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ALPP CLC Exam Questions & Answers
breast feeding: a public health priority has been recognized as a public health priority in tropical climates since the 1930's, but not until the 1990's in the US costs to prevent needless deaths less than $6 billion/year worldwide suboptimal breastfeeding accounts for more than 3,340 maternal and child deaths a year, 80% are maternal nursing a baby for a year or more decreases by 10-15% the risk of developing hypertension, diabetes, hyperlipidemia, and cardiovascular disease women who do not breastfeed are at greater risk for myocardial infarction and aspects of metabolic syndrome; are at a greater risk of breast, endometrial, and ovarian cancer WHO and UNICEF three strategies for increased breastfeeding initiation and duration in every country: promotion, protection, and support breastfeeding promotion focuses on advantages of breastfeeding on a personal, community, country, or global level breastfeeding protection focuses on government, manufacturer, and social responsibility to assure breastfeeding's ability to compete with commercial interests; includes addressing improper marketing practices; the AAP advices not to provide formula, company gift bags, and industry- authored handouts; in the US, state and local breastfeeding legislation addresses breastfeeding in public, employment issues, jury duty, family law, mothers in prison, etc. breastfeeding support focuses on the interaction of "helpers" with family as well as program development and implementation community expertise variety of community expertise is needed to promote, protect, and support breastfeeding International models for integrating breastfeeding promotion, protection, and support as well as balancing technical information, programs, and protocols
CLC
nationally recognized designation awarded by the ALPP to those who are exam eligible and pass the exam; have competenct verified CLCs and IBCLCs health professionals who provide lactation support why is breastfeeding so difficult?
- unrealistic expectations
- lack of timely interventions unrealistic expectations lack of preparation for what the newborn period would look like lack of timely interventions mother's problems at 3 to 7 days posed as the greatest risk to stopping breastfeeding trends last 150 years or som rates have declined international code of matketing of breastmilk substitutes (the code) an international health policy framework to regulate the marketing of breastmilk substitutes in order to protect breastfeeding
- published by the WHO in 1981
- internationally agreed voluntary code of practice
- written in response to the marketing activities of the infant feeding indurstry which were promoting formula feeding over breastfeeding, which in turn was leading to dramatic increases in maternal and infant morbidity and mortality
- subsequent clarifying and extending resolutions have been passed by the world health assembly the code regulates the marketing of breastmilk substitutes which includes infant formulas, follow-on formulas, and any other food or drink, together with feeding bottles and teats, intended for babies and young children; sets standards for the labeling and quality of products and for how the law should be implemented and monitored within countries restricting marketing does not mean that the products cannot be made available, neither does it restrict parents choice; it simply aims to make sure that their choices are made based on full, impartial information, rather than misleading, inaccurate, or biased marketing claims
making milk messages from the breast travel through the nervous system to the brain, then hormones travel to the breast through the blood system hormone pathways two separate hormone pathways, pituitary gland is important to both prolactin levels go down in between nursing and rise during nursing infrequent nursing leads to lower levels and less rise even with the same amount of nipple contact ongoing milk production positively associated with suckling within the first 2 hours after birth initiation for mothers of preemies initiation of milk expression before one hour resulted in significantly more milk when measured on days 7 and 42 triggering oxytocin mechanism # conditioned response - conditioned milk ejection (let down) reflex
- was probably given too much importance in the years we didn't understand the other mechanisms
- conditioned over time and lasts a lifetime
- is faster for women who already have one from previous breastfeeding
- to condition response.. smell, touch, hear the stimulus triggering oxytocin mechanism # nipple stretching, happens with a proper latch triggering oxytocin mechanism # baby hand massage, each hand movement releases oxytocin hormones of lactation have an emotional/behavioral function as well as making and moving milk; aggression, protection, bonding & trust milk composition is complex
- each species of mammal milk is different
- milk is "species specific" nest or cache mammal species with high fat/protein and low water content = infrequent feeds nest = bunnies cache = deer carry, follow, or hibernate mammal species with hither water content milk have more frequent feeds carry = koala follow = elephants hibernate = bears our culture wants us to be nesters when it comes to feeding, but
our milk composition indicates that we should be carriers the brain most rapidly developing organ in human newborns; human milk is the ideal fuel for brain growth nursing pattern should be frequent to accommodate human milk composition stages of making human milk lactogenesis I, lactogenesis II, lactogenesis III lactogenesis I secretory differentiation, placental hormones, colostrum lactogenesis II secretory activation, after complete delivery of placenta, rapid drop in progesterone, transitional milk lactogenesis III lactation, galactopoesis, prolactin from frequent nipple stimulation, frequent removal of milk, mature milk breastmilk composition human milk changes continually, makes it impossible to obtain a single representative sample of milk
breastfeeding makes a difference in maintaining the microbiota mechanisms by which ebf protects from diarrhea
- ph of gut
- low iron in gut
- presence of bifidus factor
- presence of hormones
- antibodies such as SIgA
- white blood cells
- cell wall disrupters
- B12 binding factor
- lactoferrin
- antimicrobial activity boosters
- mucosal wall protectors
- microbes
- absence of exposure to contaminants
- antibodies
- synergistic effect diarrhea mechanisms 1 - ph of the gut breastfed babies' gut is more acidic while formula-fed babies' guts are more neutral/basic gut bacterial colonies (the microbiome) of mixed fed babies are similar to exclusively formula fed babies diarrhea mechanisms 2 - low iron in the gut relatively low iron content in human milk
diarrhea mechanisms 3 - presence of bifidus factor promotes intestinal presence of lactobacillus bifidus that maintain the low pH and crowd out pathogenic organisms diarrhea mechanisms 4 - presence of hormones hormone like factors and growth factors that stimulate growth and development of the GI tract and GI motility, such as:
- GI hormones
- prolactin
- EGF (epidermal growth factor)
- prostaglandins diarrhea mechanisms 5 - antibodies such as SIgA bind to microbes in the baby's intestinal tract and prevent them from being absorbed into the rest of the body. mother's IgA has been found to protect against the development of NEC in preterm infants. maternal IgA shapes the host- microbiota relationship of pretern neonates that IgA in maternal milk is critical and necessary factor for the prevention of NEC diarrhea mechanisms 6 - white blood cells kill microbes directly or mobilize other defenses diarrhea mechanisms 7 - cell wall disrupters kill microbes by destroying the cell walls, these include fatty acids and lysozymes diarrhea mechanisms 8 - B binding factor reduces the amount of B12 in the intestines available to microbes diarrhea mechanisms 9 - lactoferrin deprives bacteria of iron, disrupts the integrity of the outer membrane of bacteria, assists in intestinal maturation and in the recovery of the intestine from injury and other mechanisms diarrhea mechanisms 10 - antimicrobial activity boosters such as fibronectin and gamma interferon diarrhea mechanisms 11 - mucosal wall protectors such as mucins and oligosaccharides, which also function as food for beneficial bacteria, adhere to microbes binding them so that they can't attach to the gut wall diarrhea mechanisms 12 - microbes from the mothers skin and bacteria in the mother's breastmilk seed, the infant gut underscoring
pregnancy & breastfeeding in re: to T2DM pregnancy itself may bring an increased risk for Type 2 diabetes in the mother, which breastfeeding can negate. compared with women who have not had children, childbearing women who do not breastfeed have a 50% increased risk of T2DM in later life weight loss in the BF neonate in first date after birth, most babies lose weight, some from normal diureses AAP weight loss stance in 2005 "weight loss in the infant of greater than 7% from birth weight indicates possible breastfeeding problems and requires more intensive evaluation of breastfeeding and possible intervention to correct problems and improve milk production and transfer" AAP weight loss stance in 2012 added "evaluate body weight gain - body weight loss no more than 7% from birth and no further weight loss by day five: assess feeding and consider more frequent follow-up" by two weeks at the latest: the baby should regained to its birth weight infants lose more weight in the first postpartum days...
- when labor meds are used... but perhaps not at a baby-friendly hospital
- when more intrapartum fluids have been given
- when there was no labor prior to cesarean however, supplementation rates for weight loss decreased with routine use of 24 hr weight and did not increase untoward effects during the hospital stay what do we know about breastfed babies who become dangerously undernourished? report by cooper & colleagues identified a significant increase in the incidence of malnutrition and hypernatremia in breastfed infants
- 5 sentinel cases in ohio began a chart review of the prior 4 years
- chart review babes were 23% below birth weight on average on readmission and showed clinical signs of dehydration and hypernatremia
- babies were: not d/c early, nursing q 3 - 4 or 4 - 6 hrs, scheduled, both breasts, 5 - 10. min a side, SLEEPY
- researchers found: the class was inadequate, inadequate follow up in the community post-
partum how do you know about breastfeeding adequacy? fewer than 4 soiled diapers on day 4 when used in conjunction with delayed onset of lactation may indicate breastfeeding inadequacy
- four on four... and each day after cooper findings re: weight loss findings
- babies were not identified before 10% weight loss
- a "contented" (sleepy) baby is NOT a well-fed baby (calorically deprived babies are sleepy) breastfeeding associated hypernatremia hypernatremia is a common complication of inadequate milk transfer during breastfeeding
- completely preventable complication that seems to be relatively common hypernatremia weight loss difference 1.6% in healthy infants vs. 16.2% in hypernatremic addmited infants hypernatremia frequency of feeds difference 10.2 for healthy infants vs. 7.6 in the NHD admitted infants how has the AAP responded to hypernatremia?
- ensure formal evaluation and documentation of breastfeeding by trained caregivers (including position, latch, milk transfer, examination) at least for each nursing shift
- all breastfeeding newborn infants should be seen by a pediatrician at 3 - 5 days of age, which is within 48- 72 hours after discharge from hospital
- evaluate: hydration (elimination patterns), body weight gain (body weight loss no more than 7% from birth and no further weight loss by day 5), discuss maternal/infant issues
- observe feeding
when the infant suckles from the breast... there is an outpouring of 19 different GI hormones in both the mother and the infant, including cholecystokinin, which cycles to the kidneys, and gastrin, which stimulates growth of the baby and mother's villi, increasing surface area and absorption of calories with each feeding how is it possible for humans to make milk with such a small amount of energy expenditure?
- maternal plasma prolactin concentration generally increases under conditions of negative energy balance, which may serve to protect lactation
- changes in maternal processes can spare energy.. this may account for a third to half of the total costs of milk synthesis
- together with the low cost of human lactation and large fat reserves from pregnancy, may account for human ability to breastfeed our infants under nutritional conditions which are often far from ideal
