• Adequate nutrition for maintaining homeostasis and for (rapid) growth and development
• Infants GIT not well-developed, therefore need food easily digested and absorbed
• Clean source of food, prevention of infection (infection is a major cause of infant mortality in 3rd world countries, repeated infections results in decreased growth)
• Early exposure to foreign protein and development of atopy
• Special requirements for preterm infants, infants with metabolic diseases and other conditions

• For maintaining homeostasis and for growth and development
• Energy: 110 kcal/kg/day, 20% required for growth, rest for activities, maintenance of body temperature
• Carbohydrate: main source of energy
• Protein: growth, certain special aa found in breast milk for brain development
• Fat: energy and also specific essential fatty acids for brain development
• Mineral and vitamins especially iron and calcium (Ca++ b/c baby growing rapidly)

Nutritional need of infant, child and adult: Comparison

Specific requirement for brain development

Protein:

• Taurine: deficiency found to cause irreversible damage to retina in growing kittens
• Cysteine: newborn infants lack the enzyme to convert methionine to cysteine

Fat:

• LC-PUFA (long chain polyunsaturated fatty acids)
• MCT (medium chain triglycerides)
• Both essential for brain growth

• Newborn infant's digestive system not fully developed yet e.g. no teeth, stomach less able to handle solids (casein curds in stomach, more difficult to digest and absorb compared to whey protein)
• Fat encased in lipase containing membranes in breast milk more easily absorbed

• Prevention of infection
• In developing countries the commonest cause of infant death is due to gastro-enteritis
• Infection will also increase the energy requirement of an infant and recurrent infection is a cause of stunted growth

• Early exposure to foreign protein and development of atopy
• Exposure of the infant in the first few months of life to foreign protein increases the chance of eczema and asthma in later life
• Immature intestinal tract more susceptible to sensitisation by foreign proteins?
• Atopy: inherited susceptibility and exposure to antigen

• Preterm infants, infants with metabolic diseases and other conditions
• Preterm infants: higher energy requirement, more susceptible to LC-PUFA deficiency, cysteine deficiency
• Metabolic disease (rare) eg. infants with galactosaemia need lactose free diet
• Infection: higher energy requirement, therefore increase caloric intake
• Chronic lung problems: higher energy requirement (eg. Oxygen therapy, immature lung)

• Nutritional value
• Easily digested and absorbable
• Prevention of infection
• Prevention of atopy
• Breast milk from mothers who deliver preterm suits the special need of the preterm infant

• Composition not constant but varies to suit the maturity of the infant and the time of the day
• More concentrated in evening (so infant need not be fed so frequently)
• Pre-term babies: mother's breast-milk has higher energy per unit volume
• During a feed: first part more dilute; end of feed breast milk more concentrated (when baby starts to suck, baby thirsty, so dilute milk satisfies thirst - end of feed: higher caloric intake satisfies hunger)
• Higher lactose and fat ie. higher energy
• Rich in taurine and cysteine
• Rich in MCT and LC-PUFA
• (Contains less iron than fortified infant formula - therefore baby on exclusive breast feeding for extended period needs iron supplements)

• More whey protein, less casein
• Fat encased in membrane containing lipase:
• The membrane helps to emulsify the fat in aqueous solution
• The lipase makes the fat more easily absorbable

? Makes the calcium more easily absorbable too

• Lactoferrin binds iron, inhibits E. Coli
• Growth factor for lactobacilli (colonisation resistance)
• IgA: mother's GIT exposed to pathogens, produce IgA against those pathogens, excreted in breast milk (therefore specific to pathogen that baby is exposed to). IgA acts locally in baby's GIT - prevents gastro-enteritis
• Living white blood cells
• Free from contamination

1. Direct from breast - therefore less change of contamination
2. Unclean water, bottles, teats -> more chance of infection (hence, gastro-enteritis)

• Infant gut immature, cannot protect against sensitisation to foreign protein
• Exclusive breast feeding for 3 to 6 months prevents exposure to foreign protein during the susceptible period
• Lower incidence of eczema and asthma

• Fertility control
• Bonding
• Uterine involution: more rapid involution, decreased bleeding from genital tract
• Lower incidence of breast cancer in woman who have breast feed
• More rapid wt loss after pregnancy (fat deposition during pregnancy is to provide energy for breast feeding - therefore, if you breast-feeding, fat will remain)

• Birth control
• Spacing out pregnancy, decreasing maternal death from childbirth
• Prevention of infection and death in infancy
• Much less costly than bottle feeding

• Anatomy, growth and development of mammary glands
• Lactation
• Initiation
• Maintenance
• Weaning
• Lactation and ovulation suppression

 Alveoli

• Milk ducts
• Adipose tissue: determines size of breast
• Mammary ducts: contain SM, squeeze milk toward nipple
• Areola: dark area around nipple (mammary glands)
• Nipple

Puberty:

• Oestrogen: milk duct proliferation
• Progesterone: alveolar development

Pregnancy:

• Oestrogen and progesterone: further alveolar hypertrophy but inhibit milk production (oestrogen (-) milk production)
• Prolactin and human placental lactogen stimulate secretory activity (milk production)
• Most woman do not have milk production due to strong inhibitory influence of oestrogen

• Initiation: after delivery (removal of placenta) the oestrogen and progesterone level rapidly decline removing inhibition on milk production
• Maintenance: suckling (infant to breast)
• Prolactin: milk production
• Oxytocin: milk ejection
• Weaning: pressure built up by milk accumulating in the alveoli (this pressure stops secretion in glands)

• Suckling
• Afferent nerve
• Hypothalamus
• Inhibit dopamine release (dopamine inhibits prolactin release from anterior pituitary)
• Removal of dopamine inhibition on prolactin release in anterior pituitary
• Prolactin released into bloodstream
• Carried to mammary gland: stimulates production of milk

• Suckling
• Afferent nerve
• Hypothalamus
• Production and transportation of oxytocin to the posterior pituitary
• contraction of myoepithelial cells
• Oxytocin has (+) effect on uterus and myoepithelial cells [this is the reason why uterus contracts better with breastfeeding]

• Initially due to high prolactin level
• Suckling increase the sensitivity to oestrogen feed back
• Decrease pulsatile GnRh release
• Decrease FSH and LH
• No ovulation
• But 10% women do have ovulatory cycles while breast feeding (therefore not be used for contraception)

 Correct position of suckling

• The whole areola (the dark part) is in the baby's mouth
• the tongue presses on the milk ducts
• the gums are not chewing the nipple

• Only the nipple is inside the baby's mouth
• The gums chew on the nipples (causes sore nipples)

• Sore nipples
• Breast engorgement

Treatment:

• Correct latching-on position
• Express milk to decrease engorgement before feeding (otherwise difficult for baby to get whole areola in mouth)

• Breast cancer (current)
• HIV positive mother
• In developing countries (no clean water source) where there is no safe alternative to breast feeding, breast feeding should still be advised
• Infants with galactosaemia

• Home and work environment
• attitude of the society
• Lack of public facilities
• Lack of family support: very important
• Lack of support from the health profession
• Promotion from formula milk companies
• A 'lost tradition"

Learn correct information on breast-feeding

• Give correct information to our patients and the general public
• Readily refer women who have problems with breast feeding to lactation consultants
• Do not accept sponsorship, free gifts from milk powder companies

1. Have a written breastfeeding policy that s routinely communicated to all health care staff
2. Train all health care staff in skills necessary to implement this policy
3. Inform all pregnant woman about the benefits and management of breast feeding
4. Help mothers initiate breastfeeding within 1/2 hour of birth (or as early as possible)
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants
6. Give newborn infants no food or drink other than breast milk unless medically indicated
7. Practice rooming-in - allow mothers and infants to remain together 24 hours a day
8. Encourage breast feeding on demand
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants ("nipple confusion")
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

• Adequate caloric intake is still needed
• Adequate protein intake should be maintained
• Adequate calcium intake
• Adequate vitamin D (if inadequate exposure to sunshine)

• Congee or rice paste, complete cessation of milk (eg. with salty fish in poorer families near coastal region, cooked with meat but with meat strained before feeding)

Problems with the traditional weaning diet

• Low in calories and low in protein, therefore rate of growth of infant slows down
• Low in calcium
• Low in Vitamin D (rickets if lack of sunshine)

Hong Kong data from the Department of Paediatrics, HKU

Change in weaning diet

• From congee without meat to Western ready made baby foods
• Continuation of milk and dairy products in various forms after introduction of other foods

Decrease in infant infection rate

• Mean episodes of infection in 1st year
• respiratory: 2.9 (1967), 2.1 (1994)
• diarrhoea : 0.9 (1967), 0.6 (1994)