BREASTFEEDING

ELAINE EUSTACE PEREIRA

1001A76020

LEARNING OUTCOMES
Differences between human and
infant formula milk
Cleft lip and cleft palate

DIFFERENCES
BETWEEN HUMAN &
INFANT FORMULA MILK

Composition of Mature Human Milk,

Cows Milk & Infant Formula

Human Milk Versus Formula Milk

Mature Human Milk

Contains 7 % carbohydrate as lactose, 3-5 %
fat & 0.9 % protein
Energy content is 60 75 kcal / dL
Approximately, 25 % of total nitrogen
represents non-protein compounds (eg. urea,
uric acid, creatinine & free amino acids)
Principal proteins are casein, alphalactalbumin, lactoferrin, IgA, lysozyme &
albumin
Fatty acid composition is rich in palmitic &

Colostrum
Premilk secretion
A yellowish alkaline secretion that may be
present in the last months of pregnancy & for
the first 2 - 3 days after delivery
Higher protein, vitamin A, immunoglobulin,
sodium & chloride content than breast milk
Lower carbohydrate, potassium & fat content
than mature breast milk
Has a normal laxative action & is an ideal
natural starter for food

Advantages of Breastfeeding
For Mother

For Infant

Helps to contract the uterus & Breast milk is digestible, of

accelerates the process of
ideal composition, available at
uterine involution in the
right temperature & right time,
postpartum period
free of bacterial contamination
Promotes mother infant Decreased
incidence
of
bonding & self confidence
diarrhea, lower respiratory tract
Gastrointestinal motility &
infection, urinary tract infection
absorption enhanced
& otitis media
Ovulatory cycles delayed
Decreased risk of developing
Helps to protect against preinsulin dependent diabetes,
menopausal cancer & ovarian
Crohns disease, ulcerative
cancer
colitis & allergic diseases later
in life

CLEFT LIP (CL) &

CLEFT PALATE (CP)

Embryology
The upper lip is derived from medial nasal and
maxillary processes
Failure of merging between the medial nasal and
maxillary processes at 5 weeks of gestation on one or
both sides results in cleft lip
CL usually occurs at the junction between the central
and lateral parts of the upper lip on either side. The
cleft may affect only the upper lip or it may extend
more deeply into the maxilla and the primary palate.
(Cleft of the primary palate includes CL and cleft of
the alveolus)
If the fusion of palatal shelves is impaired also, the CL
is accompanied by CP forming the CLP abnormality

Etiology
Caused by the interaction
environmental factors

between

genetic

&

Genetics ( 2-8 %)
Chromosomal disorders ( 15 %)
Drugs ( maternal anti - convulsant drugs)
Infections ( rubella during pregnancy)
Alcohol, smoking
Malnutrition ( dietary & vitamins deficiencies eg. folic
acid, vitamin A )

 Cleft lip can occur either unilaterally (on the left or

right) or bilaterally
The line of cleft always starts on the lateral part of the
upper lip and continues through the philtrum to the
alveolus between the lateral incisor and the canine
tooth
The clefting anterior to the incisive foramen (ie. lip
and alveolus) is also defined as a cleft primary palate

 Several subtypes of CP can be diagnosed on the basis

of severity
The uvula is the place where the minimal form of
clefting of the palate is observed
A more severe form is a cleft of the soft palate
A complete CP constitutes a cleft of the hard palate,
soft palate and cleft uvula
The clefting posterior to the incisive foramen is
defined as a cleft of secondary palate

Feeding of Infant With Cleft

The vast majority of children with cleft lip and palate
anomalies are born with a normal birth weight
However, because of feeding difficulties, the most
common problem the pediatrician has to deal with is
insufficient weight gain
One of the pediatrician's main responsibilities is to
closely monitor the infant's weight. Pediatricians may
supervise mothers themselves or may refer them to a
nutritionist, feeding specialist or experienced nurse
practitioner

 Most children born with CLP are unable to be

breastfed
Those with CP cannot produce the negative pressure
necessary for suction
Mothers of children with a unilateral CL may succeed
with breastfeeding when the child is positioned so
that the cleft in the lip is obstructed by the mother's
breast

 Most infants can complete a feeding in 18-30 minutes

If more than 45 minutes is required, the infant may be
working too hard and may be burning calories that
should be used for weight gain
An infant who nurses or bottle feeds every 3 to 4
hours tends to gain weight better than an infant who
feeds frequently (feedings < 2 hours apart) for short
periods

Hints for Breastfeeding

In a case of an isolated CL, the infant typically does
not experience feeding problems beyond learning
how to "latch on" to the nipple at the beginning of
the feeding
Infants with CP must squeeze the milk out of the
nipple by compressing the nipple between the
tongue and whatever portion of the palate that
remains
Massaging the breast and applying hot packs on the
breast 20 minutes before nursing usually helps

 The mother should apply pressure to the areola with her

fingers to help the engorged nipple protrude
Mother should hold the infant in a semi-upright position
She should support the breast by holding it between her
thumb and middle finger, making sure that the infant's
lower lip is turned out and the tongue is under the nipple
If the infant cannot hold onto the nipple anymore, the
mother can collect the remaining milk using an
electrical or manual breast pump or by squeezing the
breast with both hands and can finish the feeding with
collected milk in a bottle
The mother should increase her fluid intake by drinking
larger quantities of water

Special Needs Bottle - Haberman

Multidisciplinary Approach
Pediatrician
Nurse practitioner
Plastic surgeon
Pediatric dentist
Otolaryngologist
Genetic counselor
Speech pathologist
Orthodontist
Maxillofacial surgeon
Social worker
Psychologist

Common Treatment Protocol

Newborn

Perform diagnostic examination, general

counseling of parents, feeding instructions

Age 3 months

Repair of CL (and placement of ventilation

tubes)

Age 6 months

Pre-surgical
evaluation

Age 9 months
Age 9 12 months

Speech therapy begins

Repair of CP (placement of ventilation tubes if
not done at the time of CL repair)

Age 1 7 years
Age 7 8 years
Older than 8 years

Orthodontic treatment
Alveolar bone graft
Orthodontic treatment continues

orthodontics,

first

speech

References
Books
Lissauer T, Clayden G. Illustrated Textbook of Paediatrics (4 th
edition)
Alan H, Lauren N, Ashley S. Obstetrics & Gynecology
Current Diagnosis & Treatment (11th edition)
Online Sources
Available from : http://www.nhmrc.gov.au/_files_nhmrc/publications/attachme
nts/n56_infant_feeding_guidelines.pdf
http://www.unicef.org/malaysia/Breastfeeding_-_BFHI.pdf
http://emedicine.medscape.com/article/995535-overview#a2
http://www.cleftline.org/docs/Booklets/FDG-01.pdf

THANK
YOU!

Neonatal Jaundice

Thatsinee Jegathesan
1101Q12613
Batch 2

What is Neonatal Jaundice?

The yellowish discolouration of the skin and sclera in
newborns.
accumulation of conjugated or unconjugated bilirubin.

Clinically detected when serum bilirubin rises above 5mg/dL.

Causes of Neonatal Jaundice

Prolonged Jaundice

Visible jaundice (or serum bilirubin >

85mol/L) that persists beyond 14 days of life
in a term infant or 21 days in a preterm infant

Physiological Jaundice
Non-pathologic unconjugated hyperbilirubinemia
Common cause of hyperbilirubinemia among newborns.
In most infants, unconjugated hyperbilirubinemia reflects a
normal transitional phenomenon
Levels usually do not exceed 15 mg/dl.
Usually appears between 24-72 hours of age, peaks by 4-5
days in term and 7th day in preterm neonates and disappears by
10-14 days of life

 Causes of Physiological Jaundice

Increased bilirubin load
Defective uptake from plasma
Defective conjugation
Decreased excretion
Increased entero-hepatic circulation

Disappears without any treatment

Should be observed closely for any signs of
worsening jaundice.

Breastfeeding Jaundice

Jaundice in breast-fed babies usually appears between 24-72 hours of age,

peaks by 5-15 days of life and disappears by the third week of life.
Due to inadequate milk intake
Leading to dehydration and/or
Low calorie intake weight loss
Decreased frequency of breast-feeding is associated with exaggeration of
physiological jaundice.
Poor breastfeeding with inadequate caloric intake during the first days of
life:
Increases intestinal absorption of unconjugated bilirubin,
Delays meconium (a reservoir of unconjugated bilirubin) emptying
Enhances transfer of bilirubin from meconium into infants circulation

Breast Milk Jaundice

Type of neonatal jaundice associated with breastfeeding.
Characterized by indirect hyperbilirubinemia in a breastfed newborn that
develops after the first 7 days of life, (peaking at 2nd/3rd week of life)
persists longer than physiologic jaundice, and has no other identifiable
cause.
A diagnosis of breast milk jaundice should be considered if the serum
bilirubin is predominantly unconjugated, other causes of prolonged
jaundice have been excluded and the infant is in good health, vigorous
and feeding well and gaining weight adequately.
Cause/etiology is still not yet understood

 Possible causes:
Progesterone metabolite (pregnane-3-alpha 20 beta-diol) inhibits uridine
diphosphoglucuronic acid (UDPGA) glucuronyl transferase
Increased concentrations of nonesterified free fatty acids that inhibit hepatic
glucuronyl transferase
Increased enterohepatic circulation of bilirubin due to (1) increased content of
beta glucuronidase activity in breast milk and, therefore, the intestines of the
breastfed neonate and (2) delayed establishment of enteric flora in breastfed
infants
Increased inflammatory cytokines in human milk (interleukin (IL)-1 beta and
IL-6) in breast milk cholestatic and reduces uptake, metabolism and
excretion of bilirubin
High epidermal growth factor (EGF) levels in breast milk reduces GI
motility and increases bilirubin absorption and untake
Over time, the jaundice and elevated serum unconjugated bilirubin decline to
normal adult values even while breastfeeding continues.
The rate of decline is highly variable from infant to infant

Treatment
Prevention of potentially toxic serum bilirubin concentrations
Early initiation of breastfeeding preferably in the first hour after birth
Encourage exclusive breastfeeding and frequent feeds
DO NOT STOP BREASTFEEDING
Optimizing breastfeeding management from the beginning
American Academy of Pediatrics (AAP) guidelines states that , for
every newborn born at 35 or more weeks of gestation, health
practitioners should promote and support successful breastfeeding
Recommendation 1.0: Clinicians should advise mothers to nurse their
infants at least 8 to 12 times per day for the first several days

Treatment

Education on early feeding cues

Identification of at-risk mothers and babies
Both maternal (e.g., diabetes, Rh sensitization) and infant-related (e.g.,
bruising, prematurity, ABO disease) health factors may increase the
likelihood of an infant developing significant hyperbilirubinemia.
These factors can be additive with starvation jaundice and or breast
milk jaundice and produce even higher bilirubin levels than would
otherwise be seen.
When such risk factors are identified it is prudent to seek lactation
consultation in the early hours after delivery to assure optimal
breastfeeding management.

Treatment
Phototherapy
Once the baby is on phototherapy, visual observation as a means of
monitoring is unreliable. Serum bilirubin levels must guide the
management
Post phototherapy, visual observation is unreliable & TSB level must
guide the management!
Hospital discharge need not be delayed to observe for rebound jaundice,
and in most cases, no further measurement of bilirubin is necessary.

 If the TSB level does not decrease/ continues to rise,

intensive phototherapy is indicated.

 Failure of phototherapy has been defined as

an inability to observe a decline in bilirubin of
1-2 mg/dl (17-34 mol/L) after 4-6 hours and/or
to keep the bilirubin below the exchange
transfusion level.
If the condition remains despite the intensive
phototherapy, this strongly suggests haemolysis
Do an immediate exchange transfusion if
infant shows signs of acute
bilirubin
encephalopathy
(hypertonia,
retrocollis
opisthotonus, fever, high pitch cry) or if TSB
is 5 mg/dL (85 umol/L) above exchange levels.
Use total bilirubin level. Do not subtract
direct or conjugated bilirubin.
During birth hospitalisation, ET is recommended
if the TSB rises to these levels despite intensive
phototherapy.
Infants who are of lower gestation will require
phototherapy and ET at lower levels, (please

References
Ismail HIHM, Ng HP, Thomas T. Paediatric Protocols for Malaysian
Hospitals. 3rd ed. Kementerian Kesihatan Malaysia. 2015.
The Academy of Breastfeeding Medicine Protocol Committee. ABM
Clinical Protocol #22: Guidelines for Management of Jaundice in the
Breastfeeding Infant Equal to or Greater Than 35 Weeks Gestation.
Breastfeeding Medicine. Nov 2010; 5(2):DOI:
10.1089=bfm.2010.999. Available from:
http://www.bfmed.org/Media/Files/Protocols/Protocol%2022%20Jaund
ice.pdf
Deshpande PG, Windle ML, Carter BS, el al. Breast milk jaundice.
Medscape. Available from:
http://emedicine.medscape.com/article/973629-overview
http://www.newbornwhocc.org/pdf/jaundice.pdf

Cows Milk Allergy

Adverse reactions to cows milk can occur at any age from birth, but
not all such reactions are allergic in nature.
Terms such as milk allergy, milk intolerance and milk
hypersensitivity are often used interchangeably, despite
representing different conditions.
A recent revision of the allergy nomenclature, endorsed by the
World Allergy Organization, defines any adverse reactions to milk
as milk hypersensitivity and can be divided into immune- mediated
hypersensitivity (milk allergy) and non-immune-mediated
hypersensitivity (milk intolerance).
CMPA can be further divided into IgE-mediated CMPA and nonIgE-mediated CMPA.

 Prevalence of CMP allergy vary from 2 7.5%, with highest

prevalence during the 1st year of life
CMP allergy immunological reaction towards a protein(s)
in the milk
Lactose intolerance difficulty in digesting lactose (sugar)
IgE-mediated CMPA is thought to manifest as a phenotypical
expression of atopy; it may co-exist with atopic eczema,
allergic rhinitis and/ or asthma.
Non-IgE-mediated CMPA, however, is probably cell-mediated
and presents mainly with gastrointestinal symptoms.

Cows Milk Allergy

IgE-mediated (early reaction within 2hours )

Urticaria
Facial swelling
Anaphylaxis
Angiooedema
Vomiting
Acute flare of atopic dermatitis.
Non IgE-mediated (late onset from hours to days)
Vomiting
Diarrhoea
Abdominal pain
Atopic dermatitis
Pallor
Respiratory symptoms

Diagnosis

The most helpful screening tests for IgE-mediated food allergy

are skin-prick tests and measurement of specific IgE
antibodies in blood (RAST test).

Diagnosis relies on clinical history and examination.

Both tests may yield false-positive results, but the greater the response, the
more likely the child is to be allergic
Skin-prick test only positive in IgE-mediated
Non-IgE-mediated food allergies are harder to diagnose.
For both IgE-mediated and non-IgE-mediated food allergies, the gold
standard investigation in cases of doubt is exclusion of the relevant food
under a dietitians supervision, followed by a double-blind placebo
controlled food challenge.
This involves the child being given increasing amounts of the food or
placebo, starting with a tiny quantity, until a full portion is reached.
The test should be performed in hospital with full resuscitation facilities
available, and close monitoring for signs of an allergic reaction.

Management of CMPA
Key principles in the management of CMPA:
The key principle in the management of CMPA, regardless of the clinical
type, is dietary elimination of CMP
A substitute formula may not be necessary in infants who are breastfed and
children above the age of 2 years
Replacement of cows milk with a substitute formula is recommended for
children below the age of 2 years and non-breastfed children

Malaysian Society of Allergy and Immunology. Guidelines on the management of cows milk protein
allergy in children 2012

Strategies for the management of cows milk

protein allergy
Exclusively breastfed children
Avoidance of CMP is essential.
It takes an average of 24 weeks for symptoms to improve or disappear
Formula-fed children
Avoidance of CMP from the diet is essential.
Extensively hydrolysed formula (EHF) is recommended as a substitute to
cows milk formula in mild-to-moderate cases.
Amino acid formula (AAF) is recommended for infant presenting with
anaphylaxis, allergic eosinophilic oesophagitis or if the symptoms in mildto-moderate cases do not improve on EHF after 24 weeks.

References
Malaysian Society of Allergy and Immunology. Guidelines on
the management of cows milk protein allergy in children
2012.
http://www.allergymsai.org/file_dir/6296706325048109343baa
.pdf
Nocerino A, Guandalini S, Windle ML, et al. Protein
Intolerance. Medscape. Available from:
http://emedicine.medscape.com/article/931548-overview
Lissauer T, Glayden G. Illustrated textbook of Paediatrics, 4th
edition

BREASTFEEDING:
SOYA- BASED MILK &
CURRENT BEST
PRACTICES
CHIN ZHEN HUA
0308533
TAYLORS UNIVERSITY
PROF EUGENE

SOYA- BASED MILK

Introduction
Soy protein-based formulas have been available for almost 100
years.
Since the first use of soy formula introduced in 1929 as a milk
substitute for an infant unable to tolerate
a cow milk protein-based formula, the
formulation has changed to the current soy
protein isolate.

SOYA- BASED MILK

Composition
All isolated soy protein based formula are free of cow milk
protein and lactose, provide total energy of 67 kcal/dL.
All are iron-fortified and meet the vitamin, mineral, and
electrolyte specifications addressed in the 2004 guidelines from
the AAP for feeding term infants and established by the US Food
and Drug Administration.
The protein is a soy isolate supplemented with L-methionine, Lcarnitine and taurine.
The fat content is derived from vegetable oils.

SOYA- BASED MILK

Phytoestrogens in soya- based formula
Consist of several groups of non- steroidal oestrogens, including
isoflavones, which commonly found in soybeans.
Concern raised include potential negative effects on sexual
development and reproduction, neuro- behavioral
development, immune function, and thyroid function.

SOYA- BASED MILK

Phytoestrogens in soya- based formula
On the other hand, epidemiology studies suggested protective
effect of isoflavones against coronary heart disease, breast and
endometrial cancer
In summary, although studied done by numerous investigators in
various species, there is no conclusive evidence that dietary soy
isoflavones may adversely affect human development,
reproduction or endocrine function. Furthermore, there have been
no specific health problems documented in human infants
receiving soy formula.

SOYA- BASED MILK

Use of soya- based milk in term infants
Numerous studies have documented normal growth and
development in term neonates fed with isolated soy protein-based
formulas.
Average energy intakes in infants receiving soy protein-based
formulas are equivalent to those achieved with cow milk
formulas.

SOYA- BASED MILK

Use of soya- based milk in preterm infants
Soy protein-based formulas are not recommended for preterm
infants. Serum phosphorus concentrations are lower and alkaline
phosphatase concentrations are higher in preterm infants fed soy
protein-based formula than preterm infants that fed cow milkbased formula, which then lead to osteopenia.

SOYA- BASED MILK

Use in infants who has cows milk allergy
Prospective studies suggest that soy- protein based formula has
no relative value in the prophylaxis or prevention of allergic
disease compared to cow milk formula
The Committee of the American Academy of Paediatricians
recommend against the use of soy formula in infants who are
potentially allergic to cows milk

SOYA- BASED MILK

Use in colic and formula intolerance
The most common reason for use of soy formulas by infant care
providers is for relief of symptoms of formula intolerance
(spitting, vomiting, fussiness, colic)
Colicky discomfort is described by the parents during the first 3
months of age. Although many factors have been implicated,
parents frequently seek relief by changing infant formulas.

SOYA- BASED MILK

Use in disorders of carbohydrate metabolism
When strict dietary lactose elimination is required in the
management of infants with galactosemia or primary lactase
deficiency, soy protein-based formulas are safe and costeffective

SOYA- BASED MILK

Recommendation
In term infants whose nutritional needs are not being met from
maternal breast milk or cow milk-based formulas, isolated soy
protein-based formulas are safe & effective alternatives to
provide appropriate nutrition for normal growth & development.

CURRENT BEST PRACTICES

Review of evidence has shown that, on a population basis,
exclusive breastfeeding for 6 months is the optimal way of
feeding infants.
Thereafter infants should receive complementary foods with
continued breastfeeding up to 2 years of age or beyond.

CURRENT BEST PRACTICES

CURRENT BEST PRACTICES

Advantages of breastfeeding for infants
Provides the ideal nutrition for infants during the first 4 6
months of life
Life saving in developing countries
Reduces the risk of gastrointestinal infection
Enhances mother- child relationship
Reduces risk of insulin- dependent diabetes, hypotension and
obesity in later life

CURRENT BEST PRACTICES

Advantages of breastfeeding for mother
Promotes close attachment between mother and baby
Increase time interval between children
Helps with a possible reduction in premenopausal breast
cancer

CURRENT BEST PRACTICES

Complications of breastfeeding

Transmission of infection
Breast milk jaundice
Transmission of drugs
Nutrient inadequacies
Vitamin K deficiency
Potential transmission of environmental contaminants
Less flexible

CURRENT BEST PRACTICES

While breastfeeding is a natural act, it is also a learned behaviour.
An extensive body of research has demonstrated that mothers and
other caregivers require active support for establishing and
sustaining appropriate breastfeeding practices.
WHO and UNICEF launched the Baby-friendly Hospital
Initiative in 1992, to strengthen maternity practices to support
breastfeeding. There is a total of 125 baby-friendly hospitals in
the country

CURRENT BEST PRACTICES

Protecting, Promoting and Supporting Breastfeeding

CURRENT BEST PRACTICES

40-hour Breastfeeding Counselling by WHO and UNICEF:
A training course to train a cadre of health workers that can
provide skilled support to breastfeeding mothers and help them
overcome problems, so that they become competent and able to
promote appropriate breastfeeding, complementary feeding and
feeding of infants in the context of HIV.

CURRENT BEST PRACTICES

Recommendation from MOH

Prepare for breastfeeding during pregnancy

Initiate breastfeeding within one hour of birth
Breastfeed frequently and on demand
Give only breast milk to baby below 6 months with no
additional fluid or food

CURRENT BEST PRACTICES

Recommendation from MOH
Continue to give babies breast milk even if the baby is not
with the mother
Introduce complementary foods to baby beginning at 6 months
of age
Lactating mother should get plenty of rest, adequate food and
drinks to maintain health
Husbands and family members should provide full support to
lactating mother

CURRENT BEST PRACTICES

CURRENT BEST PRACTICES

Acceptable reasons for use of breast milk
substitute

CURRENT BEST PRACTICES

CURRENT BEST PRACTICES

Mother who need to avoid breastfeeding
HIV infection
Herpes simplex virus type 1
Maternal medication:
Sedating psychotherapeutic drugs, anti- epileptic drugs and opioids that
cause side effects such as drowsiness and respiratory depression
Cytotoxic chemotherapy requires that mother stop breastfeed during
therapy

REFERENCES
Tom Lissauer, Graham Clayden. Illustrated Textbook of
Paediatrics. 4th edition. U.K.: Mosby Elsevier; 2012
http://
www.moh.gov.my/images/gallery/Garispanduan/diet/km12.pdf
http://
pediatrics.aappublications.org/content/pediatrics/121/5/1062.ful
l.pdf
http://news.bbc.co.uk/2/hi/health/1998946.stm
http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/