NATURAL

Rationality in infants is the key to their adequate growth and development, as well as a high quality of life, as in the early childhoodand in subsequent years.

Composition of human milk

The optimal food product for a child during the first months of life is mother's milk, which corresponds to the characteristics of his digestive system and metabolism, and ensures the adequate development of the child's body with a rational diet of a nursing woman. All nutrients in human milk are easily absorbed, since their composition and ratio correspond to the functional capabilities of the gastrointestinal tract of an infant, and also due to the presence of enzymes (amylase, lipase, phosphatase, proteases, etc.) and transport proteins in human milk. Breast milk is a source of hormones and various growth factors (epidermal, insulin-like, etc.), which play an important role in the regulation of appetite, metabolism, growth and differentiation of tissues and organs of the child.

Due to the presence of immune complexes, active leukocytes, lysozyme, macrophages, secretory immunoglobulin A, lactoferrin and other biologically active substances, breast milk increases the protective functions of the child's body. Oligosaccharides and low levels of protein and phosphorus in human milk promote the growth of healthy intestinal flora. In recent years, bifidobacteria and lactobacilli, which determine the development of immunity, have been found directly in human milk (Fig. 2).

Therefore, children who are breastfed are much less likely to get sick with infectious diseases, develop a more persistent post-vaccination.

The protective properties of human milk are not limited only to anti-infective protection. Breastfeeding reduces the risk of developing in subsequent years such diseases as atherosclerosis, hypertension, diabetes mellitus, obesity, leukemia, etc. breastfeeding Cases of sudden death are less common.

Natural feeding has a beneficial effect on the development of the central nervous system of the child and his mental status. The union of mother and baby during breastfeeding has a deep, mutual emotional impact. It is noted that children who were fed with mother's milk are distinguished by harmonious physical development, they are calmer, more balanced, friendly and kindly desirable compared to children who were on artificial feeding, and later they themselves become attentive and caring parents.

According to some reports, children who received breastfeeding have a higher IQ, which is possibly partly due to the presence in breast milk of long-chain polyunsaturated fatty acids (DPUFA), which are necessary for the development of brain and retinal cells. In the blood of children who are breastfed, the amount of DPUFA is significantly higher than that of children receiving artificial feeding

Human milk protein consists mainly of whey proteins (70-80%), which contain essential

amino acids in the optimal ratio for the child, and casein (20-30%). Protein fractions of human milk are subdivided into metabolizable (food) and non-tabolizable proteins (lactoferrin, lysozyme, etc.), which are 70-75% and 25-30%, respectively.

In human milk, unlike cow's milk, there is a large amount of alpha-lactalbumin (25-35%), which is rich in essential and conditionally essential amino acids (tryptophan, cysteine). Alpha-lactalbumin promotes the growth of bifidobacteria, the absorption of calcium and zinc from the child's gastrointestinal tract.

Human milk contains nucleotides, which account for about 20% of all non-protein nitrogen. Nucleotides are the initial components for the construction of ribonucleic and deoxyribonucleic acids; they play an important role in maintaining the immune response, stimulating the growth and differentiation of enterocytes.

The main components of human milk fat are triglycerides, phospholipids, fatty acids, and sterols. Its fatty acid composition is characterized by a relatively high content of essential polyunsaturated fatty acids (PUFAs), the concentration of which in human milk is 12-15 times higher than in cow's milk. PUFA are precursors of arachidonic, eicosapentaenoic and docosahexaenoic fatty acids, which are an important component of cell membranes, from which various classes of prostaglandins, leukotrienes and thromboxanes are formed, they are also necessary for myelination of nerve fibers and the formation of the retina.

Long chain polyunsaturated fatty acids - arachidonic and docosahexaenoic are found in human milk in small amounts (0.1-0.8% and 0.2-0.9% of the total fatty acids, respectively), but significantly higher than in cow's milk.

Fats from mother's milk are digested more easily than cow's milk, since they are more emulsified; in addition, breast milk contains the enzyme linden, which is involved in the digestion of the fatty component of milk, starting from the mouth.

The cholesterol content in human milk is relatively high, ranging from 9 to 41 mg%, stabilizing by 15 days of lactation at the level of 16-20 mg%. Breastfed babies have higher cholesterol levels than formula fed babies. Cholesterol is essential for the formationof cell membranes, tissues of the nervous system and a number of biologically active substances, including vitamin D.

Human milk carbohydrates are represented mainly by the disaccharide L-lactose (80-90%), oligosaccharides (15%), and a small amount of glucose and galactose. Unlike a-lactose of cow's milk, b-lactose of human milk is slowly broken down in the small intestine of the child, partially reaches the large intestine, where it is metabolized to lactic acid, promoting the growth of bifidobacteria and lactobacilli. Lactose promotes better absorption of minerals (calcium, zinc, magnesium, etc.).

Oligosaccharides are carbohydrates containing from 3 to 10 monosaccharide residues that are not degraded by digestive tract enzymes, are not absorbed in the small intestine and reach the lumen of the large intestine unchanged, where they ferment, being a substrate for the growth of bifidobacteria. In this case, there is a competitive inhibition of the development of conditionally pathogenic flora. In addition, human milk oligosaccharides have receptors for bacteria, viruses (rotaviruses), and toxins, thereby blocking their binding to the enterocyte membrane. The considered functions of oligosaccharides, as well as lactose, underlie the prebiotic effects of human milk, largely determining its protective effect against intestinal infections in infants.

The mineral composition of human milk significantly differs from cow's milk, which contains 3 times more salts, mainly due to macroelements. The relatively low content of minerals in human milk ensures its low osmolarity and reduces the burden on the immature excretory system. Macronutrients include calcium, phosphorus, potassium, sodium, chlorine and magnesium. The rest of the minerals are trace elements and are present in the tissues of the human body in small quantities. Ten of them are currently classified as essential: iron, zinc, iodine, fluorine, copper, selenium, chromium, molybdenum, cobalt and manganese.

Mineral substances enter the body with food and water, and are excreted in urine, feces, sweat, desquamated epithelium and hair.

It is assumed that iron, calcium, magnesium, zinc are absorbed much better from human milk than from cow's milk. This is primarily due to their optimal ratio with other minerals (in particular, calcium with phosphorus, iron with copper, etc.). High bioavailability of microelements is also ensured by transport proteins of human milk, in particular, lactoferrin - an iron carrier, ceruloplasmin - copper. The low level of iron in human milk is compensated by its high bioavailability (up to 50%).

The lack of trace elements, which are regulators of metabolic processes, is accompanied by a decrease in the adaptive capabilities and immunological protection of the child, and their pronounced deficiency leads to the development of pathological conditions: disruption of the processes of building the skeleton and hematopoiesis, changes in the osmotic properties of cells and blood plasma, and a decrease in the activity of a number of enzymes.

All water and fat-soluble vitamins are present in human milk. The concentration of vitamins in milk is largely determined by the nutrition of the nursing mother and the intake of multivitamin preparations. It should be emphasized, however, that the level of vitamin D in human milk is extremely low, which requires additional prescription for breastfed children.

Vitamin deficiency leads to disturbances in enzymatic activity, hormonal dysfunctions,

decrease in the antioxidant capabilities of the child's body. In children, polyhypovitaminosis is more common, and isolated deficiency of one micronutrient is less common.

The composition of human milk changes during lactation, especially during the first days and months of breastfeeding, which makes it possible to fully meet the needs of the infant. A small volume of milk (colostrum) in the first days of lactation is compensated for by a relatively high content of protein and protective factors; in the following weeks, the concentration of protein in human milk decreases and remains practically unchanged in the future. The most labile component of human milk is fat, the level of which depends on its content in the diet of a nursing mother and changes both during each feeding, increasing towards its end, and during the day. Carbohydrates are a more stable constituent of human milk, but their levels also change during feeding, being the highest in the first milk portions.

Organization of breastfeeding

In a maternity hospital, in order to achieve sufficient volume and duration of lactation, a healthy newborn child should be laid on the mother's breast in the first 30 minutes after an uncomplicated birth for a period of at least 30 minutes.

THE ARGUMENTATION OF THIS METHOD INCLUDES THE FOLLOWING PROVISIONS:

1. Early attachment of the baby to the mother's breast ensures a quick activation of the mechanisms of milk secretion and a more stable subsequent lactation;
2. Sucking the baby promotes vigorous release of suoxytocin and thereby reduces the risk of blood loss in the mother, promotes earlier uterine contraction;
3. Mother-child contact: - has a calming effect on the mother, disappears

stress hormonal background; - promotes through the mechanisms of imprinting the strengthening of the feeling of motherhood, increasing the duration of breastfeeding; - ensures that newborns receive mothers

coy microflora. The volume of colostrum on the first day is very small, but even drops of colostrum are extremely important for a newborn baby. It has a number of unique properties:

• contains more leukocytes and other protective factors than mature milk, which largely protects the child from intensive bacterial contamination, reduces the risk of purulent-septic diseases;
• has a mild laxative effect, thanks to which the child's intestines are cleansed of meconium, and with it of bilirubin, which prevents the development of jaundice;
• promotes the formation of optimal intestinal microflora, reduces the duration of the phase of physiological dysbiosis;
• contains growth factors that influence the maturation of the child's intestinal functions. To ensure that the baby can receive as much colostrum as possible, the frequency of breastfeeding should not be regulated. For the purpose of free feeding on demand, healthy

the child must be in the same room as the mother. It has been shown that with free feeding the volume of lactation is higher than with feeding by the hour. Early latching on to the breast and "free feeding" are key factors in ensuring full lactation and promote the establishment of close psycho-emotional contact between mother and child.

Night feeds are especially important for maintaining lactation, since prolactin levels are higher at night. The duration of the attachment of a healthy baby to the breast in the first days should not be limited, even when he practically does not suck anything, but slumbers at the breast. The need for contact and sucking can be independent, relatively independent of eating behavior. However, in the future, excessively frequent attachment of the baby to the mother's breast at the slightest anxiety can lead to overfeeding. In this regard, one of the important tasks of pediatricians, especially district ones, is to teach the mother to differentiate the “hungry” cry of the child from the cry caused by other reasons: infant colic, discomfort, change of environment, overheating or cooling of the child, pain, etc. ...

Assessment of the adequacy of lactation requires a careful analysis of the child's behavior, the nature of the stool, and the frequency of urination. Likely signs of insufficient lactation are:

• restlessness and crying of the baby during or immediately after feeding;
• the need for frequent breastfeeding;
• long-term feeding, in which the child performs many sucking movements, in the absence of swallowing;
• a feeling by the mother of a quick complete emptying of the mammary glands during active sucking of the child, when expressing after feeding there is no milk;
• restless sleep, frequent crying, "hungry" cry;
• scanty sparse stools However, the most reliable signs of malnutrition are low weight gain and rare urination (less than 6 times per day) with the release of small amounts of concentrated urine. The final conclusion about insufficient lactation can be made on the basis of the results of weighing the child at home after each feeding during the day ("control" weighing).

In some cases, even with a sufficient amount of milk, the mother cannot breastfeed:

• baby breastfeeds but does not suck, swallow, or suck very little
• when the mother tries to breastfeed, the child screams and resists;
• after a short sucking, it comes off the breast, choking from crying;
• the baby takes one breast but refuses the other. The reasons can be different, among which the most common are:
• violations of the organization and technique of feeding (incorrect position of the baby at the breast);
• excess milk from the mother, in which it flows too quickly;
• teething,
• diseases of the child (perinatal damage to the nervous system, partial lactase deficiency, gastrointestinal food allergy, acute respiratory viral infection, otitis media, thrush, stomatitis, etc.). Finding out the reason and carrying out if necessary

True hypogalactia (or) is rare, in no more than 5% of women. In other cases, a decrease in milk production is caused by various reasons, the main of which are: the absence of a dominant lactation (psychological mood) in a woman due to poor preparation during pregnancy, as well as emotional stress, early and unjustified introduction of supplementary feeding with infant formula, the need for going to work, child's illness, mother's illness, etc.

In some cases, hypogalactia is of a transient nature, manifesting itself in the form of so-called lactation crises, which are understood as a temporary decrease in the amount of milk that occurs for no apparent reason. Lack of information about them and lack of knowledge of methods of correction are the most frequent factors of termination of breastfeeding.

Lactation crises are based on the features of hormonal regulation of lactation. They usually appear at 3-6 weeks, 3, 4, 7, 8 months of lactation. The duration of lactation crises is on average 3-4 days, and they do not pose a danger to the health of the child. In such cases, more frequent latching to the breast in combination with feeding from both breasts is sufficient. Peace and rest of the mother is necessary; varied, nutritious food with high taste; Warm drinking of beverages, especially with the use of lactogonic herbs or preparations 15-20 minutes before feeding, as well as special products of lactogonic action.

If the mother is not prepared in advance for such a situation, then at the first signs of a decrease in lactation, she tries to feed the baby with formulas. Therefore, one of the important tasks of the district doctor and nurse of the children's polyclinic is to explain the safety of short-term lactation crises.

Measures used in secondary hypogalacia (lactation crises):

• more frequent breastfeeding;
• regulation of the mother's regimen and nutrition (including the optimal drinking regime due to the additional use of at least 1 liter of liquid in the form of tea, compotes, water, juices);
• impact on the psychological mood of the mother;
• orientation of all family members (father, grandmothers, grandfathers) to support breastfeeding;
• a contrast shower on the area of \u200b\u200bthe mammary glands, gentle rubbing of the breast with a terry towel;
• the use of special drinks with lactogonic action; At the same time, infant milk formulas are not introduced into a child's diet without a doctor's recommendation.

Numerous observations show that a sufficient production of breast milk mainly depends on the mother's “attitude” to breastfeeding her baby, her conviction that it is important and necessary and that she is able to do it .. More successful development of lactation and its continuation take place in conditions where, in addition to the mother's desire and confidence, she is actively supported by all family members, as well as professional advice and practical assistance from medical workers. It is advisable for women to be trained in breastfeeding during pregnancy at the School for Pregnant Women.

Doctors and nurses play a critical role in promoting breastfeeding, who should actively promote family and social support for breastfeeding, provide parents with

complete information about its all-round positive effect on the child's body and the benefits over infant formula. In order to carry out activities for the successful establishment and maintenance of natural feeding practices, all health care workers involved in obstetrics and medical supervision of infants must have the ability to provide practical assistance to mothers in breastfeeding.

In accordance with the WHO / UNICEF international program “Protection, promotion and support of breastfeeding practice”, which sets out the main provisions in the form of ten principles of successful breastfeeding, the Ministry of Health of the Russian Federation has developed a breastfeeding support program and approved a number of normative methodological documents (1994, 1996, 1998, 1999, 2000). According to these documents, it is recommended to carry out the following work to support natural feeding in medical and prophylactic institutions for obstetrics and childhood:

• have readily available printed information on breastfeeding practices that should be communicated regularly to all health care personnel;
• inform all pregnant women about the benefits of breastfeeding and the need for early attachment of the newborn to the mother's breast (within the first 30 minutes after birth);
• ensure that mother and child stay together 24 hours a day in the mother and child ward of the maternity hospital and encourage breastfeeding at the request of the child;
• teach mothers how to breastfeed and maintain lactation;
• strive for exclusive breastfeeding during the first 4-6 months of life, that is, do not give healthy newborn babies any food other than breast milk, except for cases due to medical reasons;
• ensure continuity in the work of the women's consultation, the obstetric hospital, the children's polyclinic and the children's hospital. These activities must be carried out taking into account the health status of both the mother and the child.

Possible contraindications for breastfeeding on the part of the mother are: eclampsia, severe bleeding during childbirth and in the postpartum period, an open form, a state of severe decompensation in chronic diseases of the heart, lungs, kidneys, liver, as well as hyperthyroidism, acute mental illnesses , especially dangerous infections (typhus, etc.), herpetic eruptions on the nipple of the mammary gland (before their further treatment), HIV infection.

It has now been established that an HIV-infected woman has a 15% chance of infecting her baby through breast milk. In this regard, in the Russian Federation, children born from HIV-infected mothers are recommended to be fed with adapted formulas.

With such diseases of a nursing mother as rubella,,, epidemic, cytomegalovirus infection, herpes simplex, acute intestinal and acute respiratory viral infections, if they proceed without pronounced, breastfeeding, subject to the rules of general hygiene, is not contraindicated. The presence of hepatitis B and C in women is currently not a contraindication to breastfeeding

feeding, however, feeding is carried out through special silicone pads. In case of acute hepatitis A in the mother, breastfeeding is prohibited.

With mastitis, breastfeeding continues. However, it temporarily stops when a massive growth of Staphylococcus aureus in breast milk is detected in an amount of 250 CFU or more in 1 ml and single colonies of representatives of the Enterobacteriacae family or the species Pseudomonas aeruginosa (Guidelines for bacteriological control of breast milk, Moscow, 1984). breast is a possible complication of mastitis and is most likely when breastfeeding is abruptly interrupted. Feeding from the healthy gland should continue, and milk from the infected breast should be carefully expressed and discarded.

Stop breastfeeding when the mother takes therapeutic doses of cytostatics, immunosuppressive drugs, anticoagulants such as phenindione, radioisotope contrast agents for treatment or examination, lithium preparations, most antiviral drugs (except for acyclovir, zidovudine, zanamivir, limovudine, oseltamivir - caution), anthelmintic drugs, and also some: (, midecamycin, roxithromycin, spiramycin), tetracyclines, quinolones and fluoroquinolones, glycopeptides, nitroimidazoles, chlorine mphe nicol,. However, drugs alternative to the listed antibiotics are not contraindicated for breastfeeding.

Usually, short courses of paracetamol, acetylsalicylic acid, ibuprofen are used in medium doses; most antitussive medicines; - and other penicillins,; (except for rifabutin and); antifungal agents (except for fluconazole, griseofulvin, ketoconazole, intraconazole); antiprotozoal drugs (except for metronidazole, tinidazole, dihydroemetine, primaquine); bronchodilators (); ; antihistamines; antacids; antidiabetic agents; most antihypertensive drugs, as well as single doses of morphine and other drugs. At the same time, while the mother is taking medications, it is necessary to carefully monitor the child in order to detect their side effects in a timely manner.

It is possible to suppress lactation when a woman takes estrogens, including estrogen-containing contraceptives, thiazode diuretics, ergometrine.

The transfer of an infant, especially a newborn, to artificial feeding due to drug treatment of the mother with medications in a therapeutic dosage carries a certain threat to his health and quality of life.

Given the negative effects of tobacco smoke, tar and nicotine on the child's body and on lactation, women who smoke during lactation are advised to quit smoking. Nicotine can reduce the volume of milk produced and inhibit its production, as well as cause irritability in the baby, intestinal cramps, and lead to a slow rate of weight gain during infancy. Women who smoke have lower prolactin levels, which can shorten the lactation period, and have a lower concentration of vitamin C in breast milk compared to nonsmokers. Women who smoke should be motivated to quit smoking, or at least significantly reduce the number of

smoked cigarettes. The content of harmful substances in breast milk will be less if a woman smokes a cigarette after breastfeeding, and not before.

Mothers who are addicted to alcohol or drugs (heroin, morphine, methadone or their derivatives) should not breastfeed.

Breastfeeding may continue during a new pregnancy.

Contraindications to early attachment to the mother's breast by the child - assessment of the condition of the newborn on a scale below 7 points in severe newborn, birth trauma, seizures, respiratory distress syndrome, as well as deep prematurity, severe malformations (gastrointestinal tract, maxillofacial apparatus, heart, etc.).

Until very recently, delivery by cesarean section was also among the contraindications to early attachment to the mother's breast. However, if this operation is performed under epidural anesthesia, it is possible to attach the baby to the breast in the delivery room. If the delivery was carried out under anesthesia, then after the end of the operation the postpartum woman is transferred to the intensive care unit of the maternity hospital, and the baby to the children's ward of the postpartum department. A few hours (no more than 4) after the end of the anesthesia, the nurse brings the newborn to the mother and helps her attach it to the breast. This is repeated several times during the first day. On the second day, when the mother and baby are in a satisfactory condition, they are reunited in the postnatal department of the joint stay of mother and child.

With a number of severe congenital disorders (heart defects with decompensation, cleft palate, cleft lip, etc.), when latching to the breast is impossible, the child should receive expressed breast milk. Absolute contraindications to breastfeeding by the child at the subsequent stages of lactation are very limited - hereditary enzymes (and others). In phenylketonuria, the volume of breast milk in combination with medicinal products is set individually.

It is necessary to dwell on the issues of supplementing children who are exclusively breastfed. The practice of domestic pediatricians shows that newborns and older children who are breastfed sometimes need liquid. This condition may be associated with low humidity in the apartment, high ambient temperature, abundant fatty foods eaten by the mother the day before, etc. In these situations, you can offer the child water from a spoon, and if he began to drink willingly, it means he needed it. ... In addition, supplementation is necessary for sick children, especially in diseases accompanied by high fever, diarrhea, vomiting, hyperbilirubinemia.

Currently, there are more than 50 diseases that in children in the neonatal period can manifest as icteric coloration of the skin. Therefore, long-term preservation of jaundice in a newborn requires mandatory examination.

Even with severe physiological jaundice in children in the first days of life, breastfeeding should not be abandoned. Early attachment to the breast and frequent feedings are important in preventing jaundice, since colostrum, as a laxative, causes meconium to pass more quickly. With insufficient nutrition of the newborn child, it can be more intense and prolonged due to the thickening of bile. Supplementation with water or glucose solutions does not help to prevent jaundice, but reduces its severity. It is important that the baby is getting an adequate amount of milk, as bile thickening syndrome develops with insufficient nutrition.

Associated with breastfeeding - from breast milk or jaundice of Arias develops in 1-4% of children after the first week of life, is characterized by an increase in the level of unbound bilirubin and does not affect the child's condition. The pathogenesis has not been studied enough, it is assumed that it is associated with various components of breast milk. You can get confirmation of the diagnosis by stopping the attachment of the baby to the breast and using pasteurized breast milk for feeding for 1-2 days. During this time, the intensity of jaundice is significantly reduced and breastfeeding can be continued.

It is advisable to breastfeed a child with hyperbilirubinemia due to ABO incompatibility from birth, since those contained in milk are destroyed by hydrochloric acid and enzymes of the digestive system. In case of a Rh conflict, if the child has not undergone a replacement blood transfusion, then during the first 10-14 days he is fed with pasteurized (antibodies are destroyed during pasteurization) mother's or donor milk. In cases of replacement blood transfusion, the child can be applied to the breast 3-5 hours after the operation.

It is advisable to continue breastfeeding until 1-1.5 years of age, and the frequency of breastfeeding after a year decreases to 1-3 times a day.

Lecture number 3

There may be difficulties in breastfeeding by the mother and baby. There are absolute and relative contraindications to breastfeeding.

From the mother's side

1. Moderate to severe nephropathy
2. Operative delivery
3. Large blood loss during childbirth
4. Perineal rupture grade 2
5. Purulent-inflammatory diseases of the mother
6. Rhesus conflict
7. Some extragenital diseases of the mother (hypertension, stage 2, diabetes mellitus, severe anemia, diseases of the cardiovascular system and kidney with decompensation).

From the side of the child:

1. Apgar score less than 7 points
2. Asphyxia
3. Birth injury
4. Hemolytic disease of the newborn
5. Developmental defects
6. Prematurity with no swallowing and sucking reflexes
7. Respiratory distress syndrome

Complications arising from feeding:

1. Development of lactostasis:

a) Primary inflammatory lactostasis - 2-4 days after childbirth, the woman's diet should be limited to the use of liquid (especially warm), as often as possible to apply the baby to the breast. If milk flow occurs at night and the baby does not wake up, breast milk is expressed With pronounced lactostasis, it is recommended once - sinestrol 300,000 units, a means that reduces the viscosity of milk (25% solution of magnesium sulfate, 30 ml 2 times a day, hypothiazid, 0.1 times a day), a means that increases the evacuation capacity of a woman's milk ( oxytocin 5 nasal drops, proserin 1 tablet 10 minutes before feeding).

b) Secondary inflammatory lactostasis - chest pain + fever up to 38 and above, chills - the above treatment is carried out for 2-3 days with anti-inflammatory therapy.

Absolute contraindications on the part of the child

1. birth injury
2. HDN in the first ten days
3. deep prematurity

Children in these cases are fed with expressed milk, with HDN - donor milk.

Absolute contraindications on the part of the mother:

1. Malignant tumors
2. acute mental illness
3. Severe forms of blood and hematopoietic diseases
4. pronounced form of Graves' disease
5. Severe forms of kidney disease
6. Severe forms of CVD diseases with decompensation

With pneumonia, flu, sore throat, the question of breastfeeding decide depending on the mother's condition: in severe cases - temporarily stop feeding, in the lungs - fed with boiled expressed milk. With an active form of tuberculosis, the child is separated from the mother from the moment of birth and removed from the house for 1.5-2.0 months (to the neonatal pathology department) in order to develop immunity after vaccination.

Relative contraindications on the part of the mother:

1. Irregular nipples (small, inverted). The baby has to adjust to the nipples. In severe cases, you temporarily have to feed through special glass nozzles.
2. Mastitis is a serious obstacle: the pediatrician and obstetrician-gynecologist decides whether to attach the baby to the breast. It is taken into account that, on the one hand, good suction from the mammary glands will lead to the reverse development of inflammatory changes, on the other hand, a septic infection can be introduced to the newborn. Therefore, breastfeeding with purulent mastitis is contraindicated, resumes after a strictly individual decision.
3. A common cause is cracked and abraded nipples. To prevent cracks, oil pads with vitamin A, sea buckthorn oil, rosehip, and calendula oil are used. They are washed off before feeding. For cracks, drugs are used:

a) Galascorbin - 2 teaspoons + 100 ml of distilled water are treated with a napkin 3-4 times a day.

b) 5% synthomycin ointment - 1-2 times a day on the affected areas before feeding, wash off

c) the eucalyptus leaves are poured cold, then boiled for 15 minutes, insisted for 2 hours, the breast is treated before feeding

d) chlorophyllipt solution 2% - processed after feeding.

Child's relative obstacles:

1. Cleft lip and hard palate - you can adapt to sucking. In severe cases, spoon-fed or tube-fed
2. Thrush is a temporary problem that requires treatment
3. Short frenulum of the tongue - no difficulty in sucking
4. Human milk intolerance - rarely (enzymopathy) - the child is transferred to medicinal mixtures.

Hypolactia is the reason for transferring children to mixed and artificial feeding in 80-90%.

1. Primary - a condition in which a severe milk deficiency in the mother is noted from the first days in 3-8% - is associated with diseases of the gastric complex and a violation of the level of hormones in the woman's body.

2. Secondary - more often the cause is mastitis, cracked nipples, acute diseases of the mother. The leading place is the psychological factor - the lack of a firm attitude towards the need for breastfeeding, mental illness and trauma. Violation of the feeding rhythm - violation of the milk production function - sucking activity decreases. Sluggish sucking - insufficient irritation of the mammary glands - decreased lactation. Secondary hypolactation leads to: complications of pregnancy, childbirth, postpartum period, irrational lifestyle, malnutrition, overwork, diseases of the CVS, respiratory organs, kidneys, etc., late attachment of the baby to the breast, a long break between feedings.

The variability in the amount of milk sucked out may be greater, therefore, the diagnosis of hypolactation should be carefully diagnosed. Confirmed by the observation of diuresis, the dynamics of the increase in body weight, control feedings are carried out for several days.

4 degrees of milk deficiency:

To maintain long-term lactation and prevent hypolactation, it is necessary:

1. Tranquil home environment
2. Strong confidence in the need for breastfeeding
3. Extra sleep and rest
4. Correct, balanced diet with the use of special products (femilak-2)
5. Frequent latching of the baby to the breast (on demand)

To eliminate primary hypolactation, therapeutic hormonal drugs, lactogenic hormones are used (lactin - 6 U * 3 times a day * 6 weeks, mammofizin - 0.5 ml * 3 times a day before feeding).

Reveal the causes of hypolactation and eliminate them.

In the treatment of secondary hypolactation, in addition to establishing the causes

use metabolic complexes (biogenic stimulants, vitamins, trace elements), they are prescribed for 7-10 days and repeated as needed

Complex number 1

Apilak tablets 0.01 3 times a day under the tongue until completely absorbed

Multivitamins - gendevit (up to 30 years old), undevit (over 30, 1 tablet 2 times a day after meals. Additionally, vitamin E in tablets (with a weight of up to 60 kg. - 0.1 each, more than 60 kg. - 0.2 each) )

Glutamic acid 1.0 3 times a day 20 minutes after meals, washed down with sweet tea.

Nicotinic acid 50 mg. 4 times a day 20 minutes before feeding.

Complex number 2

Brewer's yeast 60 gr. 3 times a day (dry 1 teaspoon)

Gefetin 1 tablet 4 times a day

Calcium pantothenate 1 tablet 3 times a day

Lipoic acid 1.0 3 times a day

Asparkam 1 tablet 3 times a day

Drinks: carrot juice, carrots grated with milk, infusion of pepper, walnuts

Then - supplementary feeding (no later than 7 days). With hypolactation of 3-4 degrees - treatment and at the same time supplementation - mixed feeding

In case of insufficient breast milk, they are transferred to mixed or artificial feeding.

MIXED FEEDING - along with human milk, the child receives supplementary feed in the form of animal milk or mixtures made from it and the amount of supplementary feed is more than 1/5 of the food

ARTIFICIAL FEEDING - breast milk is completely absent or is less than 1/5 of the daily food intake.

Artificial feeding at 1 year - metabolic stress. There is a relationship between artificial feeding and an increased risk of obesity, diabetes, cardiovascular disease, etc.

Infants are fed breast milk for more than 4 weeks, the rest receive mixed or artificial feeding.

Reasons for a decrease in breastfeeding:

1. hypolactation
2. mother's employment in production
3. reluctance to breastfeed, due to the increased ability to feed with various formulas

In the absence of maternal and donor milk, animals are fed with milk.

Composition of cow's milk:

3 times more proteins and salts, but less carbohydrates. The increased protein content is not a positive factor, because foreign protein, coarsely dispersed, difficult to digest.

Main disadvantages:

1. It contains 3 times less high-grade Protein than human milk
2. In cow's milk, there are fewer albumin, excess protein is converted into ballast protein as a result of difficulty in assimilation, which creates stress in the feeding process
3. Not identical in protein and carbohydrate content in cow's milk
4. Fats break down into lower fatty acids
5. Carbohydrates are more fermentable because contain a-lactose
6. There are significantly fewer vitamins in cow's milk (C 5 times, A 9 times), vitamins of group B are well represented, which during the preparation of mixtures sharply decrease
7. Significantly fewer enzymes
8. Does not contain antibodies - no lactational immunity
9. The negative point is pollution. For artificial feeding you need guaranteed milk (baby).

Requirements for guaranteed milk

Carbohydrates not less than 4.5 g / l

Acidity no more than 20

Give at least 85 g / l dry residue

The total number of bacteria is not more than 50 thousand in 1 ml, there should be no pathogenic and putrefactive microorganisms

To avoid microbial growth, milk must be kept cold. Consume after pasteurization or boiling. Under the influence high temperature - denaturation of milk, demulsification of fats, coagulation of proteins, destruction of vitamins, therefore pasteurized no more than 5 minutes.

In a 3-week-old baby, ion-exchange milk is used as a supplement (whole milk is passed through a special apparatus containing ion-exchange resins), during this process essential amino acids and carbohydrates are introduced.

Proteins of ion-exchange milk are curdled in small flakes - absorption increases, approximately 20% of calcium is precipitated - buffering decreases and absorption improves. After passing, B vitamins are added.

Bottle-fed babies have difficulty digesting cow's milk and have a high incidence of digestive disorders. For ease of assimilation - a number of mixtures.

Mixture groups:

1. Non-adapted mixtures - prepared from cow's milk by dilution, they differ significantly in quality from human milk
2. Adapted mixtures - in them cow's milk protein is pretreated, vegetable fats with polyunsaturated fatty acids and taurine, carnitine, vitamins, mineral salts (iron, etc.) are added. They are close to human milk in composition, but have biological differences. BAS (hormones, enzymes) contained in human milk ensure the proper development and formation of the child's body, antibodies and immune complexes protect the child from diseases.

With the first drops of colostrum, the baby is naturally immunized.

Breastfeeding, carried out for a long time, reliably protects the child from early sensitization, reducing the risk of developing allergic diseases.

There are 2 groups:

Sweet mixes

Fermented milk mixtures

This has implications for metabolism and the state of local immunity in the intestine.

1.Unadapted mixtures - simple milk mixtures - dilution of cow's milk with 5% broth of various cereals (buckwheat, oatmeal, rice), in ratios

1: 2 - mixture No. 1 (43 kcal)

1: 1 - mixture No. 2 (B-mixture 54 kcal)

2: 1 - mix No. 3 (B-mix)

They are defective. Unsatisfactory mix # 1 (not used), mix # 2 is a transitional mix for a short time. Of all, the most acceptable mixture is No. 3: in 100 ml of proteins 1.9, fats - 2.3, carbohydrates - 7.58, calories 59 kcal.

The industry produces mixtures:

They are not complete. have a lot of carbohydrates and calcium, little iron and vitamins, a low amount of fats (polyunsaturated fatty acids), a deficiency of amino acids - lys, lei, three, the shaft is unbalanced. The assimilation of simple mixtures takes place with great stress on digestion.

Milk buffering is reduced by acidification method: kefir - biological acidification - by the action of lactic acid fermentation bacteria.

Kefir - stimulates the secretion of digestive juices, enhances the secretion of bile, slowly and evenly leaves the stomach - favorable conditions for digestion are created. The lactic acid of kefir hydrolyzes fats and provides gentle curdling of proteins. Kefir inhibits the growth of pathogenic microflora in the intestine.

In the first 8 months of life, the breeding of kefir - B - and B-kefir (dilution with 5% broth of cereals) is used. Sugar 5% is added, acidified with starter cultures. B-kefir as a transitional mixture (1-3d). In kefir - in the absence of adapted mixtures and certain diseases up to 8 months. You can feed whole kefir from 8 months of age. When using kefir for up to 8 months, submucous diapedetic hemorrhages appear in the intestine, which play a role in the development of anemia.

3 day kefir is used for lactase deficiency because the lactase content is insignificant, it is used for mild forms of food allergies because protein fractions have less antigenicity compared to cow's milk.

Fermented milk mixtures "Biolact" and "Biolact 2" use cow's milk, which is fermented with specially selected bacteria. "Biolact" has high proteolytic properties, contains a number of essential amino acids, vitamins (B12) and essential enzymes. Proteins are easily broken down and absorbed. When using "Biolact" hematopoiesis is activated. Biolact 2 is enriched with trace elements and vitamins. They are used in young children and newborns throughout the year.

Despite a number of positive properties of fermented milk mixtures, they differ from human milk and are not considered as substitutes.

Powdered formula, similar in composition to breast milk - adapted milk formula (breast milk substitutes). Although no processing line has been proven to be capable of producing a semblance of human milk, there is considerable similarity to dry mixes.

There are 4 types of breast milk substitutes:

1. Initial mixtures - used during the first two months of life. They are close in composition to breast milk and are adapted to the characteristics of the digestion and metabolism of children in the first year of life. They contain taurine, carnitine, which are not found in cow's milk, but are present in human milk.
2. Subsequent mixtures - intended for further feeding (after 2 months). Must be fortified with iron. by 3 months of life, iron stores are depleted - the risk of developing an iron deficiency state.
3. Partially adapted mixtures
4. Subsequent formulas - infant formula for feeding from 5-6 months of age

(For mixtures see Appendix Table 1)

When transferring a child to mixed and artificial food

1. The doctor must take into account the physiological characteristics, the ability to adapt and

needs for the main ingredients. Adapted milk formulas should be preferred.

2. It is necessary to determine the amount of mother's milk and the amount of supplementation

3. Should be supplemented after each feeding

4. Begin feeding with small portions - increase the volume to the required amount.

With mixed feeding, the diet is free (on demand when controlling the amount of milk). If the amount of supplementary food is small, it is given from a spoon, because more easily, easy entry through the nipple leads to breast rejection. For large amounts of supplementation, use a bottle with a nipple with a fine hole.

The transfer of a baby to artificial feeding in the 1st month should not be quick, because his adaptation is intense due to physiological immaturity.

In case of artificial feeding of infants 1 month of life, 7 meals a day (after 3.5 hours) are recommended before the introduction of complementary foods - 5 meals a day.

Taking into account individual characteristics, the number of feedings is changed: if the child does not eat the proposed volume, frequent feeding in small portions is required.

The timing of the introduction of food additives: with mixed and artificial feeding:

Fruit juices - from 4 months.

Fruit puree - 4.5 months.

Cottage cheese - from 6 months

Yolk - from 7 months.

Meat dishes - from 7 months.

Fish - from 8-9 months, replaces I - 2 feedings.

1st complementary food - from 5 months - vegetable puree. If it is not gaining weight well - 1m complementary foods can be porridge.

2nd in 1 month after 1st (from 6 months)

3rd - from 8 months.

It is advisable not to use whole milk in children 1 year of age.

With mixed and formula feeding, the daily protein requirement depends on the type of dairy product.

When feeding with adapted formulas: (before the introduction of complementary foods)

Proteins - 3g / kg mixed; 3.5 g / kg artificial.

When feeding with unadapted formulas: (before the introduction of complementary foods)

Proteins - 3.5 g / kg mixed; 4.0 g / kg artificial

The need for fats and carbohydrates is the same

With a mixed diet, the calorie content increases by 5%, with an artificial one by 10%. With a large body weight of children, the amount of feeding is calculated based on the average amount of proteins and carbohydrates. The daily amount of food may be below normal. At the age of 1.5-2.0 months, 1/6 of the body weight can be given, and if the dynamics correspond to age, then there is no need to increase the content of nutrients. With insufficient and excessive increase in body weight, nutritional correction is carried out.

Eating prematurely.

individually and depends on the degree of prematurity, body weight, presence or absence of swallowing and sucking reflexes. Regardless of the method chosen, the first feeding begins 2 to 3 hours after birth, but no later than 6 to 8 hours.

Children weighing 2000g. And more, who are in a relatively satisfactory condition, maybe.

attached to the breast as full-term (after 20-30 minutes). The child's fatigue is monitored - cyanosis of the nasolabial triangle, shortness of breath. With these symptoms, the number of feedings is limited.

Children weighing 1500-2000 gr. In the absence of severe pathology, a trial bottle feeding is performed.

Deeply premature babies weighing 1000-1500 g are fed through a tube (in the absence of swallowing and sucking reflexes).

If it is not possible to carry out enteral nutrition - parenteral nutrition. Complete parenteral nutrition - with a very serious condition of the child, necrotizing enterocolitis, some abnormalities in the development of the gastrointestinal tract, in the pre and postoperative period. When carrying out parenteral nutrition, daily monitoring of CBS blood, levels of basic elements, glucose, urea, measurement of urine output.

As soon as possible (with stabilization of the state), it is necessary to enter the minimum volume of enteral nutrition. As a result of the introduction of a small volume of milk (4-8 ml), the release of intestinal hormones is stimulated, its motor is improved, the intestinal wall does not suffer, which contributes to the normal development and full functioning of the gastrointestinal tract in the future.

If an immature child tolerates breastfeeding well or sucks the norm out of the bottle, a 7-8 meal regimen is set for him every 2.5 - 3.0 hours with a 4 hour night break

If necessary (weight less than 1500 grams and severe symptoms of CNS depression), premature babies are fed portionwise through a nasogastric tube (7-10 times a day). Children with underdeveloped reflexes of swallowing and sucking are fed through a probe, which is inserted at a distance equal to the distance from the bridge of the nose to the xiphoid process for 2 days, removed, sterilized and injected through the other half of the nose. When the sucking reflex appears, feed from a bottle with a nipple.

With parenteral nutrition, an indwelling catheter is inserted into a vein and fluid is injected.

Composition of infusion solutions:

glucose, electrolytes, protein hydrolyzate, vitamins, fat emulsion.

Energy coefficient 720-800 kcal in 1 liter of liquid. The solution is administered at the rate of 100-150 ml / kg of body weight / day - they gradually switch to feeding through a tube - from a bottle - to the breast.

Volumes of food

1. the first 8 days of life according to Rommel's formula: milk volume \u003d 10 + n (day of life) - this is the amount of milk per 100 grams. body weight
2. more than 10 days by volume-weight method

? - 10-14 days 1/7

? - 2-3 weeks 1/6

By 1 month 1/5

1. Calorie method for premature babies

7 days - 70 kcal

10 days 100 kcal

20 days 120 kcal

Features of metabolism

1. High caloric requirement at the age of the first 6 months. - 120 body weight from 7 to 12 months. - 115 kcal / kg body weight EB

2.Increased need for vitamins, microelements

3.Positive nitrogen balance

4.Increased need for water

1st year of life - 150 - 120 ml / kg

1 to 3 years - 120 - 100 ml / kg

From 4 to 6 years old - 100 - 80 ml / kg

From 7 to 12 years old - 80 - 60 ml / kg

From 13 to 15 years -50-40 ml / kg

Breast milk:

B - 50% -albumin all essential amino acids, Jg, finely dispersed, easily assimilated F - PUFA 9-12% a lot of PL low fatty volatile acidic (β-hydroxybutyric, etc.), more lipase activity, a significant amount in the emulsified state Y - c -lactose and oligoaminosugar - bifidogenic factors, 28 microelements, 19 enzymes, vitamins, hormones, antibodies, lysozyme, coagulation factors; naturalness, sterility; bio, communication; risk of diabetes, atherosclerosis, leukemia, chr. diseases of the digestive system, allergic diseases.

In the first 7-8 days of life, the daily volume of milk for a child can be calculated using the Finkelstein formula, V \u003d 70 (80) * n where V is the daily volume of food, n is the number of days of life, 70 and 80 are empirical figures; figure 70 is taken if the child's body weight at birth is less than 3200 g, figure 80 is the body weight of 3200 g or more.

according to the formula of G.I. Zaitseva V (2% of the child's body weight) * n, where n is the number of days of life. To calculate the daily amount of food for a child over 8 days old, use:

Volume weight method

from 9-10 days to 2 months - 1/5 body weight;

from 2 to 4 months - 1/6 of body weight;

from 4 to 6 months - 1/7 of body weight;

from 6 to 9 months - 1/8 body weight;

by the end of the first year - 1 / 8-1 / 9 body weight,

The amount of milk per feeding is calculated by dividing the daily volume by the number of feedings.

Colory way

per 1 kg of body weight, a breastfed child should receive up to 3 months - 120 kcal / day;

from 4 to 6 months - 120 kcal / day;

from 7 to 12 months - 115 kcal / day;

(Knowing the body weight and age of the child, it is easy to calculate the required amount of milk, based on the fact that 100 ml of breast milk contains 75 kcal) Kcal + 5% with mixed (125-120 kcal), + 10% with artificial feeding (130- 125 kcal)

According to the child's need for food ingredients (most accurate)

Protein requirements are:

under the age of 3 months. - 2.2-2.5 g / kg

at the age of 4-6 months. - 3 g / kg

at the age of 7-12 months - 3.5 g / kg

Fat requirement:

under the age of 3 months. - 6.5 mg / kg,

at the age of 4-6 months. -6 g / kg;

at the age of 7-12 months -5.5 g / kg.

The need for carbohydrates throughout the first year of life is 13 g / kg.

The need for proteins depends on the type of feeding, and in fats and carbohydrates remains the same for all types of feeding.

Mixed feeding: before the introduction of complementary foods 3.0 gr. protein with adapted mixtures 3.5 gr. with non-adapted mixtures; after the introduction of complementary foods 3.5 gr.

Artificial feeding: before the introduction of complementary foods 3.5 gr. protein in adapted mixtures; 4.0 g with non-adapted mixtures; after the introduction of complementary foods 4.0 gr.

Feeding mode. First feeding in the first 20-30 minutes after birth. Feeding on demand 3-4 weeks. 6 times a day in 3.5 hours - before the introduction of complementary foods. 5 single feeding after 4 hours - after the introduction of complementary foods.

Complementary foods

Nutritional supplements

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The benefits and necessity of breastfeeding are now recognized as undeniable throughout the world.

Every pediatrician should thoroughly know the benefits of breastfeeding in order to have their own deep conviction in its necessity, on the one hand, and be able to find compelling arguments for mothers when talking with them.

Children's need for basic food ingredients

Since most often, when switching to artificial feeding, the child switches to feeding with formulas based on cow's milk, we will give a comparison of the composition of breast and cow's milk.

Table 1: Comparison of Breast Milk and Cow's Milk by Main Food Ingredient

Breast milk contains 1 - 1.2 g / 100 ml of protein, which is sufficient for the development of the baby. There is much more protein in cow's milk; excess protein can lead to earlier maturation of children - earlier death - tumors; kidney damage. Protein deficiency primarily affects the gastrointestinal tract: malabsorption syndrome, “mucosal baldness”.

Comparison of breast and cow's milk in terms of protein composition shows that fine proteins predominate in breast milk, for the breakdown of which a much smaller amount of enzymes is needed (the lack of which is characteristic of children in the first year of life), while casein predominates in cow's milk, which requires preliminary curdling and subsequent digestion of significant amounts of proteases; as a result, there is an increased risk of ingestion of undegraded protein components into the bloodstream and subsequent development of allergies to cow's milk protein.

Immunological protection.

In breast milk, and especially in colostrum, there are a large number of factors that provide a child with passive immunity at first (see table).

Colostrum and mature milk of women contains a significant amount of cellular elements. These are mainly neutrophils, T- and B-lymphocytes, macrophages, epithelial cells; in colostrum, the content of cellular elements reaches 10 to the sixth power in 1 ml.

In human milk, immunoglobulins of various classes are found, which transmit passive humoral immunity from mother to child and provide the first line of defense of the gastrointestinal tract from pathogenic flora after birth.

Of particular importance among the factors of immune defense is secretory immunoglobulin A, which prevents the binding of pathogenic microbes to the receptors of epithelial cells of the intestinal mucosa, blocks the growth of bacterial colonies and contributes to the formation of normal intestinal microflora. S-IgA contains antibodies to pathogens of intestinal infections, RS virus, influenza viruses, poliomyelitis, rotaviruses, staphylococci, diphtheria and tetanus pathogens. There is an anti-lambliasis factor in breast milk.

Human milk also contains antibodies to antigens from food received by the mother. In particular, mothers who consume large amounts of cow's milk contain antibodies to its proteins in breast milk.

Protective function is also performed by human milk protein - lactoferrin, which has a pronounced antimicrobial effect: by binding iron ions, it inhibits the growth of microbes, which is associated with the capture of iron. Iron associated with lactoferrin is necessary for the synthesis of hemoglobin and tissue respiration factors (cytochromes) and, accordingly, for the proliferation and growth of all cells of a growing organism. Lactoferrin, by binding excess free iron ions, inhibits lipid peroxidation and protects tissues from damage.

The protective factors of breast milk also include C3 and C4 complement fractions and lysozyme, the content of which, especially in colostrum, is hundreds of times higher than in cow's milk.

The ratio of essential amino acids in breast milk (lysine, histidine, threonine, valine, methionine, isoleucine, leucine, phenylalanine) is much more consistent with the needs of the child than their content in cow milk. Breast milk contains an S-containing amino acid taurine,which is a growth modulator and has a stabilizing effect on cell membranes. In newborns, the need for this amino acid is increased, it is necessary for the construction of the retina, brain tissue, digestion and absorption of fats, conjugation of bilirubin. Human milk nucleotides. Breast milk contains 13 acid-soluble nucleotides, of which the most important are AMP, HMF, UMF, CMP, and IMP; which in the body play the role of regulators of various processes of biosynthesis, especially in conditions of its rapid growth, they have a positive effect on the immune response and lipid metabolism, increase the degree of absorption of iron, promote the growth of bifidoflora in the intestine and stimulate the maturation of enterocytes.

Quantities fat, providing the construction of cell membranes, tissue growth, the formation of fat depots and covering the energy needs of the child, in human and cow's milk is approximately the same, but there are significant differences in fatty acid composition. Human milk contains 50% polyunsaturated fatty acids, which is 2 times higher than in cow's milk. The absorption efficiency of breast milk fat reaches 90%. Its absorption is influenced by the presence of active lipase in breast milk and the fact that the fat of human milk is in a fine emulsion and is easier to break down. Cow's milk fats formed by saturated fatty acids easily bind with Ca and are excreted in the stool.

Higher polyunsaturated fatty acids - linoleic, linolenic, arachidonic, play a special physiological role in the growth and development of a child. Linoleic acid is referred to as essential, it is not synthesized in the body of children. From it, the child's body can actively synthesize arachidonic acid. Polyunsaturated fatty acids increase the antioxidant potential of tissues (primarily brain tissues) and serve as precursors in the synthesis of biologically active substances - prostaglandins, prostacyclins, leukotrienes, which have anti-inflammatory (leukotriene B) and histamine-like (leukotrienes C4, D4) action, are a powerful factor in the prevention of atherosclerosis ... The content of polyunsaturated fatty acids in cow's milk is 2 times lower than in female milk (there are many of them in sunflower and corn oil, lard). The ratio of polyunsaturated omega 6 (linoleic, arachidonic) fatty acids to omega 3 (linolenic) in human milk is close to optimal (5/1). In many ways, the fatty acid composition depends on the mother's nutrition. Omega 3 fatty acids are found in large quantities in fish products and fish oils. Omega 3 fatty acids have a protective role in child's diseases.

Carbohydratesin human milk are represented mainly by lactose (90% - beta-lactose). Lactose in the intestine is broken down by the enzyme lactase into glucose and galactose, which are actively absorbed. Lactase "child type" is characterized by reduced activity, and therefore part of the lactose remains unhydrolyzed and in the large intestine is broken down by bifidobacteria with the formation of lactic acid, which lowers the pH of feces in infants. Secondary lactase deficiency very often develops in infants with intestinal infections and food allergies, and then diarrhea can become protracted and a transition to low-lactose nutrition is necessary. The alpha-lactose in cow's milk is more difficult to break down by the "baby-type" lactase.

After lactose, breast milk oligosaccharides are the second most important group of breast milk carbohydrates. Oligosaccharides such as fructose, galactose, fucose, beta-galactosyl-fructose and some amino sugars in human milk have the properties of a "bifidus factor", stimulating the multiplication of bifidobacteria and being, in essence, prebiotics. They are not digested in the small intestine, reach the large intestine, where they are fermented by the body's own bifidobacteria, which leads to an increase in the biomass of the latter. In addition, undigested oligosaccharides are soluble dietary fiber that promote soft stool in babies.

Oligosaccharides of human milk can displace microorganisms from the connection with membrane receptors in the intestine, which prevents the adhesion and reproduction of microbes (galacto-mannose).

The child's need for electrolytes (see table 2) - sodium, potassium, chlorine, which are necessary to maintain osmotic and ionic homeostasis and to create the transmembrane potential of cells - is fully provided with natural feeding.

Table 2. The content of minerals and some trace elements in human and cow's milk.

However, due to the immaturity of the system of neuroendocrine and renal regulation of water-salt metabolism in infants, dehydration, hyper- and hypoosmia, hyponatremia, hypokalemia often develop. With an excess of lactic acid, metabolic acidosis easily develops. When fed with undiluted cow's milk, the child experiences significant protein and, as can be seen from the table, electrolyte overload.

Minerals - calcium, phosphorus, magnesium in human milk are in such proportions that promote their better absorption and bone mineralization. The Ca / P ratio in it is optimal and is 2: 1. With artificial feeding, the child receives significantly more Ca, but it is not absorbed, excess calcium in the diet inhibits the absorption of proteins and fats in the intestine and leads to constipation.

In addition to iron, of the microelements contained in breast milk, zinc is of great importance, which has an activating effect on the immune system and is necessary for DNA synthesis, cell division, and protein synthesis.

Copper and selenium are essential for the normal course of redox processes, immunity, and antioxidant protection.

In breast milk, a relatively stable composition (independent of nutrition) of zinc, iron, calcium.

Iodine is essential for the synthesis of thyroid hormones. The content of iodine, copper, selenium in human milk strongly depends on the geochemical characteristics of the region of residence of the family.

Disadvantage vitamins in the nutrition of young children is a proven cause of the spread of serious diseases, primarily rickets and infectious diseases.

The complex action of vitamins A, E, C and beta-carotene determines powerful antioxidant protection and a full-fledged immune response of the body.

Vitamin D plays an active role in calcium metabolism and influences muscle function. Children of the first year of life are especially vulnerable to vitamin D deficiency.

B vitamins are essential for all metabolic processes, growth and normal digestion.

Table 4. Vitamin content in human and cow's milk

Thus, the advantages of breast milk over cow's milk are obvious.

However, the pediatrician needs to explain in an accessible form to the parents and, first of all, to the mother the benefits of not only breast milk, but also breastfeeding.

Benefits of breastfeeding:

Breast milk meets the baby's needs for proteins, fats, carbohydrates, minerals and vitamins.

Children who are breastfed are less likely to get sick (see immunity factors).

Food allergies are less common in breastfed babies.

They have a lower risk of developing rickets and anemia.

They are less likely to have intestinal colic, constipation and intestinal dysbiosis.

Children who are breastfed have a lower incidence of otitis media

Less common malocclusion.

Children who are breastfed are ahead of artificially fed children in terms of neuropsychic and motor development.

Thanks to close bodily contact with their mother, they are more obedient, calm, love and understand her better.

10. In women who breastfeed their children:

the uterus contracts faster and postpartum bleeding stops

lower risk of mastopathy and breast cancer

lower risk of unwanted pregnancy

after the cessation of lactation, they better restore their original weight.

It is convenient to breastfeed (subject to hygiene, breast milk is sterile, warmed up to the desired temperature, when feeding at night, you do not need to get up and prepare the formula, the child calms down and falls asleep faster, when traveling and being outside the home, the child is always provided with food).

Breastfeeding is beneficial because the cost of an adapted formula that is "suitable" for a child can be quite high.

Prevention of hypogalactia.

Before pregnancy:

Monitoring the normal sexual development of girls

Prevention and timely treatment of hormonal dysfunctions

Prevention of inflammatory diseases of the female genital area

Breast hygiene

During pregnancy:

Examination of the mammary gland, correction of the condition of the nipples

Breast hygiene

Psychological preparation for lactation

Rational nutrition of a pregnant woman

A varied diet of the mother during pregnancy and lactation ensures the child's tolerance to food in the future

In the maternity hospital:

Natural delivery

Early (0.5 hour after birth) latching on to the breast

prolactin release

colonization of the child's digestive tract with normal microflora

uterine contraction

Joint stay of mother and child

Frequent breastfeeding

Compliance with the rules of breastfeeding:

alternation of feedings, if necessary - two breasts

expressing in case of stagnant breast milk

hygiene

correct attachment to the breast

the inadmissibility of weaning the child from the breast until it is saturated.

Do not give your child other liquids (sweet teas, water).

Do not supplement with formula or donor milk, especially from a bottle.

It is necessary to provide the nursing mother with adequate nutrition and drinking regime (2.5 - 3 l / day).

After discharge from the hospital:

Control of the pediatrician for compliance with the rules of breastfeeding

Adequate nutrition and drinking regime for the mother

Introduction of vitamins into the diet

Adequate sleep and rest

Walks in the open air

Favorable psychological climate in the family

Inadmissibility of bottle feeding during lactation crises

Control weighing for suspected hypogalactia.

If hypogalactia is suspected:

Revision of nutrition, drinking regime

If possible, eliminate the cause of hypogalactia

Using foods that increase lactation (mushroom soups, walnuts, milk tea)

Herbal medicine for hypogalactia (hawthorn fruits, decoction of hop cones, caraway seeds with sour cream, lemon balm, sweet clover, roots and leaves of wild strawberry, lactation teas)

Vitamin A 8.6% oil Solution - 4 drops 2 times a day for 20 days

Vitamin E 50 - 100 mg / day 10 - 14 days

Apilak 0.01 3 times a day 2 weeks

Nicotinic acid 0.05 - 0.1 3 times a day 0.5 hours before feeding 2 weeks

Powdered brewer's yeast 1 - 2 g 3 times a day 3 weeks

Breast massage before feeding

Table 5 WHO: Breastfeeding and Medicines

Nutrition of a nursing woman.

Adequate nutrition for a nursing mother has a significant impact on the composition of breast milk, which serves as a source of essential nutrients and vitamins for the infant.

In this regard, it is especially important for a nursing mother to receive a balanced diet. 5 meals a day are best, with small snacks between meals. The diet should be based on plant foods (about 2/3), daily use of products from cereals is necessary: \u200b\u200bbread, rice, buckwheat, pastaas well as potatoes, fresh vegetables and fruits. (Proteins - 120 - 130 g, fats - 120 - 130 g, carbohydrates - 450 - 500 g; 3700 - 4000 kcal.)

In addition, the daily diet must include protein food - meat, fish, cottage cheese, cheese, and most importantly - milk as a source of valuable protein and calcium (no more than 500 ml). Milk for pregnant women and lactating mothers "Bellakt" meets their increased requirements for easily digestible protein, contains little fat, its carbohydrates are represented only by milk sugar. It contains a high content of minerals (calcium, phosphorus, sodium, potassium, magnesium) and trace elements - iron, zinc, copper, manganese, iodine, the intake of which is necessary to replenish the loss of these substances during pregnancy and childbirth and ensure their sufficient amount in the breast milk.

Milk "Bellakt" contains vitamins A, D, E, C, group B, beta-carotene. When consuming one glass of this drink per day, additional intake of vitamins is not required.

The Bellakt milk drink contains taurine, which is necessary for a child to build the retina of the eye, brain tissue, digest and absorb fats.

If the mother or baby has intestinal dysfunctions, you can use Bellakt milk, enriched with bifidobacteria.

A nursing mother also needs a full drink, for example, in the form of fruit juices, tea, fruit drinks, compotes, since breastfeeding significantly increases the need for vitamins and minerals. It is useful to use teas to increase lactation (HIPP, for example).

The benefits and necessity of breastfeeding are now recognized as undeniable throughout the world. According to the data of the 5th session of the WHO (2004) on nutrition of infants in the first year of life, the duration of breastfeeding alone is set up to 6 months, and breastfeeding is recommended for up to 2 years or more.

However, there is a reservation - but taking into account the national conditions and the characteristics of the diet of nursing mothers. It has been established, for example, that, starting from 3-4 months of age, the child's iron depot is depleted, and the need for it increases, and breast milk can no longer cover it - this can lead to iron deficiency. From 5 to 6 months of age, the needs for other food ingredients also change - proteins, fats, carbohydrates, which leads to the need to introduce corrective food additives and complementary foods into the infant's diet.

Natural feeding is feeding a baby with human milk by latching the baby to the breast. When a mother has a question why she should breastfeed her baby, she should first of all know the benefits of breastfeeding the baby and how radically it differs from cow's milk.

Benefits of breastfeeding your baby:

1. Human milk is a unique and most balanced food product for a baby in the first year of life;
2. The composition of each mother's breast milk exactly corresponds to the needs of her baby in various substances: proteins, fats, carbohydrates, vitamins and minerals;
3. Mother's milk contains special substances - enzymes that promote the digestion and assimilation of proteins, fats and carbohydrates;
4. The mother's milk contains immunoglobulins and immune cells that protect the child from most infectious diseases: intestinal infections, infectious hepatitis, diphtheria, tetanus and others;
5. Breast milk contains substances that regulate the growth and development of the child (hormones, growth factors, taurine, zinc, iodine, etc.);
6. In the process of breastfeeding, a special, very intimate relationship develops between mother and child, the warmth of which remains throughout the rest of life;
7. Breastfeeding is good for the health of the mother because it contributes to the contraction of the uterus after childbirth, helps to restore the figure and is the best prevention of mastopathy and breast cancer.

The difference between breast milk and cow milk:

1. Protein content. There is less protein in breast milk than in cow's milk, fine fractions prevail in it, particles of coarse protein casein are several times smaller, which ensures that breast milk is curdled in the stomach with more delicate flakes, which facilitates the digestion process.
2. Breast milk proteins are similar to plasma proteins, and cow's milk proteins have a pronounced AH activity, which contributes to the appearance of allergic reactions.
3. The amino acid content in breast milk is less, which is more optimal for the baby. There are three times more amino acids in cow's milk, this leads to protein overload, which can lead to metabolic disorders.
4. Human milk, especially colostrum secreted in the first three days, is very rich in immunoglobulins, especially A, which plays an important role in the creation of local immunity in the gastrointestinal tract of newborns. The level of lysozyme is 300 times higher than in cow. It contains the antibiotic lactofelicin. Thereby infant has good immuno-biological protection.
5. The amount of fat is the same, but there is an important distinguishing feature, it is the composition of fat. Unsaturated fats predominate in breast milk. Formula feeding has been proven to often lead to obesity.
6. Carbohydrates in breast milk are abundant.
7. Breast milk is rich in enzymes: amylase, trypsin, lipase. In cow's milk, enzymes are hundreds of times less. This compensates for the temporary low enzymatic activity of the child and ensures the absorption of a fairly large amount of food.
8. The mineral composition of breast milk: the amount of calcium and phosphorus is less than in cow's milk, but absorption is twice as good, so breastfed babies are much less likely to get rickets. The content of bioelements (sodium, magnesium, iron, zinc, etc.) in breast milk is optimal and meets the needs of the child. Breast milk contains a large amount of vitamin D, which helps prevent rickets.

Basic principles of successful breastfeeding:

1. Strictly adhere to the established rules for breastfeeding and regularly bring these rules to the attention of medical personnel and women in childbirth.
2. Train health-care personnel in the skills necessary to carry out the breastfeeding practice.
3. Inform all pregnant women about the benefits and techniques of breastfeeding.
4. Help mothers to start breastfeeding within the first half hour after giving birth.
5. Show mothers how to breastfeed and how to maintain lactation even if they are temporarily separated from their babies.
6. Give infants no food or drink other than breast milk unless medically indicated.
7. To practice around the clock finding the mother and the newborn side by side in the same ward.
8. Encourage breastfeeding as requested by the infant rather than on a schedule.
9. Do not give breastfed infants any sedatives or devices that imitate the mother's breast (nipples, pacifiers).
10. Encourage the organization of a breastfeeding support group and refer mothers to these groups after leaving the maternity hospital.

Rules for successful feeding:

1) early attachment of the baby to the breast (in the delivery room);

2) in the first weeks, it is advisable to provide the child with a free feeding regime (at the request of the child) and only later transfer the child to the hourly food that he himself chose;

3) when introducing complementary foods, to prevent the extinction of lactation, it is recommended to put the baby to the breast at the end of each feeding;

4) if there is not enough milk, it is necessary to often latch the baby to the breast. It must be remembered that for nursing baby every drop of mother's milk is priceless. However, frequent breastfeeding can increase milk production in the breast.

Possible contraindications for breastfeeding on the part of the mother:

Eclampsia;

Heavy bleeding during or after childbirth;

Open form of tuberculosis;

Decompensation or chronic diseases of the heart, lungs, kidneys,

baking, as well as hyperthyroidism;

Acute mental illness;

Especially dangerous infections;

Herpetic eruptions on the nipple of the mammary gland (before their follow-up treatment);

HIV infection;

Mastitis in a woman:upon detection of massive growth of St. aureus ≥ 250 CFU in 1 ml and / or a single growth of Enterobacteriacae and Pseudomonas aeruginosa (Guidelines for bacteriological control of breast milk, Moscow, 1984);

Taking cytostatics, immunosuppressive drugs, anticoagulants, some antibacterial drugs;

Alcohol and nicotine addiction.

Breastfeeding during a new pregnancy can continue.

Contraindications to early attachment to the mother's breast with the child's side:

Apgar score below 7 points;

Birth injury;

Seizures;

Deep prematurity;

Severe malformations (gastrointestinal tract, maxillofacial apparatus, heart, etc.);

Delivery by surgery cesarean section (under anesthesia).

Absolute contraindications for breastfeeding on the part of the child in the subsequent stages of lactation:

Hereditary enzymopathies (galactosemia);

Phenylketonuria (with an individual selection of medical nutrition).

In the first days after childbirth, it is important for the development of lactation:

early breastfeeding,

feeding the baby on demand,

joint stay of mother and child,

prevention of lactocrisis.

Natural, or breastfeeding, feeding a baby by latching on to the breast of his biological mother.

Breastfeeding is not limited to providing the baby with the necessary quality nutrients and the required amount... I. M. Vorontsov (1998) writes that “breastfeeding today
- this is a phenomenon of general biological adaptation, programming and stimulation of the development of children of the neonatal period and early age, where nutrition itself is only one of the components of the integral developmental environment of the child, which forms the set of influences and interactions that constitutes the early experience of the child.

The structure of the spectrum of the effects of breastfeeding on the child's body (according to I. M. Vorontsov, E. M. Fateeva, 1998):

The chemical composition and biological properties of human milk, the benefits of natural feeding
From the beginning of lactation and in the future, there is a change in the composition of milk and its calorie content (Tables 1.48 and 1.49).
Table 1.48
Comparative composition of colostrum and milk in percent (in g per 100 ml)
(after A.F.Tur)

Table 1 49
Caloric content of colostrum and milk

Colostrum is a thick, sticky, yellow liquid. The composition and quantity of colostrum (it is small) correspond to the still weak digestive capacity of the newborn. Compared with mature milk, colostrum contains more protein, and the albumin and globulin fractions of proteins prevail over casein (casein appears only from the 4th-5th day of lactation, and its amount gradually increases); 2-10 times more vitamin A and carotene, 2-3 times more ascorbic acid; contains more vitamins B] 2 and E; 1.5 times more salts, zinc, copper, iron, leukocytes, among which lymphocytes dominate. Colostrum is especially rich in class A immunoglobulins (secretory), which, along with other factors
promotes, immediately after birth, the high efficiency of the intestinal immunological barrier. Therefore, colostrum is sometimes referred to as a factor providing the first vaccination, or, as they say, "warm" immunization of a child, as opposed to "cold" (ampoule). Conversely, the content of fat and milk sugar (lactose) in colostrum is lower than in mature milk. Many proteins of colostrum (albumins, globulins, etc.) can be absorbed in the stomach and intestines unchanged, since they are identical to the proteins of the child's blood serum. Colostrum is a very important intermediate form of nutrition between the periods of hemotrophic and amniotrophic nutrition and the period of enteral (lactotrophic) nutrition of the child.
Transitional milk - this is milk at intermediate stages of biological maturity, it is excreted during individually different periods after childbirth. With an increase in its amount, the mammary glands fill, swell and become heavy. This moment is called the "arrival" or "flow" of milk. Transitional milk contains less protein and minerals than colostrum, and the amount of fat in it increases. At the same time, the amount of milk produced is also growing, which corresponds to the child's ability to assimilate large amounts of food.
Mature milk - This is milk produced by the beginning of the 3rd week after childbirth (this happens in the vast majority of women; in 5-10% of women, mature milk may appear a week earlier). The composition of human milk (Table 1.50) largely depends on the individual characteristics of the nursing mother, the quality of her nutrition and some other factors.

Benefits of Breastfeeding for Infant and Maternal Health

Baby

• The frequency and duration of dyspeptic diseases decreases
• Provides protection against respiratory infection
• Reduced incidence of otitis media and recurrent otitis media
• Possible protection against neonatal necrotizing enterocolitis, bacteremia, meningitis, botulism and urinary tract infection
• May reduce the risk of autoimmune diseases, such as type I diabetes and inflammatory diseases of the digestive tract
• Reduces the risk of developing cow's milk allergy
• Possibly lower risk of obesity in older childhood
• Improves visual acuity and psychomotor development, which may be due to the presence of polyunsaturated fatty acids in milk, in particular, doco-hexaenoic acid
• IQ scores increase, which may be due to factors present in milk or increased stimulation
• Reduction of malocclusion due to better shape and development of the jaws

Mother

• Early initiation of breastfeeding after childbirth promotes maternal recovery after childbirth, accelerates uterine involution and reduces the risk of bleeding, thereby reducing maternal mortality, and preserves maternal hemoglobin stores by reducing blood loss, leading to better iron status
• The period of postpartum infertility increases, which leads to an increase in the interval between pregnancies, if contraceptives are not used
• Possibly accelerated weight loss and return to pre-pregnancy weight
• Reduces the risk of breast cancer in the premenopausal period
• Possibly reduced risk of ovarian cancer
• It is possible to improve bone mineralization and thereby reduce the risk of hip fractures in postmenopausal age

Breastfeeding technique and regimen

First attachment to the chest healthy full-term babies are produced as quickly as possible, optimally - within the first 30 minutes after the baby is born. After the first cry, the appearance of breathing and the initial processing of the umbilical cord, as well as rubbing, it is laid out on the mother's stomach, in its upper part. For skin contact of a newborn, it is better not to rinse with water, it is also advisable to postpone until the end of the first application and instillation of eye drops. The child, lying on his stomach, is held by the mother with her hand, and from above it is covered either only with a sterile sheet, or with a sheet and a blanket (together with the mother). The child's search behavior is expressed in sucking movements, head turns and crawling movements of the limbs. Most newborns are able to find and capture the areola of the mother's breast on their own. It is noted that early contact with the mother contributes to the rapid development of lactation, the production of breast milk in larger volume and a longer, better and faster adaptation of newborns to the conditions of extrauterine life, in particular, to an earlier colonization of the intestine and skin with bifidum flora and a decrease in the duration of the phase of transient intestinal dysbiosis. Skin-to-skin contactallows not only the baby to feel the mother's warmth, the beating of her heart, stimulates the development of the child's psyche and the establishment of mental contact with the mother. It also helps to enhance the woman's feeling of motherhood, calms the woman and eliminates her stress hormonal levels, better involution of the uterus, etc. Ideally, the mother and child should be left in close skin contact after an uncomplicated birth for 1-2 hours. If sucking at the first skin contact did not take place, then it is impractical to keep the baby on the breast for more than two hours.

In the event that it is difficult to attach the baby to the breast immediately after childbirth (caesarean section, illness of the mother or child), this should be done as soon as possible, and before that, milk must be regularly expressed and given to the child.

The main indications for later attachment to the breast:

• on the part of the child: children born in a state of asphyxia, with suspected intracranial injury, with cephalohematoma, as well as newborns whose general condition is unsatisfactory, deeply premature, children with developmental defects, from mothers with Rh-negative blood;
• on the mother's side: surgical interventions during childbirth, childbirth in preeclampsia, profuse bleeding during childbirth, the presence of any infectious processes.

It is now recommended to place the mother and the baby in the same room immediately after delivery. When staying together in the postpartum ward, the mother has unlimited access to the baby at any time of the day, she can feed him at the first request, that is, adhere to a free feeding regime. The signs of hunger can be rotational movements of the head in search of the mother's breast, active sucking movements of the lips, smacking lips, loud, persistent crying. However, in some cases, when the mother does not understand the reasons for the child's anxiety and attempts to eliminate it by frequent latching to the breast, overfeeding can be observed, which is a risk factor for the development of gastrointestinal dysfunction, excessive weight gain, and accelerated growth. A child may cry not only because he is hungry, but also for other reasons. Obviously, in these cases, feeding the child cannot eliminate the cause of the cry and, moreover, can intensify it (for example, with intestinal colic). The frequency of breastfeeding can be 12-20 or more times a day and is determined solely by the child's need... During feeding, at first, you can apply the baby to both mammary glands. Such frequent feeding promotes better lactation. It is important not to relieve the child's anxiety caused by starvation, supplementation between feedings, especially glucose or tea with sugar, especially milk formula. With a sufficient level of lactation, breast milk fully satisfies the need for fluid even in hot climates.The break between daytime feedings may not even reach two hours, and between nighttime feedings there may be no more than 3-4 hours. Moreover, to ensure long-term stable lactation in the first days after birth, night feeds are especially important.

Subsequently, as the child grows, and also as the volume of lactation increases, the frequency of feedings is reduced and stabilized in the range from 10-15 in the first days and weeks to 5-7 in subsequent periods. The transition from an indefinite feeding regimen to a relatively regular one takes from 10-15 days to 1 month. It is important to show some flexibility in shaping your diet. The number of feedings can vary widely depending on the state of lactation on that particular day, the degree motor activity and energy consumption of the child, his health, etc. This also applies to night feedings. On the one hand, night feeds are considered to be factors that contribute to lactation. On the other hand, it cannot be considered that feeding the child at night after the neonatal period, in the case of established satisfactory lactation, is strictly obligatory for all children. Getting enough sleep and getting enough rest is important for a nursing mother and helps to maintain good lactation. In the event that the child does not have a need for night feedings, he himself will refuse them and should not be prevented from doing so. "Free" or "on demand" feeding contributes to the establishment of not only optimal lactation, but also close psychoemotional contact between mother and child, correct neuropsychic and physical development of the child.

An important advantage of co-housing the newborn with the mother is that the baby's risk of infection is minimized. In the case when the mother takes care of the child from the very birth, his body is populated by those microbes that are in the mother's body. Moreover, breast milk contains specific antibodies to them. In the case when the child is placed in the nursery, where the staff of the maternity hospital takes care of him, the baby is surrounded by microorganisms inherent in "strangers". Safe for them, such bacteria can be pathogenic for the child, and there are no specific antibodies against them in the mother's milk. This often contributes to the sudden development of epidemics among newborns of skin diseases, respiratory and gastrointestinal infections.

Factors such as limited feeding time, scheduled feeding, uncomfortable or inappropriate feeding position, use of the nipple, and other fluids such as water, sugar solutions, vegetables, or dairy products reduce the duration and effectiveness of breastfeeding.

Each child determines the length of stay at the breast for himself. Some babies suckle very actively, quickly release the nipple and turn away from the breast. But there are so-called "lazy suckers" who suck slowly and sluggishly, often fall asleep at the breast, but when they try to remove the nipple, they wake up and suck again. Such prolonged feeding can damage the skin of the nipple and form cracks on it. Therefore, it is desirable that the duration of one feeding does not exceed 20-30 minutes. For this purpose, the "lazy sucker" should be stimulated - pat on the cheek, make an attempt to remove the nipple, etc.

On the first day after giving birth, the mother feeds the baby in bed, on the following days she chooses the most comfortable position for herself and the baby - lying down, sitting with her feet resting on a bench 20-30 cm high or standing (if there were perineal ruptures, perineotomy, episiotomy).

Before feeding, the mother should thoroughly wash her hands with soap and water, wash her breasts boiled water and dry with a soft towel, without rubbing the nipple and areola area. It is best to express the first drops of milk before breastfeeding. The arm supporting the child must be supported. Supporting the baby by the back and shoulders, the mother should not press on the baby's head, otherwise he will reflexively throw his head back. During feeding, the mother holds the baby facing her, "belly to belly" so that he does not have to turn his head. When using any posture and body position during feeding, the nursing woman and the baby should see each other's faces well, using the feeding time to carefully study each other's faces, facial expressions, and eye expressions. The breast is taken with fingers II and III of the opposite hand by the edges of the areola above and below the nipple and the nipple is inserted into the child's mouth. While sucking, the baby should cover not only the nipple with his mouth, but also the entire areola (areola), as well as the part of the breast below the areola. The baby's lower lip should be turned outward, the baby's chin, cheeks and nose should be close to the chest. The baby sucks in the nipple and areola of the breast, and then,
pressing on them with the tongue, squeezes out the milk. From the breast that the baby sucked it is necessary to express the remaining milk(but, of course, not to the "last drop"), then wash the breast with boiled water and hold it open for a while, let the nipple dry in the air. With sufficient lactation, the baby receives milk from only one breast during feeding, and from the other during the next feeding. However, if the baby has completely emptied one breast and there is not enough milk, the other should be offered. Feeding should be started on the other side each time. It is also very important not to stop feeding too early. Breastfeeding babies do not suckle continuously and may pause during feeding. The baby must decide not to breastfeed when offered again after a few minutes. The chemical composition of "front" and "back" milk is different Foremilk is milk produced at the beginning of a feed. Hind milk is milk produced at the end of a feed. The first portions of breast milk contain more lactose, less fat, and slightly less protein. The last ("back") portions of milk are richer in fat, the amount
which can reach up to 7-8%, which provides a sufficiently high calorie content of this milk.

After the end of feeding, the child is given an upright position for 1-2 minutes to regurgitate the air swallowed during feeding. Sometimes the baby will spit up a little milk, but this should not cause concern.

Expressed breast milk it is necessary to give it to the child in cases where, for some reason, it is impossible to apply it directly to the mother's breast (mother's illness, birth trauma, deep prematurity of the child, etc.). There are situations when the mother cannot feed the child due to domestic reasons (day work, school, etc.). If milk is given from a bottle, it is necessary that the opening in the nipple is small and the milk flows out in separate drops. Otherwise, the baby, accustomed to easily receiving food through the nipple, will quickly refuse to suckle. However, a too tight nipple and a small hole in it can contribute to swallowing air during feeding and, as a result, regurgitation, intestinal colic.

Store expressed milkit is necessary in the refrigerator at a temperature not higher than +4 ° С. Within 3-6 hours after expressing and in case of correct storage, it can be used after warming up to + 36-37 ° С. When stored for 6-12 hours, milk can be used only after pasteurization, and after 24 hours of storage, it must be sterilized. To do this, put a bottle of milk in a saucepan, pour warm water slightly above the level of milk in the bottle; during pasteurization, the water is heated to + 65-75 ° C and a bottle of milk is kept in it for 30 minutes, during sterilization, the water is brought to a boil and boiled for 3-5 minutes.

Some possible reasons child's anxiety.

• Between the ages of 3 and 4 months, babies quite often show anxiety during feeding. At the same time, the child, starting to suck on the breast, suddenly drops the nipple, cries loudly, pulls his knees to his stomach, then sucks again and cries again. The attack can last from 10 minutes to 2 hours. Such a reaction in practically healthy children can be caused by intestinal colic, when, when the first portions of milk enter the gastrointestinal tract, intestinal motility increases. Increased gas production, swallowing of air during rapid and greedy breastfeeding are also important. In this case, you should interrupt feeding, take the baby in your arms, holding him upright, or do a light massage of the abdomen with a warm hand clockwise. It is important to talk affectionately with your child. If this does not help, you can install a gas outlet tube. Sometimes gas and feces pass on their own. When the baby has calmed down, you can continue feeding. With frequent colic, the child can be given activated charcoal, smecta, chamomile decoction.
• The onset of colic in a child is sometimes associated with the consumption of any foods by the nursing mother (excess milk, rough vegetables, coffee, etc.). Moreover, they should be excluded from the diet or reduced in number. Anxiety can be related to the mother's smoking or medication.
• A baby may cry while feeding if he has thrush in his mouth. In this case, sometimes you have to spoon feed the child with expressed milk and actively treat thrush.
• The baby cannot breathe freely during feeding if there is a runny nose. Then, before feeding, you need to thoroughly clean the baby's nasal passages with cotton swabs, drip any vasoconstrictor drops. If necessary, the cleansing of the nasal passages is repeated during feeding.
• The excitement and crying of a baby during feeding are often in cases where the mother has a so-called "tight breast". At the same time, milk is produced in sufficient quantities, but it is difficult to separate, and it can be difficult for a child to suck it in the right amount. In this case, the mother should express a certain amount of milk immediately before feeding, perhaps - massage the breast, then the breast will become softer and the baby will suck easier.
• Certain difficulties with feeding the baby can arise with the wrong shape of the nipples. The nipples can be flat and inverted and the baby cannot latch on to the breast properly. It is possible to prevent such phenomena if, even before childbirth, special preparation of the nipples (massage, stretching) is carried out. If this has not been done and the child has not been able to adapt to sucking such a breast, you have to feed him through a special pad, and sometimes with expressed milk. However, many children cope with these difficulties over time.
• The reason for the crying of the child may be an increase in the child's appetite (hungry crying) due to an uneven increase in energy consumption, if, for example, he began to grow faster than before. it common reason restlessness at about 2 and 6 weeks of age and about 3 months. If the baby suckles more often over the course of several days, lactation will increase.

Feeding LBW and Premature Babies has its own characteristics. Of course, breast milk is also the optimal food for them. However, not always one human milk can satisfy all the needs of these children in macro- and micronutrients, provide high rates physical development... In this regard, it is proposed to add to the nutrition of such children (simultaneously with breast milk) fortifier mixtures, for example, Enfamil HMF (Mead Johnson), Similac Natural Care (Ross), Care Neonatal BMF (Nutricia), which correct the composition of human milk, make it the composition is more optimal for small children. This allows you to preserve the main advantages and protective properties of natural feeding of a small baby and give him the opportunity to develop intensively.

Methods for Determining the Amount of Milk Needed for a Breast

One of the main indicators of the sufficiency of a baby's breast milk is his behavior. If, after the next feeding, the baby calmly lets go of the breast, looks happy, has enough sleep until the next feeding, then he has enough milk. Objective signs of an adequate volume of milk are uniform, in accordance with age norms, weight gain, an increase in other anthropometric indicators (body length, head circumference), good skin condition, elastic soft tissue tour, normal frequency of urination and stool. If there is a suspicion of insufficient lactation, control feedings must be performed. The child (in clothes) is weighed before and after
latching on to the breast at every feed during the day... With individual feedings, the amount of milk sucked out varies so much that it is difficult to determine the amount of milk sucked out per day from one or two weighings. Obtained at check weighing the data are compared with the calculated values.

In the first 10 days of life the required amount of milk for a full-term baby can be determined by the formulas:

• Finkylyitein's formula as modified by A.F. Tour:

amount of milk per day (ml) \u003d n x 70 or 80,
where: n - day of life; 70 - with a weight at the time of birth below 3200 g; 80 - with a mass at the time of birth above 3200 g.

• Formula N.P. Shabalov:

amount of milk per 1 feeding (ml) \u003d 3 ml x day of life x body weight (kg);

• N.F.Filatov's formula as modified by G.I.Zaitseva:

amount of milk per day (ml) \u003d 2% of body weight x day of life.

From the 10th day of life the daily amount of milk is calculated in two ways:

• "Volumetric" method according to Geibner-Czerny ... The amount of food is assigned depending on age and body weight. In this case, body weight should correspond to the average age standards.

The daily amount of food is:
at the age of 10 days to 1.5 months - 1/5 of the actual body weight;
at the age of 1.5-4 months - 1/6;
at the age of 4-6 months - 1/7;
over the age of 6 months - 1/8 of body weight.

• The high-calorie method of M.S. Maslov.

The energy value of food per 1 kg of the child's body weight should be:
in the 1st quarter of the year - 120 kcal / kg / day;

in the 2nd quarter of the year - 115 kcal / kg / day;

in the 3rd quarter of the year - PO kcal / kg / day; in the 4th quarter of the year - 105 kcal / kg / day.
One liter of human milk has a caloric value of about 700 kcal.

To determine the volume of one feeding, it is necessary to divide the daily amount of food by the total number of feedings. For example, a child at the age of 1 month should receive 800 ml of milk per day. With 7 meals a day, the volume of each feeding will be equal to PO ml of milk, and with 6 meals - 130 ml. A child in the first year of life should not receive more than 1000-1100 ml of food per day.

Introduction of complementary foods

Currently, there is a tendency towards later periods of complementary feeding - not earlier than 5-6 months of life. Early introduction of complementary foods can reduce the frequency and intensity of suckling and, as a result, decrease the production of breast milk. It is advisable to use not a simple chronological (according to the age scheme) purpose of complementary foods, but to introduce them individually. This can help maintain lactation in the mother and maximize the timing of exclusive breastfeeding. This individual delay should relate primarily to the energetically significant amount of complementary foods and non-dairy foods. Along with this, all children should from the age of 5-6 months to receive fruit juices and fruit purees as a so-called "pedagogical" or "shod", complementary foods... Educational complementary foods have their own goals - it allows the child to get acquainted with the different sensations of taste and texture of food, trains the oral mechanisms of food processing and prepares the child for the period when he needs an energy supplement. The introduction of training complementary foods is not a departure from exclusive breastfeeding. Individualization of the period for the introduction of training complementary foods can be based on the following signs of the child's maturity:

• extinction of the pushing reflex (tongue) with a well-coordinated reflex of swallowing food;
• the child's readiness for chewing movements when nipples and other objects get into the mouth.

At the beginning (not earlier than the 5th month of life), breastfed children are given juice. The introduction of juice into the child's diet should be started with 1/2 teaspoon, gradually increasing its amount to 5-20 ml. It is advisable to start the introduction with apple juice without sugar, which is characterized by low acidity and low potential allergenicity. The nutritional value of juices is determined primarily by the presence of natural sugars (glucose, fructose, sucrose, etc.) in them, which are easily absorbed and oxidized in the body, being at the same time a source of energy. Another important component of juices is organic acids (malic, citric, etc.), which facilitate the digestion process. Juices also contain significant amounts of potassium and iron.

After 2-3 weeks after the appointment of juices, fruit puree is introduced into the diet (apple puree is also better). Subsequently, the assortment of fruits is expanded - in addition to apple juices and purees, plum, apricot, peach, cherry, raspberry, black currant are given. In this case, sour and tart juices should be diluted with water. Orange, tangerine, and strawberry juices, which are among the foods with high potential allergenicity, should not be given to children younger than 6-7 months. This also applies to juices from tropical and exotic fruits (mango, guava, papaya, etc.). It is not recommended to give grape juice to children because of the high sugar content in it.

The introduction of juices and fruit purees should be started with juices and purees from one type of fruit and only after getting used to it can juices and purees from mixed fruits be introduced into the diet. It is better to give "educational" complementary foods to the child in the second feeding, after he has sucked a little milk from the breast, still retained the feeling of hunger, but enjoyed feeding. A small amount of fruit puree from the tip of a teaspoon is injected into the middle of the child's tongue. It is more expedient to use canned juices and fruit purees for industrial baby food, since in conditions of an unfavorable environmental situation and an insufficient level of sanitary and hygienic knowledge of the population, it is the industrial products that provide the quality and safety guarantee necessary for 1 year old children. In addition, canned foods for babies are usually fortified with vitamins, iron and other nutrients that babies need.

Actually "complementary foods" should be introduced into the diet of a healthy full-term baby no earlier than 5-6 months. At the same time, it is recommended to approach the timing of the introduction of complementary foods based not on the formal age principle, but taking into account the individual characteristics of the organism. An indication for the introduction of a dense, energetically significant complementary food can be the behavior of the child - the manifestation of the child's dissatisfaction in the form of anxiety, increased screaming, the need for more frequent attachment of the baby to the breast, repeated awakenings at night with a hungry cry, brisk movements of hands and feet at the sight of food, a decrease in the number of wet diapers and stool reduction. Some children, on the other hand, become lethargic and lethargic. An important objective sign of malnutrition is a slowdown in the rate of weight gain (Table 1.53).

From 8 months, as an independent complementary food, you can give a sour-milk drink (children's kefir, beef-kefir and other fermented milk products specially designed for feeding children of the first year of life). Fermented milk products are characterized by high nutritional value and significant physiological, including probiotic, activity. Unmodified (fresh) cow's milk for drinking should not be given to infants under 9 months of age, but it can be used in the preparation of complementary foods from 6-9 months.

Currently, there is a tendency to introduce new baby food products into the diet of children in the second half of their life instead of kefir and whole milk - mixtures of the follow ir group (“subsequent formulas”) - mixtures “Pikomil-2”, “Enfamil-2”, “ Bebelak-2 "," Nutrilon-2 "," Nan 6-12 months with bifidobacteria ", etc. This trend is due to the need to ensure a multicomponent balance of the daily diet with a decreasing amount of breast milk in its composition, the desire
reduce direct immunotoxic effect of cow's milk casein on the intestinal epithelium.

By the end of the first year of life, instead of follow-up formulas for the milk component of the diet, it is advisable to use cow's milk substitutes for children of the 2nd and 3rd year of life (for example, the Enfamil Junior mixture).

At the end of the first year (usually from 11 months), to further stimulate biting and chewing, in addition to crackers and cookies, they give slices of bread and rolls, sliced \u200b\u200bfruits, etc.

With any scheme for the introduction of complementary foods, the expansion of their range and quantity occurs due to the "displacement" of breast milk. As the number of breastfeeding decreases, the amount of milk produced by the mother will also decrease. However, there are reasons to consider it expedient to preserve at least one feeding per day with breast milk for up to 1.5-2 years and even longer, as recommended by WHO and UNICEF. It is very important to keep breastfeeding during the hot summer months if the baby is sick.

MIXED AND ARTIFICIAL FEEDING

Contraindications to breastfeeding on the part of the mother:

• open form of tuberculosis with bacilli excretion;
• HIV infection;
• especially dangerous infections (smallpox, anthrax), tetanus;
• the state of decompensation in chronic diseases of the heart, kidneys, liver;
• acute mental illness;
• malignant neoplasms.

For infections in the mother, such as measles and chickenpox, breastfeeding can be done if the baby is given immunoglobulin. With typhoid, chronic hepatitis, dysentery, salmonellosis, the mother can express milk and feed the baby with this milk after sterilization. With acute respiratory viral infections, sore throat, bronchitis and pneumonia, feeding can be carried out by latching on to the breast after lowering body temperature and improving the general condition of the woman. In this case, it is necessary to use masks and limit contact between mother and child during the break between feedings. A serious contraindication for feeding a child, including expressed milk, is the use of medicines in the treatment. These include: antibiotics (chloramphenicol, tetracycline), isoniazid, nalidixic acid (negram or nevigramone), sulfonamides, estrogens, cytostatics, cyclosporine, antithyroid drugs, diazepam, lithium salts, meprotan, phenylin, reserpine, atropine, ergotamine, drugs hexamidine.

Contraindications to breastfeeding by the child : hereditary metabolic diseases - galactosemia, phenylketonuria, maple syrup-smelling urine.

For making simple mixturesmilk is diluted with water or cereal broths (rice, buckwheat) in a 1: 1 ratio - mixture No. 2 (in the first 2 weeks of life); 2-1- mixture No. 3 (aged from 2 weeks to 3 months). Dilution of milk is primarily aimed at reducing the amount of protein per unit volume. The lack of carbohydrates is replenished by adding sugar, and fat - with cream. After 3 months, children are given whole cow's milk with the addition of 5% sugar (mixture No. 5). However, according to modern recommendations, unadapted mixtures (both sweet and kefir) can be given no earlier than 8-9 months. At the same time, fermented milk products (including adapted ones) should make up no more than 50% of the total daily volume of breast milk substitutes and (or) “subsequent” mixturesreceived by the child, since their large amount can cause shifts in the acid-base balance in infants. The introduction of unadapted mixtures into the diet at a younger age can have an adverse effect on nitrogen metabolism and the function of immature kidneys.

To prevent the baby from breastfeeding, with mixed feedinga small amount of supplementary food is given from a spoon. If the amount of supplementation is greater, then the mixture is given from the bottle through the elastic teat. It should have one or more very small holes that are burned with the tip of a hot needle. When the bottle is tipped over, the mixture should flow out in drops, not in a trickle. If mixed feeding is carried out in connection with hypogalacia, it is advisable to use breast milk as much as possible at each feeding. Therefore, first, the child is applied to the breast and only after its emptying is it fed. The remains of breast milk are expressed and given either in the same feeding or in the next

In children who are bottle-fed, complementary foods can be introduced at an earlier date,than in breastfed babies. This is due to the fact that children are already receiving in the composition of breast milk substitutes a significant amount of "foreign" food products: cow's milk, sweet syrups, vegetable oils containing a fairly large amount of new nutrients - proteins, oligosaccharides, lipids, different in structure from of these ingredients in human milk. Thus, children are to a certain extent adapted to "foreign" nutrition. The first complementary food (vegetable puree) with artificial feeding is introduced into the diet from 4.5-5 months, the second complementary food (on a cereal basis) - from 5.5-6 months. However, taking into account the individual characteristics of development, as well as with natural feeding, cereals can also be used as the first complementary foods, better - enriched with iron, vitamins, microelements. Fruit juices and purees should be prescribed from 3 and 3.5 months, respectively. Earlier (from 1.5 months) introduction of juices is also acceptable, taking into account their individual tolerance. It is advisable to use the yolk from the age of 6 months, meat - from 7 months. Kefir, other fermented milk products and whole cow's milk as complementary foods can be introduced into the diet from 8 months, however, it is more preferable to use "subsequent" formulas in these children.