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Objectives of the Course

Nutrition Module Notes Pediatric I – Second Year Rebecca Abiog -Castro, M.D. Rhodora Garcia de Leon, M.D Faculty of Medicine & Surgery, UST. Objectives of the Course. At the end of the course a Second Year Medical Student should be able:

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Objectives of the Course

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  1. Nutrition Module NotesPediatric I – Second YearRebecca Abiog-Castro, M.D.Rhodora Garcia de Leon, M.DFaculty of Medicine & Surgery, UST

  2. Objectives of the Course At the end of the course a Second Year Medical Student should be able: • To discuss briefly the anatomy of the breast and physiology of lactation; • To discuss the benefits of breastmilk and the benefits of breastfeeding to both infant and mother; • To discuss the barriers on breastfeeding; • To discuss the composition of mature breast-milk; • To discuss the difference between breast-milk and cow’s milk;

  3. Objectives of the Course • To discuss the steps to encourage Breast-feeding in the hospital: UNICEF / WHO Baby-Friendly; • To discuss the features of complementary foods; • To discuss the proper method to introduce complementary foods; • To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children; • To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for its use; • To discuss the supplements for breastfed infants.

  4. Mother's milk is the best food a baby can have exclusively in the first 6 months of life;should be continued untiltwo years and beyond.

  5. Anatomy of Breast Internal structures External structures: Cross section of alveolus

  6. Breast Structure

  7. Anatomy of the Breast

  8. Palate Teat Tongue

  9. Physiology of lactationEndocrine control Three main phases of lactation 1) Mammogenesis or mammary growth 2) Lactogenesis or initiation of milk secretion: Stage I: 12 wks before parturition Stage II: 2-3 days postpartum 3) Stage III of Lactogenesis or Galactopoiesis maintenance of milk secretion: 14-30 das.

  10. Three Main Phases of Lactation (hormonal) Phase I - Mammogenesis Profound during pregnancy in preparation for lactation Placental lactogen, estrogen, progesterone Ductal Sprouting (estrogen), lobular formation (progesterone), Prolactin essential for complete gland growth

  11. Phase I - Mammogenesis

  12. Phase I - Mammogenesis INDUCTION OF GROWTH (Normal animals) • Estrogens alone induce alveolar growth • Larger than normal alveoli • Estrogen and progesterone induce normal growth

  13. Phase II - LACTOGENESIS INITIATION OF LACTATION • At parturition the mammary gland switches from a growing non secretory tissue to a secreting, non-growing tissue • Change is endocrine mediated

  14. Three Main Phases of Lactation (hormonal) Phase II - Lactogenesis(initiation of milk): Stage I: starts 12 wks before delivery Gathering of all substrates for milk production Stage II: starts 2-3 days postpartum Milk secretion is copious

  15. ENDOCRINE REGULATION OF LACTOGENESIS Endocrine Patterns Related to Parturition

  16. Endocrine Control of Lactation • Milk Production Reflex: Prolactin is a key lactogenic hormone, stimulating initial alveolar milk production • Milk Ejection Reflex: Oxytocin contracts the myoepithelial; cells, forcing milk from the alveoli into the ducts and sinuses where it is removed by the infant

  17. ENDOCRINE REGULATION OF LACTOGENESIS Effect of different hormones in the initiation of milk production • Glucocorticoids • Development of RER (rough endoplasmic reticulum) • Prolactin • Maturation of Golgi • Secretory vesicles • Responsible for milk secretion • Progesterone • Promotes mammary growth specially alveolar tissue • Blocks epithelial secretion • As it decreases, the block for lactogenesis is removed

  18. Effect of different hormones in the initiation of milk production MAMMARY GROWTH SLOWS DOWN • Most hormones involved in growth have been removed • Progesterone • CL has regressed and placenta is removed • Estrogens • Feto-placental unit no longer available • Placental lactogens • Placenta was expelled After parturition mammary growth slows down because most growth promoting hormones are no longer available

  19. Phase III – Galactopoiesismaintenance of Breastmilk Secretion Stage III of Lactogenesis or Galactopoiesis Maintenance of milk secretion From 14- 30 days Mature milk is established Prolactin and Oxytocin essential for effective maintenance of milk supply

  20. MAINTENANCE OF LACTOGENESIS(Galactopoiesis) Hormones in charge of supporting continuous milk production • Responsibility of prolactin and growth hormone • Supported by thyroid, parathyroid and adrenal glands through adequate metabolic function

  21. Autocrine Control of Lactation Influence of of Local Factors Acting on the Breasts • It is not just the level of maternal hormones, but the efficiency of milk removalthat governs the volume product in each breast • A protein factor called feedback inhibitor of lactation (FIL)is secreted with other milk components into the alveolar lumen • FIL, insensitive to prolactin   milk production

  22. Autocrine Control of Lactation FIL FIL FIL

  23. Anatomy & Physiology: Milk production Risk factors for delayed onset of lactation were: • Stage II labor > 1 hr, • Pre-pregnant maternal BMI > 27 kg/m2, • Breastfeeding problems at day 3,and • Being primiparous. Dewey et al, 2001

  24. Anatomy & Physiology: Milk production Factors associated with breastfeeding problems at day 7 included: • flat or inverted nipples at day 7, • stage II labor > 1 hour, • birthweight < 3601 gms, • Pre-pregnant maternal BMI > 27 kg/m2 • non breast milk fluids given in the first 48 hours of life Dewey, 2003

  25. Breastmilk composition

  26. Breast-milk Variations of Breastmilk • Colostrum (1st 3-5 days of life) • Term breastmilk ( mother’s own: 7 - 10 – 28 days) • Pre-term Milk ( day 7- 28 days) • Mature breastmilk ( >30 days) • Drip breastmilk ( 30-90 days postpartum)

  27. Colostrum • First postpartum week’s mammary secretion consisting of yellowish (beta carotene) thick fluid; • Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x); • Protein content is rich insIgA and immunologically competent mononuclear cells; • Containsantioxidants which trap neutrophil-generated oxygen radicals.

  28. Distribution of Immunoglobulins and other Soluble Substances in the Colostrum and Milk Delivered to the Breast-Fed Infant During a 24-Hour Period

  29. Type of Volume Energy Protein CHO FAT NA Milk ml/d Kcal/100 ml G/100mL G/100 ml G/100 ml mmol/100MLColostrum 100 0.67 2.3 5.3 2.9 1.7 (1-5 d)TermD7 558 0.73 1.95 6.72 3.52 0.97 D 14 591 0.67 1.62 6.97 3.88 1.27Breastmilk 750 0.69 1.1 7.4 4.2 0.70(Mature>30 d)

  30. Type of Volume ENERGY PROTEIN CHO FAT NAMilk (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml mmol/100 mlPreterm D7 461 0.647 2.59 6.23 4.02 2.45D14 413 0.68 2.29 6.21 4.71 2.2 D28 452 0.652 1.91 6.39 4.33 1.51DripBM 0.54 1.35 7.1 2.2 0.5Cow 0.67 3.4 4.6 3.9 2.3

  31. Calculated Nutrient Intakes Compared to Estimated Needs for LBW

  32. Nutrients in human and animal milk Human Cow Goat Fat Protein Lactose HUMAN COW GOAT BUFFALO

  33. VITAMIN CONTENT

  34. Comparison of Human Milk and Cow’s Milk

  35. Supplements for Breastfed Infants The following supplementation is generally recommended: • Vitamin K supplement in the immediate postpartum period. • 400 IU of Vitamin D • Breastfeeding women should continue taking prenatal vitamins especially vitamin D, calcium and iron • Complementary foods should be given once infants reach six months of age

  36. Review Questions • The part of breast responsible for milk secretion _________ under the influence of what hormone? ______ • Two important reflexes that are needed for BM secretion? ________ • Which part of the breast is milk stored? ________ • Hormone secreted during BF which can reduce BF________ • Major source of protein in BM ______

  37. Benefits of Breastmilk / Breastfeeding to Infants and Mothers

  38. Benefits ofBreastmilk • Enhances Cognitive Development • Protective: Both for baby and mother • Cheap & Free: Benefits the Economy • Safe

  39. Benefits of Breastmilk:Infant • Enhances Cognitive Development • Docosohexanoic Acid (DHA) • Lactose • ‘Skin to skin’ Contact and ‘face to face’ position

  40. Benefits of Breastmilk: Infant DHA (Docosohexanoic Acid): • Fatty acid derived from Linolenic Acid • Only found in breastmilk in consistent level • Important substance for the myelin sheath of nerve fibers • Vital nutrient for the growth and development of brain tissue and good vision • Researches showed that it is this substance that enhances cognitive development

  41. Benefits of Breastmilk: Infant Lactose • Predominant carbohydrate of breastmilk • Disaccharide consisting of glucose and galactose • Galactose combines with lipid to form a valuable nutrient, galactose-lipid, for brain tissue development

  42. Benefits of Breastmilk: Infant ‘Skin to skin’ contact & ‘Face to Face’ position • Enhances the cognitive and educational development of children as each feeding time is a learning opportunity for mother and child

  43. Benefits of Breastmilk: Infant Breastmilk is Protective • Protective properties of BM is divided into two: • Humoral factors: • Consists of the 5 immunoglobulins (antibodies): • IgA, s IgA, IgG, Ig E, Ig D, Ig M • Cellular factors: • White Blood cells: • Neutrophils • Lymphocytes • Epithelial cells • Macrophages

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