Breastfeeding to prevent double burden of malnutrition Sirinuch Chomtho MD PhD Nutrition Unit, Department of Paediatrics, Faculty of Medicine, Chulalongkorn

Breastfeeding to Breastfeeding to prevent double burden prevent double burden

of malnutritionof malnutrition

Sirinuch Chomtho MD PhDSirinuch Chomtho MD PhD

Nutrition Unit, Department of Nutrition Unit, Department of Paediatrics, Paediatrics,

Faculty of Medicine, Chulalongkorn Faculty of Medicine, Chulalongkorn UniversityUniversity

Breast milk compositionBreast milk composition Special fluid that keep changing !!!???Special fluid that keep changing !!!???

Colostrum-Transitional milk-mature milkColostrum-Transitional milk-mature milk Foremilk-HindmilkForemilk-Hindmilk Premature milk-Fullterm milkPremature milk-Fullterm milk

Nutrients in breast milkNutrients in breast milk

MacronutrientsMacronutrients Lipids-most important E source Lipids-most important E source

(50%)(50%) ProteinProtein CarbohydrateCarbohydrate

MicronutrientsMicronutrients VitaminsVitamins MineralsMinerals

Composition/100ml

Colostrum

Mature milk

Cow milk

Codex standard

Energy (kcal) 58 -657

0

64 60-70

Lipids (gm ) -152.0

-354.8.

366. 2.95-4.0

Carbohydrate (gm)

Lactose (gm)

Oligosaccharides (gm)

Glucose (gm)

-572 -5

-222.4

-002.01.

-708.5

67. -7.0

-121.4

-002.00.3

465.4.5TraceNR

6.0-9.4

Protein (gm) Casein Whey α-lactalbumin β-

lactoglobulin lactoferrin lysozyme serum

albumin sIgA IgM IgGNon-protein

nitrogen (gm)

-152.0

038.-111.

5

0.36-0.350.01-

0.020.40.2-1.20.0020.0010.05

-081.1

0.3-0.5-050.

6

-020.3

--010.

3

0.010.30.05-

0.10.0010.0050.045

3.2-3.5

2.70.50.10.36TraceTrace0.040.0030.0060.0030.02

1.2-2.0

LipidsLipids

LCPUFALCPUFA highest in breast milk highest in breast milk >>>> cow’s milk >>>> cow’s milk (saturated (saturated short/medium chain FA)short/medium chain FA) linoleic acid (C18:2, n-6)/linoleic acid (C18:2, n-6)/αα-linolenic -linolenic

(C18:3, n-3) (C18:3, n-3) arachidonic acid (ARA ; C20:4, n-6)/ arachidonic acid (ARA ; C20:4, n-6)/

docosahexaenoic acid (DHA ; C22:6, docosahexaenoic acid (DHA ; C22:6, n-3) n-3)

higher in premature human milkhigher in premature human milkMinda H et al. Acta Paediatr 2002;91(8):874-81.Simmer K et al. Cochrane Database Syst Rev 2008;(1):CD000376.Simmer K et al. Cochrane Database Syst Rev 2008;(1):CD000375.Kramer MS et al. Arch Gen Psychiatry 2008 May;65(5):578-84.

DHA is the largest PUFA source DHA is the largest PUFA source in the retina and in the brainin the retina and in the brain

LipidsLipids LCPUFALCPUFA

depends on maternal diet (oily fish, egg depends on maternal diet (oily fish, egg yolk, seaweed)yolk, seaweed)

higher DHA in erythrocyte membrane higher DHA in erythrocyte membrane lipids in BF vs FFlipids in BF vs FF

DHA+ Formula vs. DHA-Formula ??????DHA+ Formula vs. DHA-Formula ?????? RCT: PROBIT study (RCT: PROBIT study (Promotion of Promotion of

Breastfeeding Intervention Trial)Breastfeeding Intervention Trial) BF group has better cognitive function BF group has better cognitive function

at 6.5 yrsat 6.5 yrsMinda H et al. Acta Paediatr 2002;91(8):874-81.Simmer K et al. Cochrane Database Syst Rev 2008;(1):CD000376.Simmer K et al. Cochrane Database Syst Rev 2008;(1):CD000375.Kramer MS et al. Arch Gen Psychiatry 2008 May;65(5):578-84.

prevalence of exclusive breastfeedingin the experimental and control group at 3 mo =43.3% vs 6.4%)

Nutrients in breast milkNutrients in breast milk

MacronutrientsMacronutrients Lipids: most important E source Lipids: most important E source

(50%)(50%) Protein:Protein: CarbohydrateCarbohydrate

MicronutrientsMicronutrients VitaminsVitamins MineralsMinerals

Fat-soluble vitaminsFat-soluble vitamins Vitamin AVitamin A

colostrum >> mature milk >>> cow’s milkcolostrum >> mature milk >>> cow’s milk retinol ester + carotenoids (retinol ester + carotenoids ( lutein, lutein,

zeaxanthine)zeaxanthine) Vitamin DVitamin D

lower than DRI but adequate if 2 hour/week lower than DRI but adequate if 2 hour/week sun exposuresun exposure

Vitamin EVitamin E colostrum >> mature milk >>> cow’s milkcolostrum >> mature milk >>> cow’s milk adequateadequate ((αα-tocopherol:PUFA ratio 0.79 mg/gm)-tocopherol:PUFA ratio 0.79 mg/gm)

Vitamin KVitamin K Universal vit K 1 mg IM at birth to prevent Universal vit K 1 mg IM at birth to prevent

hemorrhagic disease of newbornhemorrhagic disease of newborn

Water-soluble vitaminsWater-soluble vitamins

depends on maternal diet > fat-depends on maternal diet > fat-soluble vitaminssoluble vitamins

Vitamin CVitamin C High in breast milk >>> cow’s milkHigh in breast milk >>> cow’s milk

Vitamin BVitamin B groupgroup Adequate exc. Vegan mother (B6, Adequate exc. Vegan mother (B6,

B12)B12) Mother with B1 deficiency, Mother with B1 deficiency,

thiaminase containing diets thiaminase containing diets

MineralsMinerals

Breast milk has low osmolarity, renal Breast milk has low osmolarity, renal solute loadsolute load

Adequate Na, K, ClAdequate Na, K, Cl Lower Ca than cow’s milk but good Lower Ca than cow’s milk but good

absorptionabsorption, Ca:P ratio 2:1, Ca:P ratio 2:1 Inadequate Ca, P for premature infantsInadequate Ca, P for premature infants High bioavailability of trace elementHigh bioavailability of trace element Fe 20-50% availability, adequate for Fe 20-50% availability, adequate for

‘healthy full-term’ infants until 6 mos.‘healthy full-term’ infants until 6 mos.

Influence of maternal diet on milk Influence of maternal diet on milk compositioncomposition

Little or no effectLittle or no effect Lactose concentrationLactose concentration Macromineral concentration (Ca, P, Mg)Macromineral concentration (Ca, P, Mg) Some trace elements (Fe, Zn, Cu)Some trace elements (Fe, Zn, Cu) Electrolytes (Na, K, Cl)Electrolytes (Na, K, Cl)

Minimal effect, except severe malnutritionMinimal effect, except severe malnutrition Protein (conc./composition)Protein (conc./composition) Non-protein nitrogen (conc./composition)Non-protein nitrogen (conc./composition)

Influenced by maternal dietInfluenced by maternal diet Fatty acid content and compositionFatty acid content and composition

LCPUFA, trans-fatty acidsLCPUFA, trans-fatty acids Mn, I, SeMn, I, Se Water-soluble vitamin (Vit C, B1, B2, B6, B12, Water-soluble vitamin (Vit C, B1, B2, B6, B12,

niacin)niacin) Fat-soluble vitamin (A,D,E,K)Fat-soluble vitamin (A,D,E,K)

Donovan SM. In: Duggan C, Watkins JB, Walker WA, editors. Nutrition in Pediatrics: Basic science and clinical applications. 4th ed. 2008. p. 341-54.

Production of breast milk is robust! Breast milk still contain protective factors regardless.

Who should we give ‘extra’ supplement to ??? A. Mother B. Baby

Non-nutritive factors in Non-nutritive factors in breast milkbreast milk

Secretary IgASecretary IgA (90% of total Ab) (90% of total Ab) very high in colostrum 0.2-1.2 gm/dL (twice very high in colostrum 0.2-1.2 gm/dL (twice

adult sIgA produced per day), 0.1 gm/dL in adult sIgA produced per day), 0.1 gm/dL in mature milkmature milk

Protects mucosal surfaces eg gut, respiratory Protects mucosal surfaces eg gut, respiratory tract immediately after birthtract immediately after birth

Composed of specific antibodies against Composed of specific antibodies against bacteria that mother has encountered in the bacteria that mother has encountered in the environment (appear in milk around 1 day after environment (appear in milk around 1 day after mother infected)mother infected)

Infant starts to make its own SIgA after some Infant starts to make its own SIgA after some weeks weeks takes much longer in less exposed takes much longer in less exposed infantsinfants

Secretary IgA in breast milkSecretary IgA in breast milk

the secretory component protects them from digestion 2-4 grams sIgA per litre presents in infant’s stool


Living immunityLiving immunity Macrophages and neutrophils

May protect mammary gland against infectious mastitis

May kill microbes in baby’s gut Macrophages make lysozyme secreted in milk

Lymphocytes – B and T cells May enter infant’s body and transfer immune

functions mother’s cells tolerated by baby enhanced response to vaccines increased tolerance to kidney transplant from

mother


LactoferrinLactoferrin binds iron which inhibits binds iron which inhibits bacterial growth, kills bacteria, viruses bacterial growth, kills bacteria, viruses and Candidaand Candida

LysozymeLysozyme breaks down cell walls of many bacteria

OligosaccharidesOligosaccharides stop bacteria attaching to epithelium, prebiotics effects

NucleotidesNucleotides building blocks of nucleic acids; enhance maturation of immune system


> 100 cytokines+immunomodulatory > 100 cytokines+immunomodulatory factorsfactors do not cause inflammation do not cause inflammation e.g TGF-e.g TGF-ββ ((Transforming Growth Factor beta)

Epidermal growth factorsEpidermal growth factors Hormones: leptin, thyroid hormones, Hormones: leptin, thyroid hormones,

erythropoietin, prolactinerythropoietin, prolactin Enzymes: bile salt-stimulated lipaseEnzymes: bile salt-stimulated lipase

How to maintain adequate How to maintain adequate milk supply?milk supply?


Prolactin & Prolactin & OxytocinOxytocin


Early stage:Early stage: Frequent + effective nursingFrequent + effective nursing

Every 1-3 hours esp. during the night!!!Every 1-3 hours esp. during the night!!! Rooming-in + maternal confidence/supportRooming-in + maternal confidence/support

Later stage (after 4-6 weeks)Later stage (after 4-6 weeks) LOCAL LOCAL control:control:

Breast emptying (one at a time!)Breast emptying (one at a time!) Demand & supplyDemand & supply

Full breast Slower milk production

Empty breast Faster milk production

What to eat during What to eat during lactation?lactation?

Exclusive breast feeding mother needExclusive breast feeding mother need Extra energy 500 kcal/day, protein 15-25 Extra energy 500 kcal/day, protein 15-25

gm/daygm/day Adequate waterAdequate water Beware of maternal malnutritionBeware of maternal malnutrition

vitamin B group e.g. Bvitamin B group e.g. B11, B, B1212

vitamin Dvitamin D Calcium, Phosphorus, Iron, Copper, Calcium, Phosphorus, Iron, Copper,

Folate, Iodine22Folate, Iodine22

What to eat during What to eat during lactation?lactation?

Hypoallergenic diet ????Hypoallergenic diet ???? Diary product, fish, egg, peanut Diary product, fish, egg, peanut

avoidance during lactationavoidance during lactation

Galactogogue ???Galactogogue ???

Breastfeeding to prevent Breastfeeding to prevent

“double burden” of “double burden” of malnutritionmalnutrition

Slow weight gain in Slow weight gain in breastfed babybreastfed baby

BF baby BF baby normal/faster growth in normal/faster growth in 11stst 4-6 months 4-6 months

Then slower growth rate Then slower growth rate become become leaner than FF baby by the end of leaner than FF baby by the end of 11stst year year

Weight deviate from standard Weight deviate from standard growth chart (combine FF>>BF)!growth chart (combine FF>>BF)!

WHO child growth standard WHO child growth standard (http://www.who.int/childgrowth/)(http://www.who.int/childgrowth/)

Dewey et al. Pediatrics 1992; 89: 1035-41Dewey KG. Pediatr Clin North Am 2001; 48: 87-104

Complementary foodComplementary food““อาหารอาหาร ((เสรมเสรม) ) ตามวั ยตามวั ย””

413

202

379

307

346

548

0100200300400500600700800900

En

erg

y n

eed

(k

cal)

6-8 9-11 12-23

Age (months)

Energy need from complementary food in infant aged 0-2 year

From breast milk From complementary food

Dewey KG and Brown KH. Food Nutr Bull 2003; 24:5-28

Some problem nutrients Some problem nutrients in BM?in BM?

BF vs IronBF vs Iron????????

e.e.

r=0.306, p=0.009

How to prevent iron deficiency in Thai How to prevent iron deficiency in Thai infants?infants?

Prevention of maternal iron Prevention of maternal iron deficiency/anemia during pregnancy?deficiency/anemia during pregnancy?

Delayed cord clamping?Delayed cord clamping? Screening in infants at risk?Screening in infants at risk? Iron supplement medication?Iron supplement medication?

Iron tolerance and complianceIron tolerance and compliance Adverse effect of iron e.g. saturation of Adverse effect of iron e.g. saturation of

lactoferrinlactoferrin Food fortification?Food fortification?

Advice re: complementary food high Advice re: complementary food high in iron!in iron!

How to prevent iron deficiency in Thai How to prevent iron deficiency in Thai infants?infants?

Long term effect of Long term effect of breastfeeding in obesitybreastfeeding in obesity preventionprevention

Early life risk factors for obesity Early life risk factors for obesity in childhoodin childhood

John J Reilly, Andrea Sherriff ,et al. Early life risk factors for obesity in childhood: cohort study. BMJ 2005;10:1-7.

Obesity Obesity

Intrauterine & perinatal- Birthweight (low and high)- Maternal smoking

Infant feeding and weaning practice -Breast feeding (lack of)-Time of introduce complementary food (too soon)

Family characteristics and demographics- Parental obese

Lifestyle in early childhood-Sleep pattern-Sedentary behavior-Dietary pattern

Potential causes for the protective Potential causes for the protective effects ofeffects of

breastfeeding on later obesitybreastfeeding on later obesity

Modulating child behavior BF infantBF infant

Different suckling Different suckling patternpattern

Higher suckling Higher suckling frequencyfrequency

Greater degree of Greater degree of control on meal size & control on meal size & intervalinterval

BM BM Varies taste & smell >> Varies taste & smell >>

programmed to different programmed to different food selection & dietary food selection & dietary habit in later lifehabit in later life

Early growth and substrate supply

BM Lower average

caloric density Lower protein intake

per kg bodyweight Slower growth rate

in the 1st year

http://themedicalbiochemistrypage.org/gut-brain.php


Leptin

-Leptin secretion by mammary gland & transfer form blood-Oral leptin >> reduce food intake & trigger down-regulation of endogenous leptin >> satiety signal -Promote formation of neural circuit controlling food intake & adiposity later in life-Higher serum leptin in BF than FF infant

Savino F and Liguori SA. Update on breast milk hormones. Clinical Nutrition 2008;27:42–47.


Savino F and Liguori SA. Update on breast milk hormones. Clinical Nutrition 2008;27:42–47.

Ghrelin

-Influence on growth in first months of life- Higher seum ghrelin conc >> inc. appetite-Only in FF infant a positve correlation between serum ghrelin level fasting time emerged

Early protein intake and later Early protein intake and later obesity riskobesity risk

Berthold Koletzko. Am J Clin Nutr 2009;89(suppl):1502S–8S.

Protein supply

Insulin releasing amino acid

Increase insulin & IGF1

Rapid weight gain Adipogenic activity

ObjectiveObjective To examine the influence of initial infant feeding on obesity in To examine the influence of initial infant feeding on obesity in

later lifelater life MethodsMethods

A systematic review of published studies investigating the A systematic review of published studies investigating the association between infant feeding and a measure of obesity association between infant feeding and a measure of obesity was performed with Medline (1966 onward) and Embase (1980 was performed with Medline (1966 onward) and Embase (1980 onward) databasesonward) databases

ResultsResults Sixty-one studies reported on the relationship of infant feeding to Sixty-one studies reported on the relationship of infant feeding to

a measure of obesity in later lifea measure of obesity in later life of these, 28 (298 900 subjects) provided odds ratio estimatesof these, 28 (298 900 subjects) provided odds ratio estimates

Christopher G, Derek G. Cook, et al. Effect of Infant Feeding on the Risk of Obesity Across the Life Course:A Quantitative Review of Published Evidence. Pediatrics 2005;115;1367-1377.

breastfeeding was associated with a reduced risk of obesity, compared with formula feeding (odds ratio: 0.87; 95% confidence interval [CI]: 0.85– 0.89) WHO 2013 review OR 0.88

(0.83-0.93)

Michael S. Kramer, Stanley Shapiro,et al. J. Nutr. 2009;139: 417S–421S.

prevalence of exclusive breastfeedingin the experimental and control group at 3 mo =43.3% vs 6.4%)

Conclusion :

we found no effect of prolonged and exclusivebreast-feeding on height, adiposity, or BP in Belarusian earlyschool-age children

Michael S. Kramer, Stanley Shapiro,et al. J. Nutr. 2009;139: 417S–421S.

Probably too young to see the effects on body fat accumulation !

Take home message !Take home message ! Breast-fed baby with adequate lactation Breast-fed baby with adequate lactation

support have ‘ideal growth’support have ‘ideal growth’ notnot too small or too fat (!)

Good complementary feeding is essential after 6 months to address some problem nutrients e.g. iron

Long-term growth outcomes e.g. obesity prevention is not clear still need long-term prospective follow-up studies

Don’t forget other health benefits of BF esp. cognitive and immune function

Thank you for your kind Thank you for your kind attention!attention!

Documents

Breastfeeding to prevent double burden of malnutrition Sirinuch Chomtho MD PhD Nutrition Unit, Department of Paediatrics, Faculty of Medicine, Chulalongkorn