BREASTFEEDING IN THE 21st CENTURY
Dr. Armida Fernandez *
Former Dean, LTMMC Hospital, Ex. Prof & Head, Dept of Neonatology, Mumbai.*
Malnutrition has been responsible, directly or indirectly for 60% of 109 million deaths among children, two-thirds of these deaths are associated with inappropriate feeding practices. (1) The child survival data in Lancet 2003, states that promotion of exclusive breastfeeding in the first six months is the single most effective intervention that will reduce under 5 child mortality by 13-15%.(2) Evidence in the 21 st century dictates that exclusive breastfeeding must continues for the survival of children.

Besides survival, breastfeeding is the ideal food for the physical, mental and emotional growth and contains a number of protective and bioactive factors that play an important part in the immuno-protection of the baby. Evidence suggests that breastfeeding has long-term benefits. It reduces the risk of insulin dependent diabetes mellitus, childhood cancer, obesity and inflammatory bowel disease. There is also evidence to suggest that breastfeeding improves intelligence and cognition functions particularly in preterm babies.(3) Besides there are additional benefits of breastfeeding for the mother - it reduces the chances of a next pregnancy for six months if the baby is exclusively breastfed, reduces the risk of ovarian and pre-menopausal breast cancer, coronary heart disease and osteoporosis.(4,5,6) Breastfeeding not only saves lives but saves the family enormous finance, which is of particular importance in country like ours. Scientific evidence of these various benefits of breastmilk has reversed the declining trend of breastfeeding in the western world. More and more mothers are breastfeeding their babies. In the Indian context though breastfeeding was the social norm there was an alarming decline of breastfeeding in the 80's.(7) The Baby Friendly Hospital Initiative promoted by the UNICEF / WHO has had impact in training health professional and hospital staff in the importance and the correct practices of breastfeeding. The World Breastfeeding Week celebrated from the 1 st to the 7 th August has also played an important role in the promotion of breastfeeding in the community.

There are several issues that need particular attention:

Insufficient breast milk: The commonest reason for introduction of alternative milks is that the mother feeds her milk is insufficient for the baby. The approach to this problem is to determine whether her milk is really insufficient for the baby. If the baby passes urine 6-7 times a day and is gaining adequate weight (15-30 grams/day, the mother is producing sufficient milk and all she needs is reassurance. If the baby is not gaining weight adequately it could be due to an incorrect technique and the mother needs to be taught correct positioning and latching of the baby to the breast. Wrong hospital practices of delayed first feed, infrequent feeds, use of prelacteals and pacifiers and bottle feeds can come in the way of milk production.

The best way to increase milk production is to advice the mother to feed her baby frequently, in the correct position. The best galactogogue is increasing the mother's confidence, supporting her in her efforts. Metocloprapamide has been found useful. Health professionals play an important role in promoting breastfeeding right through the antenatal, postnatal period and the first 6 months of life. Support from family and other mothers who had successfully breastfeeding is of help.

HIV and Breastfeeding : HIV passes via breastfeeding to about 1 out of 7 infant born to HIV-infected women. Analysis of available data shows that the maximum risk of transmission is during labour. However in many situations where there is a high prevalence of HIV, the lack of breastfeeding is associated with a 3 to 5 fold increase in mortality. There are certain factors that increase the risk for postnatal transmission of HIV. In the mother, recent infection, poor immune status, increased plasma viral load, local breast infection are high risk factors. The longer the duration of breastfeeding, greater the risk (8). Non-exclusive breastfeeding also increases the risk (8). Other risk factors in the baby include prematurity and lesions in the mouth and intestine. The dilemma in resource poor countries is whether to breastfeed give replacement feeds to the baby. A recent review by Smith (9) postulates some biological explanation why exclusive breastfeeding many pose less risk for HIV transmission than partial breastfeeding some of which include decreased exposure to dietary antigens and enteric pathogens. Biology factors in milk help modulate infant's immune response.
The decision to breastfed or not should be taken by the mother it should be on informed decision where the risk of breastfeeding and not breastfeeding are clearly explained to the mother. In environments where replacement feeding is safe, acceptable, feasible affordable, and sustainable avoidance of breastfeeding by all HIV positive women is recommended from birth.(10)

Use of breastmilk in the NICU: Critical illness in babies generally precludes enteral feeding in the NICU. However the recognition that small volume of breastmilk promotes maturation of gut function has encouraged the use of early enteral feeding of both sick term and preterm babies in the NICU.(11) Such trophic feeds are of particular importance in developing countries where parenteral feeding may be expensive and difficult. Babies started on trophic feeds i.e., nutritionally inconsequential amounts of fees have been shown to have improved tolerance of enteral feeds, more rapid achievement of full breastfeeds and lesser incidence of NEC and reduced hospital stay. These findings underline the importance of starting early feeds of expressed breastmilk in sick babies in the NICU.(12)

Human milk feeding in VLBW babies: Since the first report by Atkinson et al of a higher concentration of nitrogen in preterm milk compared with milk of mothers at term, several publications have delineated the differences in composition relative to gestational age.(13) Higher concentration of nitrogen, immune proteins, total lipid, medium chain fatty acids, energy, vitamins and sodium have been reported.(14) However controversy yet exists regarding the adequacy of preterm milk to sustain long-term growth and development. Based on the higher reported protein content of preterm human milk at one, two and four weeks, protein intake of 3.9 - 2.8 gms/kg can be achieved from mother's milk alone if fed in volumes more than 160 ml/kg/day.(15) After the first month of lactation, protein supplements to mother's milk may be necessary to meet recommended protein intake especially in VLBW babies.

Fortification of Human milk: For infants more than 32 weeks or above 1500 grams birth weight, fortification of mother's milk is not necessary. Babies less than 1000 grams birth weight or those with a prolonged, difficult perinatal course may require fortification especially for sodium, phosphorus and protein status.(16)

Working Women and Breastfeeding: The workforce of women is on the increase be it in rural or urban setting. Exclusive breastfeeding poses a special problem to women who work outside the home. Working mothers can be given some alternatives. The first is to extend maternity leave for six months if possible. Use facilities of a crèche if available at the work place. Working mother should also be taught and asked to express milk. Months before she resumes work. This milk can be stored in stainless steel or polypropylene containers in the deep freeze for a period of 3 months and for 24 hours in a refrigerator. When needed, milk should be defrosted at room temperature and warmed in lukewarm water and fed to the baby with a spoon and cup. Once a mother returns from work she can continue to feed the baby when at home or during holidays should expressed milk can be feed to the baby while she is at work.
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