Presentation on theme: "Breastfeeding to prevent double burden of malnutrition"— Presentation transcript:
1Breastfeeding to prevent double burden of malnutrition Sirinuch Chomtho MD PhDNutrition Unit, Department of Paediatrics,Faculty of Medicine, Chulalongkorn University
2Breast milk composition Special fluid that keep changing !!!???Colostrum-Transitional milk-mature milkForemilk-HindmilkPremature milk-Fullterm milk
3Nutrients in breast milk MacronutrientsLipids-most important E source (50%)ProteinCarbohydrateMicronutrientsVitaminsMinerals
4Composition/100ml Colostrum Mature milk Cow milk Codex standard Energy (kcal)5865-706460-70Lipids (gm)3.66Carbohydrate (gm)Lactose (gm)Oligosaccharides (gm)Glucose (gm)5-72-54.654.5TraceNRProtein (gm)CaseinWheyα-lactalbuminβ-lactoglobulinlactoferrinlysozymeserum albuminsIgAIgMIgGNon-protein nitrogen (gm)0.380.36-0.350.40.0020.0010.050.010.30.0050.0418.104.22.168.040.0030.0060.02
5LipidsLCPUFA highest in breast milk >>>> cow’s milk (saturated short/medium chain FA)linoleic acid (C18:2, n-6)/α-linolenic (C18:3, n-3)arachidonic acid (ARA ; C20:4, n-6)/ docosahexaenoic acid (DHA ; C22:6, n-3)higher in premature human milkMinda H et al. Acta Paediatr 2002;91(8):Simmer K et al. Cochrane Database Syst Rev 2008;(1):CDSimmer K et al. Cochrane Database Syst Rev 2008;(1):CDKramer MS et al. Arch Gen Psychiatry 2008 May;65(5):
6DHA is the largest PUFA source in the retina and in the brain
7LipidsLCPUFAdepends on maternal diet (oily fish, egg yolk, seaweed)higher DHA in erythrocyte membrane lipids in BF vs FFDHA+ Formula vs. DHA-Formula ??????RCT: PROBIT study (Promotion of Breastfeeding Intervention Trial)BF group has better cognitive function at 6.5 yrsMinda H et al. Acta Paediatr 2002;91(8):Simmer K et al. Cochrane Database Syst Rev 2008;(1):CDSimmer K et al. Cochrane Database Syst Rev 2008;(1):CDKramer MS et al. Arch Gen Psychiatry 2008 May;65(5):
8prevalence of exclusive breastfeeding in the experimental and control group at 3 mo =43.3% vs 6.4%)
10Nutrients in breast milk MacronutrientsLipids: most important E source (50%)Protein:CarbohydrateMicronutrientsVitaminsMinerals
11Fat-soluble vitamins Vitamin A Vitamin D Vitamin E Vitamin K colostrum >> mature milk >>> cow’s milkretinol ester + carotenoids ( lutein, zeaxanthine)Vitamin Dlower than DRI but adequate if 2 hour/week sun exposureVitamin Eadequate (α-tocopherol:PUFA ratio 0.79 mg/gm)Vitamin KUniversal vit K 1 mg IM at birth to prevent hemorrhagic disease of newborn
12Water-soluble vitamins depends on maternal diet > fat-soluble vitaminsVitamin CHigh in breast milk >>> cow’s milkVitamin B groupAdequate exc. Vegan mother (B6, B12)Mother with B1 deficiency, thiaminase containing diets
13Minerals Breast milk has low osmolarity, renal solute load Adequate Na, K, ClLower Ca than cow’s milk but good absorption, Ca:P ratio 2:1Inadequate Ca, P for premature infantsHigh bioavailability of trace elementFe 20-50% availability, adequate for ‘healthy full-term’ infants until 6 mos.
14Influence of maternal diet on milk composition Little or no effectLactose concentrationMacromineral concentration (Ca, P, Mg)Some trace elements (Fe, Zn, Cu)Electrolytes (Na, K, Cl)Minimal effect, except severe malnutritionProtein (conc./composition)Non-protein nitrogen (conc./composition)Influenced by maternal dietFatty acid content and compositionLCPUFA, trans-fatty acidsMn, I, SeWater-soluble vitamin (Vit C, B1, B2, B6, B12, niacin)Fat-soluble vitamin (A,D,E,K)Donovan SM. In: Duggan C, Watkins JB, Walker WA, editors. Nutrition in Pediatrics: Basic science and clinical applications. 4th ed pProduction of breast milk is robust! Breast milk still contain protective factors regardless.Who should we give ‘extra’ supplement to ??? A. Mother B. Baby
15Non-nutritive factors in breast milk Secretary IgA (90% of total Ab)very high in colostrum gm/dL (twice adult sIgA produced per day), 0.1 gm/dL in mature milkProtects mucosal surfaces eg gut, respiratory tract immediately after birthComposed of specific antibodies against bacteria that mother has encountered in the environment (appear in milk around 1 day after mother infected)Infant starts to make its own SIgA after some weeks takes much longer in less exposed infants
16Secretary IgA in breast milk the secretory component protects them from digestion2-4 grams sIgA per litre presents in infant’s stool
17Non-nutritive factors in breast milk Living immunity Macrophages and neutrophilsMay protect mammary gland against infectious mastitisMay kill microbes in baby’s gutMacrophages make lysozyme secreted in milkLymphocytes – B and T cellsMay enter infant’s body and transfer immune functionsmother’s cells tolerated by babyenhanced response to vaccinesincreased tolerance to kidney transplant from mother
18Non-nutritive factors in breast milk Lactoferrin binds iron which inhibits bacterial growth, kills bacteria, viruses and CandidaLysozyme breaks down cell walls of many bacteriaOligosaccharides stop bacteria attaching to epithelium, prebiotics effectsNucleotides building blocks of nucleic acids; enhance maturation of immune system
19Non-nutritive factors in breast milk > 100 cytokines+immunomodulatory factors do not cause inflammation e.g TGF-β (Transforming Growth Factor beta)Epidermal growth factorsHormones: leptin, thyroid hormones, erythropoietin, prolactinEnzymes: bile salt-stimulated lipase
21How to maintain adequate milk supply? Prolactin & Oxytocin
22How to maintain adequate milk supply? Early stage:Frequent + effective nursingEvery 1-3 hours esp. during the night!!!Rooming-in + maternal confidence/supportLater stage (after 4-6 weeks) LOCAL control:Breast emptying (one at a time!)Demand & supplyFull breast Slower milk productionEmpty breast Faster milk production
23What to eat during lactation? Exclusive breast feeding mother needExtra energy 500 kcal/day, protein gm/dayAdequate waterBeware of maternal malnutritionvitamin B group e.g. B1, B12vitamin DCalcium, Phosphorus, Iron, Copper, Folate, Iodine22
24What to eat during lactation? Hypoallergenic diet ????Diary product, fish, egg, peanut avoidance during lactationGalactogogue ???
25Breastfeeding to prevent “double burden” of malnutrition
26Slow weight gain in breastfed baby BF baby normal/faster growth in 1st 4-6 monthsThen slower growth rate become leaner than FF baby by the end of 1st yearWeight deviate from standard growth chart (combine FF>>BF)!WHO child growth standard (http://www.who.int/childgrowth/)Dewey et al. Pediatrics 1992; 89:Dewey KG. Pediatr Clin North Am 2001; 48:
34BF vs Iron????Chuansumrit A, Arnutti P, Apivanich S. Iron status of one-year-old infants in a well baby clinic. J Med Assoc Thai 2002; 85(suppl4): S Similar results.Meinzen-Derr JK, Guerrero ML, Altaye M,Ortega-Gallegos H, Ruiz-Palacios GM, MorrowAL. Risk of infant anemia is associatedwith exclusive breast-feeding and maternalanemia in a Mexican cohort. J Nutr. 2006;136(2):452– 458
39e.0.7 mL of a vitamin-iron preparation (Tri-Vi-Sol with Iron)daily. Thisprovided 7mg of iron in the form of ferrous sulfate in addition to1059IUofvitaminA,270IUof vitamin D, and 24.5mgof vitamin breastfed infants absorb ’7.8% of supplemental iron given between meals
42How to prevent iron deficiency in Thai infants? Prevention of maternal iron deficiency/anemia during pregnancy?Delayed cord clamping?Screening in infants at risk?Iron supplement medication?Iron tolerance and complianceAdverse effect of iron e.g. saturation of lactoferrinFood fortification?
43How to prevent iron deficiency in Thai infants? Advice re: complementary food high in iron!
44Long term effect of breastfeeding in obesity prevention
45Early life risk factors for obesity in childhood Intrauterine & perinatal- Birthweight (low and high)- Maternal smokingInfant feeding and weaning practiceBreast feeding (lack of)Time of introduce complementary food (too soon)ObesityLifestyle in early childhoodSleep patternSedentary behaviorDietary patternFamily characteristics and demographics- Parental obeseJohn J Reilly, Andrea Sherriff ,et al. Early life risk factors for obesity in childhood: cohort study. BMJ 2005;10:1-7.
46Potential causes for the protective effects of breastfeeding on later obesity Modulating child behaviorEarly growth and substrate supplyBF infantDifferent suckling patternHigher suckling frequencyGreater degree of control on meal size & intervalBMVaries taste & smell >> programmed to different food selection & dietary habit in later lifeBMLower average caloric densityLower protein intake per kg bodyweightSlower growth rate in the 1st year
48Leptin Leptin secretion by mammary gland & transfer form blood Oral leptin >> reduce food intake & trigger down-regulation of endogenous leptin >> satiety signalPromote formation of neural circuit controlling food intake & adiposity later in lifeHigher serum leptin in BF than FF infantSavino F and Liguori SA. Update on breast milk hormones. Clinical Nutrition 2008;27:42–47.
49Ghrelin Influence on growth in first months of life Higher seum ghrelin conc >> inc. appetiteOnly in FF infant a positve correlation between serum ghrelin level fasting time emergedSavino F and Liguori SA. Update on breast milk hormones. Clinical Nutrition 2008;27:42–47.
50Early protein intake and later obesity risk Protein supplyInsulin releasing amino acidIncrease insulin & IGF1Rapid weight gainAdipogenic activityBerthold Koletzko. Am J Clin Nutr 2009;89(suppl):1502S–8S.
51of these, 28 (298 900 subjects) provided odds ratio estimates ObjectiveTo examine the influence of initial infant feeding on obesity in later lifeMethodsA systematic review of published studies investigating the association between infant feeding and a measure of obesity was performed with Medline (1966 onward) and Embase (1980 onward) databasesResultsSixty-one studies reported on the relationship of infant feeding to a measure of obesity in later lifeof these, 28 ( subjects) provided odds ratio estimatesChristopher G, Derek G. Cook, et al. Effect of Infant Feeding on the Risk of Obesity Across the Life Course:A Quantitative Review of Published Evidence. Pediatrics 2005;115;
52breastfeeding was associated with a reduced risk of obesity, compared with formula feeding (odds ratio: 0.87; 95% confidence interval [CI]: 0.85– 0.89)WHO 2013 review OR 0.88 ( )
53prevalence of exclusive breastfeeding in the experimental and control group at 3 mo =43.3% vs 6.4%)Michael S. Kramer, Stanley Shapiro,et al. J. Nutr. 2009;139: 417S–421S.
54Probably too young to see the effects on body fat accumulation ! Conclusion :we found no effect of prolonged and exclusivebreast-feeding on height, adiposity, or BP in Belarusian earlyschool-age childrenProbably too young to see the effects on body fat accumulation !Michael S. Kramer, Stanley Shapiro,et al. J. Nutr. 2009;139: 417S–421S.
55Take home message !Breast-fed baby with adequate lactation support have ‘ideal growth’ not too small or too fat (!)Good complementary feeding is essential after 6 months to address some problem nutrients e.g. ironLong-term growth outcomes e.g. obesity prevention is not clear still need long-term prospective follow-up studiesDon’t forget other health benefits of BF esp. cognitive and immune function