Episode 131: Breastfeeding Part 2. Lia and Aruna explain some updates given by the American Academy of Pediatrics regarding breastfeeding. Dr. Arreaza adds some comments about breastfeeding. Written by Aruna Sridharan, MS4, and Lia Khachikyan, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.
Episode 131: Breastfeeding Part 2
Lia and Aruna explain some updates given by the American Academy of Pediatrics regarding breastfeeding. Dr. Arreaza adds some comments about breastfeeding.
Written by Aruna Sridharan, MS4, and Lia Khachikyan, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.
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The motivation for this episode was a recent publication by the American Academy of Pediatrics, on June 27, 2022, titled Policy Statement: Breastfeeding and the Use of Human Milk. During this episode, we included updated information along with other useful material.
Duration of breastfeeding:
The American Academy of Pediatrics (AAP), World Health Organization (WHO), and Center of Disease Control (CDC) recommend exclusive breastfeeding at least for the first 6 months, after which one can start to introduce complementary pureed foods. The US Department of Agriculture states that initiating complementary foods earlier than 6 months offers no benefit to the baby and can even be associated with a higher risk of overweight or obesity, especially if introduced before 4 months. Mothers are then encouraged to continue breastfeeding for at least one year and can further continue up to 2 years of age or longer - as long as mutually desired by mother and child. This is an update from previous recommendations regarding the duration of breastfeeding until 1 year of age.
Composition of human breastmilk:
As the sole source of nutrition for infants in the first 6 months of life, breast milk plays a critical role in development. Human milk has a unique composition of proteins, fats, and lactose, as well as vitamins, electrolytes, antimicrobial, anti-inflammatory immunoregulatory agents, and living leukocytes, all of which contribute to the developing immune system of the child. Breast milk is rich in Vitamins B1, B2, and B6, Vitamins C, A, E, Ca, Mg, phosphate, and folate.
However, it is low in Vitamins K, D, B12, and iron, therefore supplementation of these nutrients is required. It is important for mothers to consume an adequate and healthy diet for their breastmilk to contain appropriate levels of these nutrients.
Water-soluble and Fat-soluble vitamins can be low in breast milk if the mother has a deficiency. Selenium can be low if maternal serum levels are low. Dietary iodine deficiency may also be exacerbated by smoking; iron deficiency; and consumption of large amounts of foods that interfere with the production of thyroid hormones, known as goitrogens, including Brussels sprouts, kale, cabbage, cauliflower, and broccoli.
Maternal diet:
Mothers should consume iodine-rich foods, such as lean meat, eggs, dairy, beans, and lentils. It is important to choose a variety of whole grains, as well as fruits and vegetables, and continue taking multivitamins. Fun fact: Different foods will change the flavor of your breast milk. This will expose your baby to different tastes, which might help him or her more easily accept solid foods down the road! It is recommended that mothers consume 290 mcg of iodine and 550mg of choline a day.
Is there anything that mothers should avoid in their diet?
-Limit seafood: Although fish is a good source of protein and lean meat, it contains some mercury, which can be transferred to the baby’s diet. High amounts of mercury can have an adverse effect on the baby’s brain and nervous system.
-Limit caffeine: Also, we know a lot of people love their morning dose of espresso! Low to moderate amounts, equivalent to 2-3 cups of coffee per day, do not adversely affect the infant. However, anything more than around 300 mg of caffeine can cause irritability, poor sleeping patterns, fussiness, and jitteriness. Remember! This also includes sodas, energy drinks, tea, and even chocolate! As a reminder, one cup of coffee can have 95mg of caffeine.
Vegan mothers: Vegetarian/vegan mothers may have very limited amounts of vitamin B12 in their bodies, which can result in neurological damage to the baby. Iron levels may also be sparse since plant-based foods only contain non-heme iron, which is less absorbable than heme iron. The American Dietetic Association recommends supplementation of vitamin B12, iron, and other nutrients such as choline, zinc, iodine, or omega-3 fats.
Benefits:
For the baby: Studies show that exclusively breastfeeding for 6 months decreased rates of neonatal and infant mortality as well as pediatric disorders such as otitis media, diabetes mellitus, obesity, lower respiratory tract disorders, asthma, atopic dermatitis, sudden infant death syndrome (SIDS), severe diarrhea, and inflammatory bowel disease. The longer an infant is breastfed, the greater the protection from certain illnesses and long-term diseases.
For the mother: The longer a mother breastfeeds, the greater the benefits to her health as well. Mothers who breastfeed experience a lower risk of hypertension, type 2 diabetes, and breast, ovarian, and endometrial cancers.
Contraindications:
-Alcohol: Having up to 1 drink per day is not harmful to the baby, especially if the mother waits at least 2 hours before feeding the infant. This allows time for the blood alcohol concentration in the breastmilk to decrease. Consuming more than 2 standard alcoholic drinks daily is highly discouraged.
-Tobacco: Cigarette smoking, or the use of nicotine products, is associated with decreased production of milk, shorter lactation time, and an increased risk of SIDS, asthma, and other respiratory illnesses in infants. Therefore, mothers should be strongly encouraged to stop smoking and minimize secondhand exposure. We know it is very difficult for people to quit abruptly. While transitioning to cessation, mothers should be counseled to smoke right after breastfeeding to allow the greatest amount of time for nicotine to exit the body until the next feed. Other cessation alternatives such as the patch or gum can also be used during breastfeeding.
Varenicline: No human data is available to assess the risk of infant harm, but it is likely excreted in the milk, no data on the assessment of milk production.
-Other substances: Marijuana, opioids, amphetamine, cocaine, and other illicit drugs are contraindicated due to their effects on neurodevelopmental behaviors. If these substances have been used intrapartum or during breastfeeding, it is important to monitor the baby for Neonatal Abstinence Syndrome. Some symptoms include poor weight gain, tremors, high-pitched crying, stuffy nose, poor feeding/sucking, seizures, irritability, poor sleep, vomiting, and diarrhea.
-Maternal infections: Breastfeeding is not contraindicated during most maternal infections. Some exceptions include HIV, Human T-cell lymphotropic virus type I or II, untreated brucellosis, Ebola virus, or active Herpetic lesions on the breast. Women with herpetic lesions may breastfeed from the unaffected breast.
-Maternal medications: Medications are relatively safe for breastfed babies, but some contraindications include anticancer drugs, oral retinoids, lithium, iodine, and amiodarone. Mothers should go over their medication list with their primary physician.
Pregnancy and Lactation Labeling Final Rule (PLLR): Classification of drugs according to their impact on pregnancy and breastfeeding (categories A, B, C, D, X) was started in 1979, but it was stopped in 2015 and replaced by the Pregnancy and Lactation Labeling Final Rule (PLLR). The former categories were replaced with narrative sections and subsections to include: Pregnancy (including labor and delivery), Lactation, and information for Females and Males of Reproductive Potential (pregnancy testing, contraception, infertility).
Role of the physician and stigmas:
It is well known that breastfeeding can strengthen the bond between the mother and her child. Therefore, when latching becomes a problem, mothers are quick to become discouraged. If this happens, pediatricians should educate the parents that many breastfeeding problems commonly arise between 4-7 days after birth. Sometimes, exclusive or any amount of breastfeeding is not always possible, despite the mother’s best intentions. This can understandably cause them to feel a lot of guilt and disappointment as a new mother.
Physicians should provide a safe, non-judgmental environment for the parents to openly discuss their difficulties while educating them on proper latching techniques and other alternatives for breastfeeding.
Conclusion: Now we conclude our episode number 131 “Breastfeeding Part 2.” Aruna and Lia explained that the American Academy of Pediatrics now recommends continued breastfeeding until 2 years or as long as the mother and the baby desire it. It is important to remember some contraindications such as babies with galactosemia, mothers who are using illicit drugs, and some maternal infections such as HIV, untreated brucellosis, and Ebola virus.
This week we thank Hector Arreaza, Aruna Sridharan, and Lia Khachikyan. Audio editing by Adrianne Silva.
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