Indications for Supplemental Feedings SeparationMaternal illness resulting in separation of infant and mother (e.g., shock or psychosis)Mother not at the same hospitalInfant with inborn error of metabolism (e.g., galactosemia)Infant who is unable to feed at the breast (e.g., congenital malformation, illness)Maternal medications (those contraindicated in breastfeeding)MSUD and PKU are also IEMs with contraindications for exclusive breastfeedingMaternal meds:Antineoplastic agents, Immunosuppressants, Lithium, Chloramphenicol, Ergot alkaloids, Radiopharmaceuticals,Bromocriptine, Iodides
7Why is Supplementation Discouraged? Can prevent the establishment of maternal milk supplyHas adverse effects on breastfeeding (e.g., delayed lactogenesis, maternal engorgement)Alters infant bowel floraSensitizes the infant to allergens (depending on the content of the feeding and method used)Interferes with maternal infant bondingBlomquist HK, Jonsbo F, Serenius F, Persson LA: Supplementary feeding in the maternity ward shortens the duration of breast feeding. Acta Paediatrica 83:1122–1126, 1994
8Supplementation? Common situations in which evaluation and breastfeeding management may be necessarybut supplementation is NOT indicated:The sleepy infant with fewer than 8 to 12 feedings in the first 24 to 48 hours with < 7% weight loss and no signs of illness.Newborns are normally sleepy after an initial 2-hour alert period after birth. They then have variable sleep–wake cycles, with an additional one or two wakeful periods in the next 10 hours whether fed or not. Careful attention to an infant’s early feeding cues, and gently rousing the infant to attempt breastfeeding every 2–3 hours is more appropriate than automatic supplement after 6, 8, 12, or even 24 hours.The general rule in the first week is: “an awake baby is a hungry baby!”Increased skin-on-skin time can encourage more frequent feeding.
9Supplementation?The infant with bilirubin levels < 20 mg/dL after 72 hours of age, when the baby is feeding well and stooling adequately with weight loss <7%The infant who is fussy at night or constantly feeding for several hoursThe sleeping motherDuring emergencies and stressful situations, breastfeeding should continue.During growth spurtsno
10Consider Supplemental Feedings Infant Indications Asymptomatic HypoglycemiaDocumented by laboratory blood glucose measurement (not bedside screening methods)Unresponsive to appropriate frequent breastfeedingSymptomatic infants should be treated with intravenous glucoseSignificant Dehydration10% weight loss, high sodium, poor feeding, lethargy, etc.Not improved after skilled assessment and proper management of breastfeedingWeight loss of 8–10% accompanied by delayed lactogenesis II (day 5 [120 hours] or later)
11Consider Supplemental Feedings Infant Indications (continued) Delayed bowel movements or continued meconium stools on day 5 (120 hours)Insufficient intake despite an adequate milk supply (poor milk transfer)Low Birth WeightWhen sufficient milk is unavailableWhen macronutrient supplementation is indicatedHyperbilirubinemiaNeonatal jaundice associated with starvation where breastmilk intake is poor despite appropriate interventionBreastmilk jaundice when levels reach 20–25 mg/dL (mol/L) in an otherwise thriving infant and where a diagnostic and/or therapeutic interruption of breastfeeding may be helpfulNo clear reason to intervene if baby thriving
12Consider Supplemental Feedings Maternal Indications Primary glandular insufficiency (primary lactation failure), as evidenced by poor breast growth during pregnancy and minimal indications of lactogenesisOccurs in <5% of womenDelayed lactogenesis II (after day 3–5) and inadequate intake by the infantRetained placenta (lactogenesis probably will occur after placental fragments are removed)Sheehan’s syndrome (postpartum hemorrhage followed by absence of lactogenesis)Breast pathology or prior breast surgery resulting in poor milk productionIntolerable pain during feedings unrelieved by interventionsUnavailability of mother due to severe illness or geographic separationBreast pathology that may interfere with breastfeedingTubular breasts, Reduction mammoplasty, Augmentation mammoplasty, Lumpectomy, Previous treatment for breast cancer, Trauma and burns, Pierced nipplesSheehan’s Syndrome is hypopituitaryism caused by infarction of the blood supply to the pituitary secondary to severe postpartum hemorrhage.• Retained placenta results in continued high levels of progesterone, which inhibits milk production.
13Which Supplemental Feed? Expressed human milk is the first choiceBut sufficient colostrum in the first few days (0–72 hours) may not be availableHand expression may elicit larger volumes than a pump in the first few days and may increase overall milk supplyBreast massage along with expressing with a mechanical pump may also increase available milkPasteurized donor human milk is second choiceProtein hydrolysate formulas are next choicePreferable to standard artificial milks as they avoid exposure to cow’s milk proteinsReduce bilirubin levels more rapidlyMay convey the psychological message that the supplement is a temporary therapy, not a permanent inclusion of artificial feedingsSupplementation with glucose water is not appropriate
14How Much? Breast milk transfer (example 3.5kg newborn) Day 1: 6ml/kg/24h (21ml per day)Day 2: 25ml/kg/24h (87.5ml per day)Day 3: 66ml/kg/24h (231ml per day)Day 4: 106ml/kg/24h (371ml per day)Infants fed artificial milks commonly (but unnecessarily) have higher intakes than breastfed infantsNewborn stomach capacity5ml/kg for an average of 20ml7-123 ml/day first dayAverage 45ml first day
15Recommended Volumes Day of Life Volume per feed Day 1 2-10ml Day 2 Breast or bottle feeds
16Milk StorageHuman milk is a fresh, living food with antioxidant, antibacterial, prebiotic, probiotic, and immune-boosting properties along with nutrients.Some nutrients and health properties change with storage, but milk may be safely stored with maintenance of its unique qualities.
17Stored Human Milk Smell and taste may be different Due to lipase activityBreaks fat into fatty acidsAids the infant in milk digestion, especially preterm infantsIs not harmfulSome infants may refuse to drink older milkDo not reheat above 40°C (104°F)Results in loss of enzyme activity
18Human Milk Storage Recommendations based on bacterial growth Room temperature (10°-29°C, 50°-85°F)3-4 hours for warmer rooms (80°-89°F)6-8 hours for cooler roomsSmall cooler (15°C, 59°F)24 hours based on minimal bacterial growth in a study by HamoshWarmer rooms 27-32C
19Human Milk Storage Refrigerator (4°C, 40°F) Recommendations based on bacterial growthLow growth after 4-8 daysRecommendations based on bactericidal capacitySignificant loss by hoursBacterial growth is in milk with low levels of contamination at time of expression
20Human Milk Storage Freezer (-4° to -20°C) Safe for at least 3 months Well preservedVitamins A ,E, and B, total protein, fat, enzymes, lactose, zinc, immunoglobulins, lysozyme, and lactoferrinSignificant decreaseVitamin CNo bacterial growth for at least 6 weeksFoods frozen at -18°C (0°F) are indefinitely safe from bacterial contaminationPreserved bactericidal capacity for at least 3 weeksStore in back of freezer in a well sealed containerBack of freezer to avoid intermittent rewarming from freezer door openingWell sealed container to avoid contamination
21Milk Storage Guidelines Storage LocationTemperatureMaximum recommended storage durationRoom temperature16°-29°C60°-85°F3-4 hours optimal6-8 hours under very clean conditionsRefrigerator≤4°C39F72 hours optimal5-8 days with very clean conditionsFreezer<-4°C24°F6 months optimal12 months acceptable
22Use of Stored Milk Use oldest milk first Milk may be drunk cool, at room temperature, or warmed based on infant preferenceTo defrostThaw in refrigerator overnightRun under warm waterSet in a container of warm waterDo not microwaveDecreases bacteria count BUTHeats milk unevenly andDecreases anti-infective qualities of milk
23Use of Stored Milk Thawed milk Loses ability to prevent bacterial growth within 24 hours of thawingPreviously frozen milk should not be at room temperature for more than a few hours after being thawed for 24 hoursLittle information on refreezing thawed milkNo recommendation can be made
24Use of Stored Milk Remaining milk after partial feed Bacterial contamination of milk from baby’s mouth occursRecommendations are to discard milk 1-2 hours after the feedBased on related evidenceNo studies on how long this milk can be kept at room temperature after a feed
25Human Milk StorageUniversal precautions are not required for handling of human milkCan be stored in workplace refrigerator where food is storedCan be stored in personal freezer pack
26Human Milk and Bacteria Normally contains nonpathogenic bacteriaImportant in establishing the neonatal intestinal floraAre probiotics as they create intestine conditions that are unfavorable to pathogenic organismsNo need to discard milk from a mother with breast or nipple pain due to bacterial or yeast infectionDiscard milk that is stringy, foul, or purulent
27Shelf life Human milk Formula Meant to be consumed at time of productionFormulaMust have a shelf life of at least one year
28Human Milk Substitutes Three formsReady to feedNo additional preparation neededSterileConcentrated liquidMust add equal amount of waterGenerally come in 13oz can which is diluted to 26oz formulaPowderAdd 1 scoop of powder to 2oz of water12.9oz can will make ~95oz formula25.7oz can will make ~189oz formulaNot sterile
29Indications for Soy Formula GalactosemiaVegetarian parents who want infant to have vegetarian dietHereditary lactase deficiency (very rare)Do not use in cow milk protein allergy~15% will also be allergic to soyDo not use in milk protein-induced enteropathy or enterocolitisCan be also be sensitive to soy proteinsNo value for treating colic or fussinessDoes not prevent development of atopic diseases
30Protein Hydrolysate Formulas Partially hydrolyzed and extensively hydrolyzed formulas may NOT be used interchangeably in infants with milk protein allergy.
31Protein Hydrolysate Formulas Partially Hydrolyzed Protein FormulasEnfamil GentleaseNestle Good StartNestle Good Start SoyMarketed as easier to digestNo real indication for theseNot beneficial for cow milk protein enteropathy
32Protein Hydrolysate Formulas Extensively Hydrolyzed Protein FormulasProtein-basedPregestimil Nutramigen AlimentumAmino Acid-basedElecare NeocateUseful for infants who cannot digest or are severely intolerant to intact cow milk proteinsMPA/cow milk protein enteropathy or enterocolitisUseful in infants with significant malabsorption due to GI or hepatobiliary diseaseCF, short gut syndrome, biliary atresia, cholestasis, and protracted diarrhea
33IngredientsHuman MilkCow MilkCow Milk Protein-Based FormulaSoy Protein-Based FormulaProtein Hydrolysate FormulaCarbohydrate (g/dL)Lactose 7.0Lactose 4.8Lactose Corn Syrup 3.6 to 3.7Sucrose Corn Syrup 3.6Sucrose Corn Syrup 3.4 to 3.7Protein (g/dL)Human milk protein whey: casein ratio of 75:25Total: 1.1Cow milk protein, whey: casein ratio of 22:78Total: 3.3Nonfat milk Demineralized whey1.4Soy isolate Methionine1.8 to 2.0Cow milk protein hydrolyzed to reduce allergenicity1.9Fat (g/dL)Human milk fat contains more absorbable triglyceride (3.8)Butterfat contains more volatile fatty acids (3.7)Soy oilCoconut oilPalm Oil3.6 to 3.7Palm OleinCoconut OilMedium-chain triclyceride oil3.4 to 3.7Calcium (mg/L)2801,226530710- higher calcium content due to inhibition of adsorption by phytates640 to 710Phosphorus (mg/L)147956284 to 360507 to 56012Iron (mg/L)Vitamin C and lactose facilitate absorption (0.4)0.55.0Suggested UsesPreferred for all infantsChildren older than 1 year of age who have normal gastrointestinal tractInfants who have normal gastrointestinal track but cannot be breastfedInfants who have cow milk allergy (30% may have cross-reactivity), lactose malabsorption, galactosemiaInfants who have good allergies or underlying gastrointestinal damageThis table shows the differences in composition between human milk, cow milk, and infant formulas. It is from Peds in Review Nov 2006
34Growth Differences between Breastfed and Formula fed Infants Breastfed infants gain more weight than formula fed infants during the first 3-4 months then slow down during the latter half of the first yearThe breastfed infants are healthy but become leanerBecause of this normal growth pattern they are all too often are judged as faltering in their growth The pediatric growth charts more recently released by the United States Center for Disease Control (CDC) are an improvement but represent an average growth pattern of breast-fed and formula-fed infants, both sick and well.
35WHO International Code of Marketing of Breastmilk Substitutes
36The CodeAims to address safe, adequate nutrition for infants while protecting and promoting breastfeeding and ensuring the availability and proper use of breastmilk substitutes with appropriate marketing and distributionIf substitutes are needed, they should be available when needed but not promotedDoes NOT ban formula
37The CodeApplies to the marketing of any food that is marketed as suitable for infants (all formulas, juices, commercial semisolid weaning foods) as well as feeding bottles and nipples.Has not been completely updated, but it has been revised every two years by the WHA to remain current and relevant as an international guiding document
38The CodeEnsures proper use of Breastmilk Substitutes (BMS)-medically necessary; requested after informed consent documented.Prohibits marketing of BMS, complementary foods, bottles and teatsEducational materials free of BMS marketing and no group education on preparation of formulaEducation on BMS includes hazards of preparation that are eliminated by breastfeeding
39Ten Major Provisions of The Code No advertising or promotion of breastmilk substitutes and products within the scope of the code and relevant WHA resolutions to the general publicMeans no special displays, discount coupons, or special salesNo free samples or gifts to mothers or healthcare workersInformation and labels must advocate breastfeeding and warn against bottle feeding and contain no pictures or text that idealizes the use of breastmilk substitutesThe health care system must not be used to promote the use of breastmilk substitutesNo free or low cost supplies of breastmilk substitutes
40Ten Major ProvisionsHealth professionals allowed to receive samples only for research purposesInformation to health workers must be scientific and factualNo contact between marketing personnel and mothersNo gifts or personal samples to healthcare workersAll information on artificial feeding, including labels, should explain the benefits of breastfeeding, the costs and hazards associated with artificial feeding and the correct use of breastmilk substitutes
41WIC PackagesExclusive BF Package Mostly BF Package No Breastfeeding
44AAP Recommendations on Breastfeeding Management for Healthy Term Infants Exclusive breastfeeding for about 6 monthsBreastfeeding preferred; alternatively expressed mother’s milk, or donor milkTo continue for at least the first year and beyond for as long as mutually desired by mother and childComplementary foods rich in iron and other micronutrients should be introduced at about 6 months of ageFrom the American Academy of Pediatrics “Breastfeeding and the Use of Human Milk” March 2012
45AAP Recommendations on Breastfeeding Management for Healthy Term Infants Peripartum policies and practices that optimize breastfeeding initiation and maintenance should be compatible with the AAP and Academy of Breastfeeding Medicine Model Hospital Policy and include the following:Direct skin-to-skin contact with mothers immediately after delivery until the first feeding is accomplished and encouraged throughout the postpartum periodDelay in routine procedures (weighing, measuring, bathing, blood tests, vaccines, and eye prophylaxis) until after the first feeding is completedDelay in administration of intramuscular vitamin K until after the first feeding is completed but within 6 h of birthEnsure 8 to 12 feedings at the breast every 24 hEnsure formal evaluation and documentation of breastfeeding by trained caregivers (including position, latch, milk transfer, examination) at least for each nursing shiftGive no supplements (water, glucose water, commercial infant formula, or other fluids) to breastfeeding newborn infants unless medically indicated using standard evidence-based guidelines for the management of hyperbilirubinemia and hypoglycemiaAvoid routine pacifier use in the postpartum periodBegin daily oral vitamin D drops (400 IU) at hospital dischargeFrom the American Academy of Pediatrics “Breastfeeding and the Use of Human Milk” March 2012
46AAP Recommendations on Breastfeeding Management for Healthy Term Infants All breastfeeding newborn infants should be seen by a pediatrician at 3 to 5 d of age, which is within 48 to 72 h after discharge from the hospitalEvaluate hydration (elimination patterns)Evaluate wt gain (wt loss no more than 7% from birth and no further wt loss by day 5: assess feeding and consider more frequent follow-up)Discuss maternal/infant issuesObserve feedingMother and infant should sleep in proximity to each other to facilitate breastfeedingPacifier should be offered, while placing infant in back-to-sleep-position, no earlier than 3 to 4 wk of age and after breastfeeding has been establishedFrom the American Academy of Pediatrics “Breastfeeding and the Use of Human Milk” March 2012
47Breastfeeding Resources Free Apps for Breastfeeding SupportLactMedHealthcare Provider’s Guide to BreastfeedingSearch for HCP Guide to BreastfeedingOnline ResourcesAcademy of Breastfeeding MedicineAAPACOGAAFPStanford University
48ReferencesAAP, Work Group on Breastfeeding. “Breastfeeding and the use of human milk.” Pediatrics 1997;100:AAP, Work Group on Breastfeeding. “Breastfeeding and the use of human milk.” Pediatrics 2012;129:3 e827-e841.ABM Protocol Committee. ABM Clinical Protocol #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised Breastfeed Med (Accessed January 5, 2011).ABM Protocol Committee. ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Breastfed Neonates, Revised June, Breastfeed Med (Accessed September 1, 2010).Chandran, Latha and Gelfer, Polina. “Breastfeeding: The Essential Principles.” Pediatrics in Review. 2006; 24;
49ReferencesFeldman-Winter, Lori. (2012, August) Clinical Update: Breast Feeding – Translating the Evidence into Care. Best Fed Beginnings. Lecture conducted from Atlanta, GA.Naylor, Audrey J. and Wester, Ruth A. “Lactation Management Self-Study Modules Level I.” WellStart International. Third Edition (Revised) OctoberWagner, Carol. (Jun 9, 2009). “Human Milk and Lactation.” EMedicine from WebMD. 25 NovemberWalker, Marsha. “Supplementation of the Breastfed Baby ‘Just One Bottle Won’t Hurt’---or Will It?” (Accessed June 15, 2013).WHO, Department of Child and Adolescent Health and Development. “Infant and young child feeding: Model Chapter for textbooks for medical students and allied health professionals.” World Health Organization. Ed. Ann Brownlee, Felicity Savage King, and Peggy Henderson October
50Thank you for completing Section 4 of Breastfeeding Education for Physicians. To obtain CME credit, please click on the link below, provide your information and complete the post-testhttps://www.surveymonkey.com/s/BreastfeedingSection4