Breastfeeding Education for Physicians: The Road

Report
DISCLOSURES
Faculty Disclosure and Resolution of Conflicts of Interest
As a provider of Continuing Medical Education accredited by the Accreditation Council for Continuing Medical
Education, the USCSOM-PH CME Organization must ensure balance, independence, objectivity, and scientific
integrity in all its educational activities. In addition, we must show that everyone who is in a position to control the
content of an educational activity has disclosed their relevant financial relationships with any commercial interest and
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Therefore, we require that all persons in a position to control the content of this educational activity (planning
committee members, moderators, faculty, etc) complete a Financial Disclosure Statement. In addition, speakers must
agree to:
1. Address the specified objectives;
2. Deliver balanced evidence-based content;
3. Present the source and type or level of evidence to participants;
4. Discuss all reasonable clinical alternatives when making practice recommendations; and
5. Disclose off-label/investigative uses of commercial product/devices.
Speakers who agree to participate in the activity who disclose that they have a relevant financial relationship are
required to attest that:
1. These relationships will not bias or otherwise influence their involvement in the activity, and
2. Practice recommendations they make relevant to the companies with whom they have relationships will be
supported by the best available evidence or, absent evidence, will be consistent with generally accepted medical
practice.
In addition, conflicts of interest are assessed and resolved through a review process conducted under the direction of
the USCSOM-PH CME Organization.
Therefore, the following disclosures are made:
1. Drs. Amrol, Krotish and Mr. Kojo Danquah-Duah disclose that neither they nor their spouses/partners have had
any relevant financial relationships in the past 12 months with any proprietary entities producing, marketing, reselling, or distributing healthcare goods and services.
Accreditation and Educational Credit
The University of South Carolina School of Medicine-Palmetto Health
Continuing Medical Education Organization designates this enduring
material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians
should claim only the credit commensurate with the extent of their
participation in the activity.
This CME Activity is planned and presented in accordance with all ACCME
Essential Areas and Elements (including the Standards for Commercial
Support) and Accreditation Policies.
Relevant financial relationships and acknowledgements of commercial
support will be disclosed to participants. Faculties are required to disclose
off-label/investigative uses of commercial products/devices.
Breastfeeding Education
for Physicians: The Road to Baby
Friendly Designation
Jennifer Amrol, MD
Assistant Professor of Clinical Pediatrics
University of South Carolina School of Medicine
Objectives
 Review the anatomy and physiology of breastfeeding.
 Examine the composition of human milk and the
significance of individual components.
Breast Anatomy
Breast
 Mammary tissue
 Alveoli
 Ducts
 Nipple and Areola
 Supporting connective tissue and fat, blood and
lymphatic vessels, nerves
 Adipose tissue distribution greatly differs among
women and is not related to milk production
Breast Anatomy
 Mammary tissue
 Alveoli
 Small sacs of milk secreting and storing cells clustered into lobules
 Surrounded by myoepithelial cells which contract in response to
oxytocin for milk ejection
 Ducts




Connect lobules to form distinct mammary lobe
Then connect lobes to end at the galactophore
Ducts beneath areola become fuller due to oxytocin during a feed
Number is not related to milk production
Breast Anatomy
 Nipple
 Has an average of 9 milk ducts passing to outside
 Has smooth muscle fibers and sensory nerves
 Shape and size vary between women
Inverted Nipples
 Women with inverted nipples can breastfed but they many need
more help postpartum.
 She should request assistance with breastfeeding as soon as
possible after her baby is born.
 After delivery, a breast pump might be useful to help evert the
nipples. If a pump is not available, a 20ml syringe with the
adaptor end cut off and the plunger inserted backwards is used
to help draw out a nipple.
 Avoid bottle and pacifier use so the baby does not become
accustomed to the longer artificial nipple which feels and flows
differently.
 When all else fails, an ultra-think silicone nipple shield can be
tried temporarily.
 Nipple preparation during pregnancy is not recommended.
Breast Anatomy
 Areola
 Circular and pigmented
 Contains Montgomery glands
 Secrete a bacteriostatic, oily fluid to protect the
areola and nipple during lactation
 Produces the mother’s scent that attracts the baby
 Shape and size vary between women
Stages of Lactation
 Mammogenesis
 Growth of the breasts
 In utero, prepubertal, pubertal
 Lactogenesis
 Functional change of the breasts so that they can secrete milk
 Occurs during pregnancy and initial postpartum period
 Galactopoiesis
 Maintaining the production of milk
 Begins 9 days postpartum
 Involution
 Termination of milk production
 With weaning
Mammogenesis
 In utero
 Mammary bulb is seen at 18-19 weeks gestation
 Fat pad precursor develops
 Rudimentary ductal system is present at birth
 After birth/before puberty
 Small set of branching ducts grows with child
 Remains inactive
Mammogenesis
 Puberty -Thelarche
 Takes 3 to 3 ½ years
 Occurs 2 ½ to 3 years prior to menarche
 Initial stages
 Increase in size and pigmentation of areola
 Development of breast bud
Mammogenesis
 Puberty -Thelarche
 Estrogen
 Breast tissue enlarges
 Stimulates growth of mammary ducts into preexisting fat pad
 Progesterone
 Effect begins with onset of menses and ovulation
 Secreted by ovary during luteal phase (second half of
menstrual cycle)
 Stimulates lobulo-alveolar development
 Alveolar clusters grow with each luteal phase and regress with
onset of menses and loss of hormones
Lactogenesis
 Mammary gland develops capacity to secrete milk
 Includes all steps needed to transform
undifferentiated breast tissue in early pregnancy to
fully differentiated state after pregnancy
 Two stages
 Beginning at the twelfth week of pregnancy
 Beginning shortly after delivery
Lactogenesis Stage 1
 Occurs by mid pregnancy
 Pregnancy hormones
 Progesterone
 Lactogenic hormones
 Prolactin and Human placental hormone
 Stimulate nipple and areolar growth
 Breast changes




Double in weight
Increased blood flow
Growth in lobules and alveoli (progesterone effect)
Increased secretory activity
 Mammary gland becomes competent to secrete milk
 Alveoli accumulate colostrum
 Colostrum is secreted immediately postpartum when the newborn feeds
 Milk secretion is prevented by elevated levels of estrogen and progesterone
Lactogenesis Stage 2
 Occurs whether or not the newborn breastfeeds
 Day 2 or 3 to day 8 after birth
 Average of 40 hours postpartum
 Earlier in multiparous women
 Tight junction in alveolar cell closes
 Onset of copious milk secretion
 Drop in levels of estrogen and progesterone
 Relative increase in prolactin levels
 Breasts are full and warm
 Switch from endocrine to autocrine control
 Continued milk production depends on regular milk removal
Lactogenesis Stage 2
 Blood flow, oxygen, and glucose uptake increase
 Progesterone
 Removal of placenta with its progesterone is required for milk
secretion
 Progesterone receptors appear to be lost in lactating tissues so that
the inhibitory effect of circulating progesterone is decreased once
lactation is established
 So progesterone only birth control can be used once lactation is going well
 Insulin, GH, cortisol, and PTH
 Maternal secretion allows for mobilization of nutrients and minerals
required for lactation
Galactopoesis




Begins 9 days after birth and continues until weaning
Established milk secretion/production is maintained
Continued autocrine system of control
Prolactin
 Required to maintain milk secretion
 Oxytocin
 Required to produce let-down to allow milk extraction
Involution
 Begins at weaning
 Regular milk extraction ceases
 Prolactin is withdrawn
 Is completed ~40 days after last breastfeeding
 Milk secretion decreases due to the buildup of
inhibitory peptides
 Mammary gland returns nearly to pre-pregnancy
state
Lactation
 The cyclical process of milk synthesis and secretion
 Occurs with the help of prolactin and oxytocin
 Regulation of milk synthesis
 Quite efficient
 Average of ~800 ml/day but volume secreted may vary depending on
infant’s requirement
 Milk production
 Improves with relaxation
 Decreases with maternal stress and fatigue
 Increased dopamine and/or norepinephrine inhibit prolactin synthesis
 Stress and fatigue inhibit oxytocin release
 Effect of Alcohol
 Lower levels may enhance milk letdown due to decreased stress but higher
doses inhibit oxytocin release thereby inhibiting letdown
Physiology of Lactation
Physiology of Lactation
 Prolactin
 Polypeptide hormone synthesized in the anterior pituitary
 Positive regulation of secretion
 Released from anterior pituitary with the peak determined by the
intensity of suckling by the infant
 Negative regulation of secretion
 Main control is from hypothalamic inhibitory factors (dopamine
acts through the D2 receptors in lactotrophs)
 Stimulates mammary gland ductal growth and epithelial cell
proliferation
 Stimulates milk synthesis in mammary gland epithelial cells
 Suppresses ovulation
Physiology of Lactation
 Prolactin
 Levels increase from 10 ng/ml in prepregnant state to ~200 ng/ml
at term
 Secretion occurs 7 to 20 times per day with peaks of up to 75
minutes
 Peak is superimposed on continuous background level of secretion
 Levels quickly rise with suckling and peak ~30 minutes after start
of a feed
 Effect on milk production is most pronounced in first few weeks
after birth
 Levels are not proportional to milk secretion and do not directly
regulate milk synthesis or secretion
 More is produced at night so nocturnal feeds are helpful in
keeping up supply
 Makes mother feels relaxed and sleepy
Physiology of Lactation
Physiology of Lactation
 Oxytocin
 Synthesized in hypothalamus and stored in the posterior
pituitary
 Release is stimulated by suckling
 Neuroendocrine reflex has a significant psychological
component
 Oxytocin release may be stimulated by thought, sight, or sound of
infant
 Stimulates myoepithelial cells in alveoli to contract and expel
milk
 Forcible milk removal is called milk ejection or let-down
 Variation in perception of let-down
 Aids in uterine involution after delivery
 Uterine contractions may be associated with “after pains” that
indicate oxytocin release
Physiology of Lactation
 Signs of Oxytocin Release
 Tingling sensation in breast before or during a feed
 Milk flowing when mother thinks of baby or hears crying
baby
 Milk flowing from other breast during feeding
 Milk streaming from breast if latch is interrupted
 Slow deep sucks and swallows by the baby during feed
 Uterine pain during feed
 Thirst during a feed
Physiology of Lactation
 Milk production
 Positive local regulation by demand
1.
2.
3.
Increased suckling
Increased emptying
Increased milk secretion/production
 Skin to Skin (SSC) supports successful breastfeeding
 Partial milk removal sets a new, lower rate of milk
production
 Negative local regulation of milk production
 Feedback Inhibitor of Lactation
 Accumulates in milk between feeds so without removal of milk,
secretion/production is inhibited
 Explains why an empty breast makes milk faster than a fuller one
 Distention or stretch of the alveoli
 Local effect to inhibit milk secretion/production
 Once milk removal stops, involution begins
Physiology of Lactation
 Feedback Inhibitor of Lactation
 Inhibitory whey protein present in breast milk
 Builds up as milk accumulates in the mammary gland
 Without milk removal, the inhibitor stops epithelial cells
from secreting/producing more milk
 Protects breast from harmful effects of overfilling
 Once milk is removed, secretion restarts
 Allows production of milk to be determined by infant’s
needs
 Especially important regulatory mechanism once
lactation is established since prolactin does not control
milk volume produced
Maternal Diet and Milk Supply
 Mothers make nourishing milk for their infants from all kinds of food.
There are no foods that must be avoided, unless mother or baby
develops an allergic reaction.
 Breastfeeding mothers have an increased thirst that usually maintains
an adequate fluid intake; no data support the assumption that
increasing fluid intake will increase milk volume.
 Mothers do not need to drink milk to make milk; thirst can be satisfied
from a variety of nourishing beverages, including water.
 Calcium is available not only in milk and milk products but in many other
foods, such as broccoli, spinach, kale, bok choy, collards, mustard and
turnip greens, almonds, and canned fish.
 Poor maternal nutrition is not a contraindication to breastfeeding.
 Mothers following a vegan diet should take a B12 supplement
Galactagogues
 Metoclopramide — most commonly used
 Domperidone — not approved in USA. Similar to
metoclopramide but less side effects as little crosses
blood brain barrier
 Fenugreek and other herbal medicines — no scientific
data except anecdotal reports
 Goat’s rue, milk thistle, anise, basil, blessed thistle, fennel
seeds and marshmallow
Metoclopramide
 Effect is to increase prolactin level
 Benefit shown in small placebo controlled crossover study with
increase of 50 cc per feed with dose of at least 30 mg per day
 Side effects
 gastrointestinal, anxiety, sedation, and rare dystonic reactions
 No documented neonatal reactions
 Short term: 1–3 weeks is common.
 No evidence supporting long-term use.
 Usually wean after 10–14 days
 Common dosing regimen
 10 mg po qd first day
 Then 10 mg po bid
 Then 10 mg po TID
Fenugreek
 Most commonly recommended herbal galactogogue
 Usual dose is 1-4 capsules (580-610mg) tid to qid
 No standard dosing
 May also be taken as one cup of strained tea tid
 ¼ tsp seeds steeped in 8oz water for 10 minutes
 Increases supply within 24 to 72 hours
 Side effects in mother
 Maple like odor to sweat, milk, and urine
 Diarrhea
 Increased asthmatic symptoms
 Lower blood sugar
 Contraindicated during pregnancy due to uterine stimulant effects
Human Milk Composition
Human Milk Composition
 Colostrum
 Denser milk provided for the first 2-3 days after birth
 Facilitates the passage of meconium to decrease enterohepatic circulation and
thus encourage elimination of bilirubin
 Aids in establishment of Lactobacillus bifidus flora in infant’s gut
 Milk Volumes




Day 1 40-50 ml (range of 7-123ml)
Day 3 300-400 ml
Day 5 500-800 ml
Low volumes encourage frequent feeds to stimulate milk synthesis
 Colostrum Energy Value
 67 kcal/100ml
 Colostrum components
 Higher concentrations of Na, K, and Cl than mature milk
 Higher percentage of protein, minerals and fat soluble vitamins than mature
milk
Human Milk Composition
 Colostrum
 Denser milk with higher concentration of proteins
 White cells and antibodies (especially sIgA)
 Important immune protection from exposures to environmental microorganisms
 40-60% of cells are macrophages
 Epidermal growth factor
 Prepares gut lining to receive nutrients in milk
 Lactose
 Prevents hypoglycemia and facilitates meconium passage and therefore
bilirubin excretion
 Vitamin A
 Protects the eyes and epithelial surfaces
 Beta carotene, its precursor, provides yellowish color of colostrum
Human Milk Composition
Immunoglobulins in Human Milk
(levels decrease over time)
Day Postpartum
1
3
7
8 – 50
Output - mg/24 hours
IgG IgM
IgA
80
120
11,000
50
40
2,000
25
10
1,000
10
10
1,000
Human Milk Composition
Note the increases in calories, lactose, and fat while the protein
decreases from colostrum to mature milk.
Human Milk Composition
 Transitional Milk
 Milk produced from days 5-12
 Intermediate composition between
colostrum and mature milk
 Volume continues to increase
 Macrophage as percentage of WBCs
increases to 80-90%
 Concentration is 104 to 105 per ml of milk
Human Milk Composition
 Mature Milk
 Milk produced after ~14 days
 Contains all the nutrients an infant needs for the
first 6 months of life and is uniquely specific for
humans
 Fat (3.8%), protein (0.9%), carbohydrates (7.2%), vitamins,
minerals, and water (87%)
 Is easily digested and efficiently used
 Composition varies through lactation: over a day,
within a feed, and between women
 Calories
 20 calories per ounce (65-75 kcal/100ml)
Formula
Milk
Breast
Milk
Note the substantial structure
of human milk under a
microscope; this is due to the
compartmentation of the
various components such as
the nutrients and bioactive
substances. This image
demonstrates that milk is a
living tissue containing about
4000 cells/cubic mm including
neutrophils, macrophages,
and lymphocytes.
Human Milk Composition
 Water
 Human milk is 87% water
 Provides sufficient fluid to maintain hydration even in
hot climates
Human Milk Composition
Fat
 Fat content




3.5-3.8g/100ml provides 50% of energy/calories in milk
Most variable component of human milk
Separates on standing
Contains cholesterol, triglycerides, short-chain fatty acids, and
long-chain polyunsaturated fatty acids
 Foremilk
 Milk that accumulates in breast since previous feed
 Lower fat content (1.5 to 2%) and looks bluish-gray
 Hindmilk
 Milk that is secreted during a feed
 Higher fat content (2-3x more than foremilk- 5 to 6%) and
looks creamy white
Human Milk Composition
 Fat content increases from the start of a feed (~1.7%)to
the end of a feed (~5.5%).
 Protein content decreases from the start (0.9%) of a
7.0
feed to the end (0.7%).
6.0
 Foremilk has less fat
but more protein than
hindmilk.
5.0
4.0
Fat
3.0
Protein
2.0
1.0
0.0
Foremilk
Hindmilk
Human Milk Composition
Fat
 Lipid Component
 Milk fat globule
 Forms with lipid secretion from apical mammary
epithelial cell and envelopment in its plasma
membrane
 Also contains proteins, growth factors, and
vitamins
 Mucins on the globule membrane adhere to
viruses and bacteria to aid in elimination from
body
Human Milk Composition
Fat
 Lipid Component
 Bile salt-stimulated lipase
 Acts on triglycerides to produce free fatty acids
and 2-monoglycerides
 Prevents fatty acids from forming soaps with
minerals
 Results in superior absorption of fat and
minerals
 Not present in formula
Human Milk Composition
Fat
 Lipid Component
 Abundance of essential fatty acids (linoleic and
linolenic acids)
 Most exist as triacylglycerols and phospholipids
 167 fatty acids have been identified in human milk
 Unique long chain polyunsaturated fatty acids (including
omega-3 fatty acids DHA and ARA)
 Term infants are able to convert long chain polyunsaturated
fatty acids to DHA and ARA so the addition of these to term
formulas may be unnecessary but is likely useful for
preterm infants who cannot convert them.
 Cholesterol is also present in significant quantities
Human Milk Composition
Protein
 Human milk contains 9g protein/L (whey and casein)
 Less than in other animal milks
 Whey proteins consist primarily of α-lactalbumin
without β-lactalbumin
 Cow milk whey contains β-lactalbumin to which infants can
become intolerant
 Contains less casein than other milks
 Provides 80% of milk’s nitrogen
 Protein content declines over 2-4 weeks but then is constant
until weaning
Human Milk Composition
Protein
 Colostrum
 90/10 ratio of whey/casein
 Mature Milk
 70/30 ratio of whey/casein
 Late Lactation
 50/50 ratio of whey/casein
 Cow Milk
 18/82 ratio of whey/casein
Human Milk Composition
Protein
 Whey (70%)
 Contains water, electrolytes, and proteins
 α-lactalbumin, albumin, lactoferrin, immunoglobulins,
enzymes (e.g., lysozyme), growth factors, and hormones
 Remains in solution after acidification
 Lactoferrin, lysozyme, and sIgA resist proteolytic
digestion and line the GI tract to provide host
defense
 Present only in human milk
 Generally more easily digested and associated with
more rapid gastric emptying
Human Milk Composition
Protein- Whey
 Lactoferrin
 Transports and promotes the absorption of iron
 Inhibits the growth of iron-dependent bacteria in the
gastrointestinal tract such as coliforms and yeast
 Lysozyme
 Enzyme that protects the infant against E. Coli and Salmonella
 Promotes the growth of healthy intestinal flora and has antiinflammatory functions
 Secretory IgA
 Primary Ig in breastmilk
 Protects the infant from viruses and bacteria, specifically
those to which the baby, mom, and family are exposed
 Helps protect against E. Coli
Human Milk Composition
Protein
 Casein (30%)
 β-casein forms a soft curd in the infant’s stomach if
pH<5
 Curd is an insoluble calcium caseinate-calcium
phosphate complex
 Low solubility in acid
 Human milk casein curds are more easily digested
than those in other milks
Human Milk Composition
 Non-protein nitrogen containing compounds
 Provide 20% of nitrogen in milk
 Epidermal growth factor
 Contributes to the development and function of intestinal
mucosa
 Taurine
 Free amino acid associated with bile acid conjugation and
neurotransmission
 Nucleotides
 Have metabolic and immune functions
 Carnitine
 Used for lipolysis of long-chain fatty acids
 Somatomedin-C, Insulin and other peptides
Human Milk Composition
Carbohydrates
 When is lactase present in the infant gut?
 Present in maximal amounts in the intestinal
brush border of full term infants
 Deficient before 34 wga
Human Milk Composition
Carbohydrates
 Lactose (90%) 7.2g/L
 Disaccharide of galactose and glucose synthesized in the breast
 Important source of glucose
 Important source of galactose for galactolipids used in infant brain
development
 Monosaccharides, oligosaccharides, and glycoproteins (10%)
 Oligosaccharides prevent bacteria from adhering to mucosal surface
 Oligosaccharides plus glycoproteins = “bifidus factor”
 Stimulate growth and colonization of newborn’s gut with Lactobacillus bifidus
(beneficial bacteria that creates an acidic gut where harmful bacteria cannot
survive)
Human Milk Composition
 Minerals
 Content is similar between mammal milks but
concentrations, ratios, and bioavailability are species
specific
 Lower quantities results in lower solute load for
immature renal system
 Iron, sodium, potassium, calcium, magnesium, zinc,
and small amounts of copper, selenium, chromium,
manganese, molybdenum, and nickel
 Zinc and Iron
 Well absorbed from human milk
 Zinc deficiency is rare in breastfed infants whose
mothers have adequate Zn intake
Human Milk Composition
 Iron
 100mcg/L versus formula with 12mg/L
 50-100% of human milk iron is absorbed
 4% of iron fortified formula iron is absorbed
 Absorption is enhanced by high lactose and vitamin C
concentrations in human milk
 Lactoferrin in whey binds iron
 Increasing digestion and absorption of iron
 Also makes iron unavailable to iron dependent bacteria in gut
 Normal full-term infants can be exclusively breastfed for
6 months without becoming iron deficient
Human Milk Composition
 Vitamins
 Vitamin A, beta carotene, and vitamin E
 Plentiful in colostrum and early transitional milk
 Vitamin A protects against infection and aids early retinal
development
 Vitamin E protects red cells against hemolysis
 Vitamin D
 Sufficient only with adequate maternal diet and maternal and infant
sun exposure
 AAP recommends 400 IU/d for all breastfed infants until they are
ingesting or exposed to sufficient Vitamin D from other sources
 Vitamin K
 Poorly transported prenatally and also limited in human milk
 All newborns must receive Vitamin K at birth
 Vitamin B12
 Mothers on vegan diets may produce B12 deficient milk so
supplements are recommended
Examples of the Non-nutritional
Components of Human milk




Antimicrobial factors
 secretory IgA, IgM, IgG
lactoferrin
lysozyme
complement C3
leukocytes
bifidus factor
lipids and fatty acids
antiviral mucins, GAGs
oligosaccharides
Cytokines and anti-inflammatory factors
 tumour necrosis factor
interleukins
interferon-g
prostaglandins
a1-antichymotrypsin
a1-antitrypsin
platelet-activating factor: acetyl hydrolase
Transporters
 lactoferrin (Fe)
folate binder
cobalamin binder
IgF binder
thyroxine binder
corticosteroid binder
Others
 casomorphins
d -sleep peptides
nucleotides
DNA, RNA
http://www.unu.edu/unupress/food/8F174e/8F174E04.htm




Growth factors
 epidermal (EGF)
nerve (NGF)
insulin-like (IGF)
transforming (TGF)
taurine
polyamines
Digestive enzymes
 amylase
bile acid-stimulating esterase
bile acid-stimulating lipases
lipoprotein lipase
Hormones
 feedback inhibitor of lactation (FIL)
insulin
prolactin
thyroid hormones
corticosteroids, ACTH
oxytocin
calcitonin
parathyroid hormone
erythropoietin
Potentially harmful substances

viruses (e.g., HIV)
aflatoxins
trans-fatty acids
nicotine, caffeine
food allergens
PCBs, DDT, dioxins
radioisotopes
drugs
Human Milk Composition
 Passive Immunization via the Enteromammary Pathway
Maternal exposure
Breast tissue and breastmilk
Antigens
Maternal gut
Lymphoblasts
Mesenteric node
Infant
gut
Other mucosal surfaces
Lymphoblasts mature into
lymphocytes that produce
immunoglobulins that
move into the
bloodstream
Blood stream
Thoracic duct
Milk Composition Differences
Human Milk
Commercial Substitutes
Protein
Appropriate (species specific)
quality/quantity, easier to digest
Corrected in quantity but not in
quality (not species specific)
Fat
Appropriate quality/quantity of
essential fatty acids, lipase present
Lipase absent
Vitamins
Adequate except for vitamins D and
K in some situations
Vitamins added
Minerals
Correct amount
Partly corrected
Anti-Infective properties
Present
Absent
Growth Factors
Present
Absent
Digestive enzymes
Present
Absent
Hormones
Present
Absent
 Thank you for completing Section 2 of Breastfeeding
Education for Physicians. To obtain CME credit, please
click on the link below, provide your information and
complete the post-test
https://www.surveymonkey.com/s/BreastfeedingSectio
n2

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