Breast Milk & Breast Feeding & SAM & NRC

Breast Milk & Breast Feeding

Initiation of Breast Feeding

• As soon as possible.

• WHO recommends within 1 hour of childbirth
• irrespective of vaginal delivery or cesarean section

Exclusive Breast Feeding

• Baby should be fed only breast milk and nothing else.

• Not even sips of water unless medically indicated.

• Recommended for first 6 months of life exclusively.

Complementary feeding

• Initiated at 6 months.

• It is defined as semi-solid, energy-dense food.
• Given in addition to breast milk.

Frequency & Consistency

Nutrient-Rich Additions

• Add ghee, oil, jaggery, pulses, eggs, milk, vegetables, fruits.

• Ensure iron- and vitamin A–rich foods (green leafy vegetables, meat, liver, fortified foods).

Avoid

• Thin watery foods (low calorie).

• Sugar water, tea, coffee, biscuits, junk food.

• Bottle feeding (risk of infection, nipple confusion).

Characteristics of food items used for complementary feeding

• Mnemonic: AFASS

• Acceptable

• Feasible

• Affordable

• Sustainable

• Safe

Storage of Expressed Breast Milk (EBM)

Factors affecting Breast Milk Output

• Q. When is the breast milk output maximum?
• At 5-6 months of lactation.
• Approx. 730 ml/day.

Milk Output Increased by

• Thought of baby

• Sight of baby

• Sound of baby

• Nighttime feeds

• Frequent feeding/Emptying of breasts

Milk Output Decreased by

• Maternal Stress,

• Anxiety

• Use of Top feeds/formula feeds

• Feeding bottle/pacifiers

• Maternal pain

Signs of Good Positioning while Breast Feeding

• Body of the baby should be well supported.

• Occiput, shoulders and buttocks of the baby should be in a straight line.

• The entire body of the baby should be turned towards the mother.

• The abdomen of the baby should touch the abdomen of the mother.

Signs of Good Attachment while Breastfeeding

• The mouth of the baby should be wide open.

• The entire areola should be in the baby's mouth
• except for a small upper part that may be visible.

• The lower lip of the baby should be everted/ turned out.

• The chin of the baby should touch the mother's breast.

Contraindications to Breast Feeding

Related to baby

• Galactosemia

• Congenital lactose intolerance

Related to mother

Absolute contraindications

• Mother on chemotherapy or radiotherapy

Relative contraindications

• Maternal HIV

• Maternal varicella involving the areola and nipple area

• Maternal untreated tuberculosis
• At least 3 weeks for the disease to become paucibacillary.

• Breast abscess

Composition of breast milk Vs Cow milk

Component	Breast Milk	Cow Milk
Lactose	• 2x buffalo milk • 7 g/dl Advantages • More energy as carbohydrate • Helps in formation of galactose & Lactobacillus in intestine	- 4.5 g/dl
Proteins	• 25% of buffalo milk. • 1 g/dl Advantages • Best quality protein • Higher in Soluble proteins • Lesser solute load on kidneys • Richer in whey proteins like Lactoglobulin (easily digestible) • Richer in Cysteine, Methionine (needed for CNS development)	- 3.5 g/dl
Lipids	• 50% of buffalo milk. • Richer in PUFA (polyunsaturated fatty acids) PUFA in Human Milk Major types: • Linoleic acid → precursor of arachidonic acid. • α Linolenic acid → precursor of docosahexaenoic acid (DHA). DHA (Docosahexaenoic acid) / Cervonic acid ↳ Important for CNS development (Promotes myelination)	ㅤ
Energy	• 50% of buffalo milk.	ㅤ
Minerals	• Ca : Phosphate = 2:1 → favours calcium absorption • Iron is more easily absorbable than in cow's milk	Richer in phosphate → hinders calcium absorption → ↑ risk of hypocalcemia
Vitamins	Contains all vitamins except: • Vitamin D, K, B12 • (especially in strictly vegan mothers)	ㅤ

• Casein : Albumin ratio = 1:1

• Vitamin C:
• maximum of all milk sources (↑ Iron absorption).

Breast Milk deficient

• Vitamin D (400 IU/day)
• Recommended to all babies till 1 year

• Vitamin K –
• Given to all babies
• 1 mg IM at birth
• Prevents hemorrhagic disease of the newborn

• Iron ???
• Adequate (↑ Bioavailability).

Babies predominantly cow milk fed:

• ↑ Risk of hypocalcemia, tetany, seizures

• ↑ Risk of scurvy
• Due to Vitamin C deficiency in cow's milk
• Vitamin C is heat labile (gets destroyed when cow's milk is boiled)

Breast milk contains Anti-infective substances

• Mnemonic - Teach for PLAB

• Transforming growth factor β

• Phagocytic macrophages

• Lactoferrin

• Lysozyme

• Antibodies especially IgA

• Bifidus factor

• Bile stimulated lipase

Breast Milk Protects Against Diseases Like

• Neonatal period:
• NEC, neonatal sepsis.

• Later in life:
• Obesity,
• HTN,
• diabetes,
• allergies,
• Bronchial asthma,
• Lymphoma.

• Breast Milk fed babies have higher IQ.

• Breast milk helps in maternal-child bonding.

• Breast milk is safe, free from contamination,

• easily available even in resource limited settings.

Colostrum

• Produced during the first 72 hours after the birth of the baby.

• Thick, yellowish coloured milk.

• Produced in small quantity.

• Rich in immunoglobulins IgA, phagocytic macrophages, low in lactose.

• Known as 1st immunization of the baby.

• Must be fed to all babies.
• Any form of prelacteal feeding is absolutely contraindicated.

Feed for Term baby in first 24 hours after delivery

• 60 ml/kg

Preterm Breast milk is richer in

• Mnemonic - S I P For Intelligent CNS

• Sodium

• Iron

• IgA

• Proteins

• Calories

• Fats also.

Depending on Each Feeding Session

• Complete emptying of each breast
• important because composition of foremilk and hind milk is different.

Fore Milk

• At the beginning of a feed.

• More thin & watery.

• Satisfies mainly the thirst of the baby.

Hind Milk

• At the end of a feed.

• More thicker and calorie dense.

• Richer in fat.

• Satisfies the hunger of the baby.

Under-Five Clinics:

• Elements:
• Promotive care
• Core
• Family planning
• Curative care
• Preventive care
• Health Education

Kangaroo mother care

• Elements (SAANS):
• Skin-to-skin (Hypothermia prevention)
• Airway disease prevention
• Ambulatory support
• Nutritional support (Exclusive breastfeeding)
• Support (Emotional)

Indication

• All stable low birth weight neonates

Components

1. Kangaroo position:
• Skin-to-skin contact

2. Kangaroo nutrition:
• Exclusive breastfeeding,
• no supplementation

3. Early discharge from hospital

Advantages

• Lesser chances of:
• Sepsis,
• Hypothermia
• Neonatal mortality

• Higher weight gain (better gain of anthropometric parameters)

• Earlier discharge from hospital

• Higher breastfeeding rates

STOP KMC

• baby attains 2.5 Kg or 37 weeks.

GOBI FFF

• Given by WHO/UNICEF.

• Aim: Promote child survival

• Components:
• Growth monitoring
• Oral rehydration solution
• Breastfeeding
• Immunization
• Female fertility
• Female literacy
• Food (Female nutrition)

BFHI, MAA, CLMC:

• Baby Friendly Hospital Initiative (BFHI):
• UNICEF initiative to promote child survival

• Mother’s Absolute Affection (MAA):
• Gov of India, MoHFW initiative to promote breastfeeding
• Normal delivery: Within 1 hour
• C-section: Within 4 hours

• Comprehensive Lactational Management Centers (CLMC):
• Promote breast milk donation
• CHCs & District hospitals:
• Breast pumps & breastmilk storage facilities (+)

Important Dates & Weeks

Date/Period	Event
April 14th	Ayushman Bharat Health & Wellness Centre Day
Last week of April	World Immunization Week
May 28th - June 8th	Intensified Diarrhoea Control Fortnight
August 1st - 7th	World Breastfeeding Week
September 1st - 7th	National Nutrition Week
November 15th - 21st	Newborn Week

Growth Charts

• Note:
• Trend of growth is most important;
• Location plot is not

• Used at Anganwadis (ICDS) for Weight for Age (general malnutrition)

• Curves:
• Curve 1: 97.5 percentile / + 2 SD
• Curve 2: -2 SD
• Curve 3: -3 SD

• Zones:
• Between +2 SD to -2 SD: Normal
• Between -2 SD to -3 SD: Mild-moderate malnutrition
• Below 3rd curve: Severe malnutrition

A baby presents for a routine examination in the outpatient department. A growth chart is utilized to record the baby's weight, which falls within the 85th - 95th percentile range. What is the present condition of the child?
A. Obesity
B. SAM
C. Overweight
D. Interpretation cannot be made without BMI

Malnutrition Indicators

• The best indicator of Acute Malnutrition:
• Decrease in weight for height (Wasting).
• Mnemonic: WHAt

• The best indicator of Chronic Malnutrition:
• Decrease in Height for age (Stunting).
• Mnemonic: HA

Weight for age:

• Marker: General/combined malnutrition (Acute on chronic)

• Most sensitive

• Low: <80% of expected

• Mnemonic: WHA → 70 - 80 (exam what nn prnj irunna 70-80)
• Wasting
• Between
• -2 to -3 Z score or
• 70-79% of expected
• Severe Wasting.
• < -3 Z score or
• <70% of expected

Height for age:

• Marker: Chronic malnutrition

• Severely low: Stunting

• Mnemonic: HAC → 85 - 90 (exam hack cheytha higher mark → 85 to 90)
• Stunting.
• Between
• -2 to -3 Z score or
• 85-89% of expected
• Severe Stunting.
• < -3 Z score or
• < 85% of expected
• If edema is present, add 'edematous' to the category.

Weight for height:

• Marker: Acute malnutrition

• Severely low: Wasting

• But Most sensitive age independent marker
• MAC

• Mnemonic:
• WHA wasted 80 ,
• HAC stunted 90

Classifications

• Waterlow’s:
• Differentiates acute/chronic malnutrition

• Welcome Trust Classification:
• For patients with edema (Kwashiorkor)
• Because weight is not reliable

Instruments for Measurement

Shakir’s tape:

• Measures MUAC (Mid-Upper Arm Circumference)

• MUAC: Most sensitive,
• Age-independent malnutrition marker
• Note: Most sensitive marker for general malnutrition → Weight for age

• Children aged 6 months to 5 years

• Color zones:

Color Zone	MUAC Measurement	Interpretation
Red Zone	< 11.5 cm	Severe malnutrition
Yellow Zone	11.5–12.5 cm	Mild to moderate malnutrition
Green Zone	≥ 12.5 cm	Normal

Salter’s weighing scale:

• Used in Anganwadis for child weight

• Measurement frequency:
• Up to 3 years: Monthly
• > 3 years: Once in 3 months

• Sensitivity: 100g
• Shows 7400gm, 7500gm
• Not 7446gm

Herpenden Callipers

• At level of triceps

Kwashiorkor v/s Marasmus

• Both involve protein deficiency
• differ in where the body loses protein.

• Kwashiorkor:
• Loss of visceral protein (albumin, neurotransmitters, enzymes).

• Marasmus:
• Loss of somatic protein (muscle protein).

Key Differences Table:

• Severely malnourished without edema - Marasmus.

• In kwashiorkor
• Pitting edema +++
• Flaky paint dermatosis.

• Seen in both kwashiorkor and marasmus
• Flag sign:
• Alternate band of pigmented and hypopigmented hairs.
• Muscle wasting

Severe Acute Malnutrition (SAM)

Definition: In a child between 6 months to 5 yrs age,

• the presence of any 1 or more of the following:
• Weight for height
• <-3 Z score or
• <70% of expected or
• Midarm circumference
• <11.5 cm or
• Symmetric bipedal pitting oedema of nutritional origin

M/c cause of malnutrition

• Infectious diseases > Socioeconomic factors

Complications of Severe Acute malnutrition

• Mnemonic: SHIELDED
• Sugar deficiency (hypoglycemia):
• Blood Glucose <45mg/dl.
• Hypothermia:
• Rectal temperature <35.5°C.
• Infections.
• ELectrolyte imbalance
• Hypokalemia
• Hypophosphatemia.
• DEhydration.
• Most Reliable Sign: Urine O/p
• Unlike in diarrhea → we use skin pinch
• Deficiency of Micronutrients.

Triad of SAM

• Hypoglycaemia

• Hypothermia

• Infection

Nutritional Rehabilitation (NRC)

Phases at NRC:

Two Phases

• Stabilization Phase:
• First 7 days.
• Goal → prevent death, manage complications.
• Diet
• Starter diet (F-75)
• 75 → 100 kcal/kg/day
• 0.9 g protein/kg/day
• Micronutrients → except Iron in 1st week

• Rehabilitative Phase:
• Beyond 7 days.
• Goal → build up the child
• Diet
• Catch-up diet (F-100) (100 kcal / 100 ml)
• 100 → 200 kcal/kg/day
• 2.9 g protein/kg/day

10 Steps of Management

1. Hypoglycaemia
• First 3 days.
• Blood sugar < 54 mg/dL.
• 10% dextrose orally or by NG tube.
• If the child is very sick, it can be given through IV route.

2. Hypothermia
• First 3 days.
• Temperature < 35.5°C (rectal).
• Remove wet clothing.
• Cover the child properly.
• Use warmer.

3. Dehydration
• First 3 days.
• Oral: Resomal (rehydration solution for malnourished child).
• It has lesser Sodium and more Potassium than the WHO ORS.

4. Infection
• Over 7 days.
• IV antibiotics: Ampicillin + Gentamicin.
• Gram-negative organisms common.

5. Electrolyte Imbalances
• Supplement magnesium and potassium.

6. Micronutrient Deficiencies
• Supplement all micronutrients.
• Iron: Avoid in first week (↑ reactive oxygen species, ↑ mortality).
• Give iron only after first week.

7. Cautious Refeeding
• First week:
• F75 (75 kcal/100 ml).
• 0.75 g protein / 100 ml
• Prevents refeeding syndrome.
• High-calorie intake too soon → excess insulin → K⁺ & PO₄³⁻ shift into cells.
• Hypophosphataemia = hallmark.

8. Catch-up Growth
• After first week:
• F100 (100 kcal/100 ml).
• 3 g protein / 100 ml
• At discharge:
• Give RUTF (Ready to Use Therapeutic Food)

9. Loving & Caring Environment

10. Follow-up

RUTF (Ready to Use Therapeutic Food)

• Calorie dense

• Paste-like, ready to use

• 543 kcal / 100 g

• Calories and proteins are increased gradually
→ to prevent Refeeding/Nutritional Recovery Syndrome

Refeeding Syndrome

• Caused by sudden increase in calorie intake

• Sequence:
• ↑ Blood glucose → ↑ Insulin
• ↑ Tissue regeneration → ↑ Phosphate consumption
• → ↓ Serum phosphate
• ↑ Use of Thiamine
• ↑ Uptake of Potassium and Magnesium into cells

Consequences

• Hypophosphatemia

• Thiamine deficiency

• Potassium deficiency

• Magnesium deficiency

• Mnemonic: paappam thinn (PPM thiamine)