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Ο θηλασμός στη Παιδιατρική


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Καλημέρα και χρόνια πολλά!!

:)

 

Είμαι σίγουρη παιδιά ότι θα σας βοηθήσει, αρκετά σύντομο και έχει τις απαραίτητες γνώσεις. καλό διάβασμα.:arrow:

 

Source: "Current diagnosis and treatement in pediatrics"

 

Breast Feeding

 

Breast feeding provides optimal nutrition for the normal infant during the early months of life. WHO recommends exclusive breast feeding for approximately the first 6 months of life, with continued breast feeding along with appropriate complementary foods through the first 2 years of life. Numerous immunologic factors in breast milk (including secretory IgA, lysozyme, lactoferrin, bifidus factor, and macrophages) provide protection against GI and upper respiratory infections. In developing countries, lack of refrigeration and contaminated water supplies make formula feeding hazardous. Although formulas have improved progressively and are made to resemble breast milk as closely as possible, it is impossible to replicate the nutritional or immune composition of human milk. Additional differences of physiologic importance between human milk and formula continue to be identified. Furthermore, the relationship developed through breast feeding can be an important part of early maternal interactions with the infant and provides a source of security and comfort to the infant.

 

Breast feeding has been reestablished as the predominant initial mode of feeding young infants in the United States. Unfortunately, breast-feeding rates remain low among several subpopulations, including low-income, minority, and young mothers. Many mothers face obstacles in maintaining lactation once they return to work, and rates of breast feeding at 6 months are considerably less than the goal of 50%. Skilled use of a breast pump, particularly an electric one, can help to maintain lactation in these circumstances.

 

Absolute contraindications to breast feeding are rare. They include tuberculosis (in the mother) and galactosemia (in the infant). Breast feeding is associated with maternal-to-child transmission of HIV, but the risk is influenced by duration and pattern of breast feeding and maternal factors, including immunologic status and presence of mastitis. Complete avoidance of breast feeding by HIV-infected women is presently the only mechanism to ensure prevention of maternal-infant transmission. Current recommendations are that HIV-infected mothers in developed countries refrain from breast feeding if safe alternatives are available. In developing countries, the benefits of breast feeding, especially the protection of the child against diarrheal illness and malnutrition, outweigh the risk of HIV infection via breast milk. In such circumstances, mixed feeding should be avoided because of the apparent increased risk of HIV transmission with mixed feeds.

 

In newborns weighing less than 1500 g, human milk should be fortified to increase protein, calcium, phosphorus, and micronutrient content as well as caloric density. Infants with cystic fibrosis can be breast-fed successfully if exogenous pancreatic enzymes are provided. If normal growth rates are not achieved in breast-fed infants with cystic fibrosis, energy or specific macronutrient supplements may be necessary. All infants with cystic fibrosis should receive supplemental vitamins A, D, E, and K, and sodium chloride.

 

 

 

Management of Breast Feeding

 

In developed countries, health professionals are now playing roles of greater importance in supporting and promoting breast feeding. Organizations such as the AAP and La Leche League have initiated programs to promote breast feeding and provide education for health professionals and mothers.

 

Perinatal hospital routines and early pediatric care have a great influence on the successful initiation of breast feeding by promoting prenatal and postpartum education, frequent mother-infant contact after delivery, one-on-one advice about breast-feeding technique, demand feeding, rooming-in, avoidance of bottle supplements, early follow-up after delivery, maternal confidence, family support, adequate maternity leave, and advice about common problems such as sore nipples. Breast feeding is undermined by mother-infant separations, bottle-feeding of infants in the nursery at night, routine supplemental bottle feedings, conflicting advice from staff, incorrect infant positioning and latch-on, scheduled feedings, lack of maternal support, delayed follow-up, early return to employment, and inaccurate advice for common breast-feeding difficulties.

 

Very few women are physiologically unable to nurse their infants. The newborn is generally fed ad libitum every 2–3 hours, with longer intervals (4–5 hours) at night. Thus a newborn infant nurses at least 8–10 times a day, so that a generous milk supply is stimulated. This frequency is not an indication of inadequate lactation. In neonates, a loose stool is often passed with each feeding; later (at age 3–4 months), there may be an interval of several days between stools. Failure to pass several stools a day in the early weeks of breast feeding suggests inadequate milk intake and supply.

 

Expressing milk may be indicated if the mother returns to work or if the infant is premature, cannot suck adequately, or is hospitalized. Electric breast pumps are very effective and can be borrowed or rented.

 

Technique of Breast Feeding

 

Breast feeding can be started after delivery as soon as both mother and infant are stable. Correct positioning and breast-feeding technique are necessary to ensure effective nipple stimulation and optimal breast emptying with minimal nipple discomfort.

 

If the mother wishes to nurse while sitting, the infant should be elevated to the height of the breast and turned completely to face the mother, so that their abdomens touch. The mother's arms supporting the infant should be held tightly at her side, bringing the infant's head in line with her breast. The breast should be supported by the lower fingers of her free hand, with the nipple compressed between the thumb and index fingers to make it more protractile. The infant's initial licking and mouthing of the nipple helps make it more erect. When the infant opens its mouth, the mother should rapidly insert as much nipple and areola as possible.

 

The most common early cause of poor weight gain in breast-fed infants is poorly managed mammary engorgement, which rapidly decreases milk supply. Unrelieved engorgement can result from inappropriately long intervals between feeding, improper infant suckling, an undemanding infant, sore nipples, maternal or infant illness, nursing from only one breast, and latching difficulties. Poor maternal feeding technique, inappropriate feeding routines, and inadequate amounts of fluid and rest all can be factors. Some infants are too sleepy to do well on an ad libitum regimen and may need waking to feed at night. Primary lactation failure occurs in fewer than 5% of women.

 

A sensible guideline for duration of feeding is 5 minutes per breast at each feeding the first day, 10 minutes on each side at each feeding the second day, and 10–15 minutes per side thereafter. A vigorous infant can obtain most of the available milk in 5–7 minutes, but additional sucking time ensures breast emptying, promotes milk production, and satisfies the infant's sucking urge. The side on which feeding is commenced should be alternated. The mother may break suction gently after nursing by inserting her finger between the infant's gums.

 

Follow-Up

 

Individualized assessment before discharge should identify mothers and infants needing additional support. All mother-infant pairs require early follow-up. The onset of copious milk secretion between the second and fourth postpartum days is a critical time in the establishment of lactation. Failure to empty the breasts during this time can cause engorgement, which quickly leads to diminished milk production.

 

Common Problems

 

Nipple tenderness requires attention to proper positioning of the infant and correct latch-on. Ancillary measures include nursing for shorter periods, beginning feedings on the less sore side, air drying the nipples well after nursing, and use of lanolin cream. Severe nipple pain and cracking usually indicate improper infant attachment. Temporary pumping may be needed.

 

Breast-feeding jaundice is exaggerated physiologic jaundice associated with inadequate intake of breast milk, infrequent stooling, and unsatisfactory weight gain. (See Chapter 1.) If possible, the jaundice should be managed by increasing the frequency of nursing and, if necessary, augmenting the infant's sucking with regular breast pumping. Supplemental feedings may be necessary, but care should be taken not to decrease breast milk production further.

 

In a small percentage of breast-fed infants, breast milk jaundice is caused by an unidentified property of the milk that inhibits conjugation of bilirubin. In severe cases, interruption of breast feeding for 24–36 hours may be necessary. The mother's breast should be emptied with an electric breast pump during this period.

 

The symptoms of mastitis include flulike symptoms with breast tenderness, firmness, and erythema. Antibiotic therapy covering -lactamase–producing organisms should be given for 10 days. Analgesics may be necessary, but breast feeding should be continued. Breast pumping may be helpful adjunctive therapy.

 

American Academy of Pediatrics Subcommittee on Hyperbilirubinemia: Management of hyperbilirubinemia in the newborn infant 35 of more weeks of gestation. Pediatrics 2004;114:297. Erratum: Pediatrics 2004;114:1138. [PMID: 15231951]

 

 

 

Maternal Drug Use

 

Factors playing a role in the transmission of drugs in breast milk include the route of administration, dosage, molecular weight, pH, and protein binding. Generally, any drug prescribed to a newborn can be consumed by the breast-feeding mother without ill effect. Very few drugs are absolutely contraindicated in breast-feeding mothers; these include radioactive compounds, antimetabolites, lithium, diazepam, chloramphenicol, antithyroid drugs, and tetracycline. For up-to-date information, a regional drug center should be consulted.

 

Maternal use of illicit or recreational drugs is a contraindication to breast feeding. Expression of milk for a feeding or two after use of a drug is not an acceptable compromise. The breast-fed infants of mothers taking methadone (but not alcohol or other drugs) as part of a treatment program have generally not experienced ill effects when the daily maternal methadone dose is less than 40 mg.

 

 

Case Western Reserve University breast-feeding web site: http://www.breastfeedingbasics.org

 

 

Dr. Hale's breast-feeding pharmacology page: http://neonatal.ttuhsc.edu/lact/

 

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