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ALPP CLC EXAM (ACTUAL EXAM) WITH
CORRECT ACTUAL QUESTIONS AND
CORRECTLY WELL DEFINED ANSWERS
LATEST 2025 ALREADY GRADED A+
intestinal barrier function - ANSWERS-EBF associated with more rapid maturation in function
- extremely premature infants who received exclusive HM diet had significantly lower incidence of NEC and mortality
HM diet of more than 98% NEC rate - ANSWERS-NEC rate of 1.3%
pre-term formula NEC rate - ANSWERS-NEC rate of 11.1%
mixed feeding NEC rate - ANSWERS-NEC rate 8.2%
mother's own milk (MOM) fortifiers and donor milk - preterm - ANSWERS-two main choices
- fortifier made with cow's milk or fortifier made with human donor milk
- preterm formula should be the last choice according to most expert groups
- "the available evidence points to an increase in adverse outcomes with the cows milk fortifier, including NEC and severe morbidity comprising NEC surgery or death"
initiation of BF guidelines - ANSWERS-should be based on cardiorespiratory stability, irrespective of current maturity, age, or weight
- birthweight and length of stay are not associated with BF behaviors
- preterm babies at the breast have better SSB coordination and oxygenation including REE (resting energy expenditure) after feeding than when bottle feeding
WHO and UNICEF three strategies - ANSWERS-for increased breastfeeding initiation and duration in every country: promotion, protection, and support
breastfeeding promotion - ANSWERS-focuses on advantages of breastfeeding on a personal, community, country, or global level
breastfeeding protection - ANSWERS-focuses on government, manufacturer, and social responsibility to assure breastfeeding's ability to compete with commercial interests; includes addressing improper marketing practices; the AAP advices not to provide formula, company gift bags, and industry-authored handouts; in the US, state and local breastfeeding legislation addresses breastfeeding in public, employment issues, jury duty, family law, mothers in prison, etc.
breastfeeding trends - ANSWERS-last 150 years or som rates have declined
international code of matketing of breastmilk substitutes (the code) - ANSWERS-an international health policy framework to regulate the marketing of breastmilk substitutes in order to protect breastfeeding
- published by the WHO in 1981
- internationally agreed voluntary code of practice
- written in response to the marketing activities of the infant feeding indurstry which were promoting formula feeding over breastfeeding, which in turn was leading to dramatic increases in maternal and infant morbidity and mortality
- subsequent clarifying and extending resolutions have been passed by the world health assembly
breast feeding: a public health priority - ANSWERS-has been recognized as a public health priority in tropical climates since the 1930's, but not until the 1990's in the US
costs to prevent needless deaths - ANSWERS-less than $6 billion/year worldwide
suboptimal breastfeeding - ANSWERS-accounts for more than 3,340 maternal and child deaths a year, 80% are maternal
nursing a baby for a year or more - ANSWERS-decreases by 10-15% the risk of developing hypertension, diabetes, hyperlipidemia, and cardiovascular disease
women who do not breastfeed - ANSWERS-are at greater risk for myocardial infarction and aspects of metabolic syndrome; are at a greater risk of breast, endometrial, and ovarian cancer
the code - ANSWERS-regulates the marketing of breastmilk substitutes which includes infant formulas, follow-on formulas, and any other food or drink, together with feeding bottles and teats, intended for babies and young children; sets standards for the labeling and quality of products and for how the law should be implemented and monitored within countries
restricting marketing - ANSWERS-does not mean that the products cannot be made available, neither does it restrict parents choice; it simply aims to make sure that their choices are made based on full, impartial information, rather than misleading, inaccurate, or biased marketing claims
the strategy - ANSWERS-is intended as a guide for action
- it identifies interventions with a proven positive impact
- it emphasizes providing mothers and families the support they need to carry out their crucial roles
- it explicitly defines the obligations and responsibilities in this regard of governments, international organizations, and other concerned parties
possible reason why: hospitals in neighborhoods with many black residents do less to promote nursing than those in areas with more white residents"
anatomy of milk cells - ANSWERS-myoepithelial cells, connective tissue, capillaries, anteriole, venule, alveolar cells
anatomy of human breast - ANSWERS-glandular tissue made up of clusters of alveoli and small ducts, fat amongst the glandular tissue, milk ducts, areola, nipple with several duct openings
making milk - ANSWERS-messages from the breast travel through the nervous system to the brain, then hormones travel to the breast through the blood system
hormone pathways - ANSWERS-two separate hormone pathways, pituitary gland is important to both
prolactin levels - ANSWERS-go down in between nursing and rise during nursing
infrequent nursing - ANSWERS-leads to lower levels and less rise even with the same amount of nipple contact
ongoing milk production - ANSWERS-positively associated with suckling within the first 2 hours after birth
initiation for mothers of preemies - ANSWERS-initiation of milk expression before one hour resulted in significantly more milk when measured on days 7 and 42
triggering oxytocin mechanism #1 - ANSWERS-conditioned response - conditioned milk ejection (let down) reflex
- was probably given too much importance in the years we didn't understand the other mechanisms
- conditioned over time and lasts a lifetime
- is faster for women who already have one from previous breastfeeding
- to condition response.. smell, touch, hear the stimulus
triggering oxytocin mechanism #2 - ANSWERS-nipple stretching, happens with a proper latch
triggering oxytocin mechanism #3 - ANSWERS-baby hand massage, each hand movement releases oxytocin
hormones of lactation - ANSWERS-have an emotional/behavioral function as well as making and moving milk; aggression, protection, bonding & trust
milk composition - ANSWERS-is complex
- each species of mammal milk is different
- milk is "species specific"
lactogenesis I - ANSWERS-secretory differentiation, placental hormones, colostrum
lactogenesis II - ANSWERS-secretory activation, after complete delivery of placenta, rapid drop in progesterone, transitional milk
lactogenesis III - ANSWERS-lactation, galactopoesis, prolactin from frequent nipple stimulation, frequent removal of milk, mature milk
breastmilk composition - ANSWERS-human milk changes continually, makes it impossible to obtain a single representative sample of milk
preterm milk - ANSWERS-appears to have a different composition for the first 5- 7 weeks after delivery independent of gestational age at delivery
- appears to be higher in protein, fat, and electrolytes than term milk
- if baby is SGA, LGA, or AGA, does not make a difference in milk composition
after 1 year of lactation - ANSWERS-has significantly increased fat and energy contents
fore vs hind milk - ANSWERS-foremilk is milk at the beginning of a feed, hindmilk is at the end of a feed
- used to think that hindmilk contained more fat content but it is more complex than originally described
- foremilk does not mean "low fat" and hindmilk is not always highest in fat
- sometimes foremilk and hindmilk have equal amounts of fat and we should not give mothers tules based on the ideas of fore and hindmilk
breastmilk composition changes - ANSWERS-- over the course of lactation
- within the day
- within a feeding
- between feedings
is also changes by the way it is taken
babyled feeding - ANSWERS-"the breast-fed baby can regulate his fat intake quickly and thus mothers should be encouraged to practice baby-led feeding"
maximum fat levels - ANSWERS-obtained 30 mins post-feed
- mothers of male infants seem to produce milk that has 25% greater energy content than mothers of female infants
milk composition, milk action - ANSWERS-milk composition is complex, milk action is redundant
- milk is more than nutrition, bioavailability of nutrients is higher in human milk than in other foods or supplements
diarrhea mechanisms 1 - ph of the gut - ANSWERS-breastfed babies' gut is more acidic while formula-fed babies' guts are more neutral/basic
gut bacterial colonies (the microbiome) of mixed fed babies are similar to exclusively formula fed babies
diarrhea mechanisms 2 - low iron in the gut - ANSWERS-relatively low iron content in human milk
diarrhea mechanisms 3 - presence of bifidus factor - ANSWERS-promotes intestinal presence of lactobacillus bifidus that maintain the low pH and crowd out pathogenic organisms
diarrhea mechanisms 4 - presence of hormones - ANSWERS-hormone like factors and growth factors that stimulate growth and development of the GI tract and GI motility, such as:
- GI hormones
- prolactin
- EGF (epidermal growth factor)
- prostaglandins
diarrhea mechanisms 5 - antibodies - ANSWERS-such as SIgA bind to microbes in the baby's intestinal tract and prevent them from being absorbed into the rest of the body. mother's IgA has been found to protect against the development of NEC in preterm infants. maternal IgA shapes the host-microbiota relationship of pretern neonates that IgA in maternal milk is critical and necessary factor for the prevention of NEC
diarrhea mechanisms 6 - white blood cells - ANSWERS-kill microbes directly or mobilize other defenses
diarrhea mechanisms 7 - cell wall disrupters - ANSWERS-kill microbes by destroying the cell walls, these include fatty acids and lysozymes
diarrhea mechanisms 8 - B12 binding factor - ANSWERS-reduces the amount of B12 in the intestines available to microbes
diarrhea mechanisms 9 - lactoferrin - ANSWERS-deprives bacteria of iron, disrupts the integrity of the outer membrane of bacteria, assists in intestinal maturation and in the recovery of the intestine from injury and other mechanisms
diarrhea mechanisms 10 - antimicrobial activity boosters - ANSWERS-such as fibronectin and gamma interferon
diarrhea mechanisms 11 - mucosal wall protectors - ANSWERS-such as mucins and oligosaccharides, which also function as food for beneficial bacteria, adhere to microbes binding them so that they can't attach to the gut wall
diarrhea mechanisms 12 - microbes - ANSWERS-from the mothers skin and bacteria in the mother's breastmilk seed, the infant gut underscoring
adult GI hormones - ANSWERS-also impacted by suckling
when mother suckles her gastrin and cholecystokinin go up. this increases the efficacy of insulin and increases the storage of ingested nutrients
pregnancy & breastfeeding in re: to T2DM - ANSWERS-pregnancy itself may bring an increased risk for Type 2 diabetes in the mother, which breastfeeding can negate. compared with women who have not had children, childbearing women who do not breastfeed have a 50% increased risk of T2DM in later life
weight loss in the BF neonate - ANSWERS-in first date after birth, most babies lose weight, some from normal diureses
AAP weight loss stance in 2005 - ANSWERS-"weight loss in the infant of greater than 7% from birth weight indicates possible breastfeeding problems and requires more intensive evaluation of breastfeeding and possible intervention to correct problems and improve milk production and transfer"
AAP weight loss stance in 2012 - ANSWERS-added "evaluate body weight gain - body weight loss no more than 7% from birth and no further weight loss by day five: assess feeding and consider more frequent follow-up"
by two weeks at the latest: - ANSWERS-the baby should regained to its birth weight
infants lose more weight in the first postpartum days... - ANSWERS-- when labor meds are used... but perhaps not at a baby-friendly hospital
- when more intrapartum fluids have been given
- when there was no labor prior to cesarean
however, supplementation rates for weight loss decreased with routine use of 24 hr weight and did not increase untoward effects during the hospital stay
what do we know about breastfed babies who become dangerously undernourished? - ANSWERS-report by cooper & colleagues identified a significant increase in the incidence of malnutrition and hypernatremia in breastfed infants
- 5 sentinel cases in ohio began a chart review of the prior 4 years
- chart review babes were 23% below birth weight on average on readmission and showed clinical signs of dehydration and hypernatremia
- babies were: not d/c early, nursing q 3-4 or 4-6 hrs, scheduled, both breasts, 5-
- min a side, SLEEPY
- researchers found: the class was inadequate, inadequate follow up in the community post-partum
how do you know about breastfeeding adequacy? - ANSWERS-fewer than 4 soiled diapers on day 4 when used in conjunction with delayed onset of lactation may indicate breastfeeding inadequacy
- four on four... and each day after
MYTH - size of the breast relates to the amount of milk - ANSWERS-the proportion of glandular and fat tissue and the number and size of the ducts are not related to milk production. for health providers, perceptions of who will have difficulty with breastfeeding may be related to breast size.
MYTH - not getting enough fluids impacts volume of milk - ANSWERS-there is not enough evidence to support increasing fluid intake beyond with breastfeeding mothers are likely to require to meet their physiologic needs
MYTH - exercising or working too hard impacts supply - ANSWERS-maternal exercise when breastfeeding was not related to changes in macronutrients or volume or infant weight gain or growth. rest is not associated with increased milk production.
MYTH - not getting enough rest - ANSWERS-"fatigue" may be tiredness, but also may be a symptom of an underlying medical problem that could affect milk supply.
MYTH? worry/stress?? - ANSWERS-increased worry/stress does not seem to directly diminish milk supply in humans, however...
- worry/stress may alter behavior, which may alter supply
maternal stress - ANSWERS-breastfeeding mothers may perceive less stress
compared to formula fed mothers, breastfeeding mothers:
- had more positive moods
- reported more positive events
- perceived less stress
stress & hormones - ANSWERS-stress + male hormones = fight or flight
stress + oxytocin + female hormones = tend and befriend
postpartum post traumatic stress disorder (PP-PTSD) - ANSWERS-up to 9% of PP women met the DSM-5 criteria for PTSD after childbirth
two conditions that increase odds of PP-PTSD - ANSWERS-- depressive symptom scores
- total number of physical symptoms experienced since birth
MYTH - its about the types or amounts of foods eaten during laction - ANSWERS-humans have breastfed and are breastfeeding under conditions we can't even imagine. this is possible because:
- lactation has a lower energy cost for humans compared to other mammals
- number of kcal/day for lactation is much less than previously believed
- the body adapts with physiological mechanisms in favor of lactation in humans
when the infant suckles from the breast... - ANSWERS-there is an outpouring of 19 different GI hormones in both the mother and the infant, including cholecystokinin, which cycles to the kidneys, and gastrin, which stimulates
