Milk enzymes

Some milk enzymes enter the alveolar milk from the mammary blood
capillaries via the intercellular fluid. Others come from the breakdown of the
mammary secretory cells. The milk enzymes, xan-thine oxidase, aldolase., and
alkaline phosphatase, are contained in the fat globule, membrane, and miik serum.
The most significant enzyme, lipase, splits triglycerides.
Human milk contains both proteolytic enzymes and protease inhibitors. 2S
Amylase facilitates digestion of polysaccharides by the infant. Sulfbydryl (SH)
oxidase catalyzes oxidation of SH groups. Glutaihione peroxidase facilitates the
delivery of selenium to the infant. Lysozyme and peroxidase are bactericidal

Cellular components
Human milk has been called a "live fluid" by many _and "white blood" in
many ancient rites. Breast milk contains up to 4000 cells/mL, which have been
identified with leukocytes and enter the milk via the paracelrular pathway, pathway
V.100 The cell number ?s particularly high in colostrum. The cells in greatest n amber
are the macrophages, which secrete lysozyme and lactoferrin. Lymphocytes, neuirophii;. and epithelial cells are also present. Lymph; cytes-produce IgA and
interferon
Macrophages constitute a major cellular component in milk compared with
levels in blood and can survive ""icier conditiort^simulating the infant's gastrointestinal tract.3" Because they release secretory 'A in association with
phagocytosis, it is believed '1e.v play a role in host defense. Macrophage colony-

stimulating factor in human milk and mammary gland epithelial cells are believed to
be responsible for expansion of the macrophages m milk.

IN VOLUTION: WEAN ING

AND APOPTOSIS
During weaning, significant increases in milk protein, chloride, and sodium
sodium concentrations and decrease lactose occur when milk volumes fall below
400 mL/day. Glucose and magnesium levels are unchanged. 62 This suggests that
volume is regulated differently during weaning than during iacto-genesispfo
sentinel substance is a reliable predictor of volume in all stages, but normal ranges
of milk components during full lactation are sodium, 3 to 18 mmol/L; chloride, 8 to
24 mmoi/L; protein. 8 to 23 g/L; and lactose, 140 to 230 mmo!/L. Values out- jfe
side these ranges suggest mastitis or weaning. During gradual weaning, between 6
and 15 months post partum, glucose, citrate, phosphate, and calcium levels
decrease, whereas lipitl, potassium, and magnesium increase63 (see Fig. 3-19).
Postlactational involution of thejnammary gland is characterized by'
Twa-"9Tstmct physiologic processes.54 First, secretory epithelial cells undergo
apoptosis and programmed cell death. Second, the mamrrary gland's basement
membrane undergoes prc'ieulytic degradation. Apoptosis is almost absent during
lactation but develops within 2 days of involution. In the initial phase of involution,
apoptosis of fully differentiated mammary epithelial cells occurs without visible
degradation of the extracellular matrix. The second phase consists of extracellular
remodeling and altered mesenchymal-epithelial interactions followed by apoptosis

of cells no longer differentiating^8 During postlactational mammary gland

involution, most mammary epithelium dies -. and is reabsorbed
SUMMARY
In the human, lactogenesis occurs slowly over the first few days post partum as
progesterone levels drop. Women experience "milk coming in" as a feeling of
fullness between 40 and 72 hours, usually corresponding to the degree of parity, with
multi-paras sensing this more quickly than primiparas. Volume of milk increases over
time for the first 2 weeks, starting at less than 100 mL/day and increasing to about
600 mL/day at 96 hours (Fig. 3-20). This parallels the rise in citrate production,
reflecting the metabolic activity of the mammary gland. Lactose, sodium chloride,
and protein rise promptly, stabilizing at 24 hours and reflecting the.

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39. Kent JC, Ramsay DT, Doherty D: Response of breasts to diffsrer.: stimulation
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49. Lincoln DW, Renfree MB: Mammary gland growth and milk ejection in the
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50. Linzell JTL Peaker M: The permeability of mammary ducts. JPhysiol
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The biochemistry of human milk encompasses a mammoth supply of

scientific data and information, most of which has been generated since 1970. Each
report or study adds a tiny piece to the complex puzzle of the nutrients that make up
human milk. The answers to some questions still elude us. A question as simple as
the volume of milk consumed at a feeding remains a scientific challenge. The
methodology must be accurate, reproducible, noninvasive, and suitable for home use
night or day and must not interrupt breastfeeding. The precision analysis available
for measuring the concentration of the most minuscule of elements, however, is
remarkably accurate and reproducible in the laboratory.
Advances in analytic methods bring greater sensitivity, resolving power, and
speed to the analysis f milk composition. Previously unknown and unrecognized
compounds have been detected. We now know milk brings both nutrients and
nonnutri-tive signals to the neonate. With few exceptions, all milks contain the
nutrients for physical growth and

dev

elopment When the offspring develops rapidly,

we m^ is nutrient dense; when it develops slowly, * e milk is more dilute. All milks
contain fat, car-hydrate, and proteins, as well as minerals, vitals, and other nutrients.
The organization of milk composition includes lipids in emulsified globules

C0ateci wit

a membrane, colloidal dispersions of eins as micelles, and the remainder as a true

solution.159 At no other time in life is a single food adequate as the sole source of
nutrition. The discussion in this chapter is limited to infor-mation perceived as
immediately useful to the clinician. Considerable detail and species variability are
overlooked to help focus attention on details directly influencing management.
Extensive and exhaustive reviews are referenced to provide the reader with easy

access to greater detail and validation of the general conclusions reported here.
Human milk is not a uniform body fluid but a secretion of the mammary gland of
changing composition (Fig. 4-1). Foremilk differs from hindmilk. Colostrum differs
from transitional and mature milks. Milk changes over time of day and as time goes
by. As concentrations of protein, fat, carbohydrates, minerals, and cells differ,
physical properties such as osmolarity and pH change. The impact of changing
composition on the physiology of the infant gut is beginning to be appreciated. Many
constituents have dual roles, not only nutrition but infection protection, immunity, or
a host of other effects.
The more than 200 constituents of milk include a tremendous array of molecules
whose descriptions continue to be refined as qualitative and quantitative laboratory
techniques are perfected. Resolution of lipid chemicals has advanced dramatically in
recent years, but new carbohydrates and proteins have been identified as well. Some
of the compounds identified may well be intermediary products in the process.
That occurs within the mammary cells and may be only incidental in the final
product.216 Milk includes true solutions, colloids, membranes, membrane-bound
globules, and living cells. Human and bovine milks are known in the greatest detail 83;
however, much information exists about the milk of the rat and the mouse, as well as
five other species: the water buffalo, goat, sheep, horse, and pig. Several are listed in
Table 4-1. Miscellaneous data are available on the milk of 150 more species but there
are almost no data at all on another 4000 species. Jenness and Sloan112 have compiled
a summary of 140 species from which a sampling has been extracted (Table 4-2).
The constituents of milk can be divided into the following groups, according to their

specificity112: H
1. Constituents specific to both organ and species (e.g., most proteins and lipids)
2. Constituents specific to organ but not to species (e.g., lactose)
3. Constituents specific to species but not to organ (e.g., albumin, some
immunoglobulins)
NORMAL VARIATIONS IN HUMAN MILK
In defining the constituents of human milk, it is important to recognize that
the composition varies with the stage of lactation, the time of day, the sampling time
during a given feeding, maternal nutrition, and individual variation. Many early
interpretations of the content of human milk were based on spot samples or even
pooled samples from multiple donors at different times and stages of lactation.
Samples obtained by pumping may.
The variation in the fat content has received some attention. Fat content
changes during a given feeding, increasing at the end of the feeding. Fat content rises
from early morning to midday; the volume increased from two to five times, as
reported in early studies when feedings were controlled. Multiple studies in different
countries and different decades, summarized by Jackson and coworkers 108 reveal that
some of the variation is related to other factors. Demand feeding (Thai mothers in
1988) has a different circadian variation than scheduled feeding (U.S. mothers in
1932) (Fig. 4-3). In the later part of the first year of lactation, the fat content
diminishes. Work done by Atkinson and associates13 and confirmed by other
investigators has shown that the nitrogen content of the milk of mothers who deliver
prematurely is higher than that of those whose pregnancies reach full term. For a
given volume of milk, the premature infant would receive 20% more nitrogen than

the full-term infant if each were fed his or her own mother's milk. Other constituents
of milk produced by mothers who deliver prematurely have also been studied.
An additional consideration in reviewing information available on the levels of
various constituents of milk is the technique used to derive the data. In 1975,
Hambraeus83 reported that, there was less protein in human milk than originally
calculated. The present techniques of immunoassay measure the absolute amounts,
whereas earlier figures were derived from calculations based on measurements of the
nitrogen content. About 25% of the nitrogen in human milk is nonprotein nitrogen.
Cow milk has only 5% nonprotein nitrogen.
A major concern about variation in content of human milk is related to the
mother's diet. Maternal diet is of particular concern when the mother is malnourished
or eais an unusually restrictive diet. Malnourished mothers have approximately the
same proportions of protein, fat and carbohydrate as well-nourished mothers, bat
they produce less milk. Levels of water-soluble vitamins, such as ascorbic acid,
thiamin, and vitamin Bp, are quickly affected by deficient diets. "From a nutritional
perspective, infancy is a critical and vulnerable period. At no other stage in life is a
single food adequate as a sole source of nutrition,*" writes Picciano. 177 This results
from the immaturity of the tissues and organs involved in the metabolism of
nutrients, which limits the ability to respond to nutrition excesses and deficiencies.
'The system is species-specific and depends on the presence of the self-contained
enzymes and Hgancls to facilitate digestion at the proper stage while preserving
function (such as slgA). It continues to facilitate absorption and utilization.