Transcript Slide 1

Breastfeeding and Infant
Feeding
Nelly Schottel, MD
Breastfeeding
AAP recommends that infants be
exclusively breastfed through 6
months, continued up to 1 year
and beyond if mutually desired
Advantages of Breastfeeding
 More bioavailable, easily digestible
 Decreased incidence of infectious disease,
allergies, celiac disease, IBD, SIDS, diabetes,
obesity
 Improved neurodevelopmental outcomes
 Maternal infant bonding
 Maternal health advantages
 Reduces incidence of ovarian cancer
and premenopausal breast cancer
 Earlier return to pre-pregnancy weight,
decreased incidence of Type 2 DM,
osteoporosis and PP depression
 Ovulation suppression – 98% protection
from pregnancy with full time
breastfeeding in first 6 months
 Economic advantage
 Estimated that if 90% of US mothers
complied with the recommendation to
breastfeed exclusively for 6 months savings of $13 billion per year1
1 Bartick
M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a
pediatric cost analysis. Pediatrics. 2010;125(5).
 Exclusively breastfeeding mothers – eligible
to receive enhanced WIC food package and
longer duration of benefits than mothers
who formula feed
 WIC also offers breast pumps, nipple shields
and supplements to breastfeeding mothers
Breastfeeding Basics
 Newborns should breastfeed q 2-3 hrs (about 8-12 times
per day)
 10 minutes per breast provides 90% of the available milk
 Important to have proper latch and position
 Place newborn to breast as soon as possible after birth
 Avoid bottles/pacifiers as much as possible
 Recognize early signs of hunger – increased alertness,
activity, mouthing, rooting
 Prolactin increases milk
production
 Oxytocin causes myo-epithelial
cells to contract
 Both primarily stimulated by
suckling
 May diminish after as little as
16-24 hours without nursing
 Emptying of the breast also
affects milk production,
prolactin levels decline if breast
not regularly emptied
Good latch
 Entire areola into baby’s
mouth with nipple
against posterior palate
and tongue under areola
 Baby’s top and bottom
lip should be everted
 Baby’s chin should be
pressed into the breast
 Nose should also be
resting on the breast
 Sucking on tip of nipple causes
frustration for both mother and baby
 Use rooting reflex
 Stimulate baby to stay awake after first
few minutes of feeding
Troubleshooting
 Flat or inverted nipples
 Previous breast surgery
 No change in breast size during pregnancy
 Medications or medical conditions
 Lack of support
Sore/cracked nipples
 One of the major causes of terminating breast feeding in the
first week post-partum
 Generally caused by improper technique
 Assess position, latch and suckling process
 Check for ankyloglossia
 Remedies:





Expressed breast milk
Lanolin cream
Warm moist compress
Hydrogel pads
Wet tea bags
Flat or inverted nipples
Nipple shield: temporary
solution for difficult latch
 Small or preterm
infants
 Flat or inverted nipples
Vitamin supplementation
 Trivisol (Vit A, C, D) for all exclusively
breastfed infants
 Most formula-fed infants do not receive 400
IU of Vitamin D/day so generally
recommend for all infants
 Need 1L (33 ounces) per day to receive 400
IU of Vitamin D
 Essential that breastfeeding be discussed
during office visits
 Early involvement of lactation specialists
www.lalecheleague.com
www.breastfeeding.com
Contraindications to Breastfeeding
 Infant with galactosemia
 Mother with active, untreated tuberculosis
 Maternal exposure to radioactive isotopes
 Maternal exposure to chemotherapeutics and/or drugs
of abuse (and other contraindicated meds)
 HSV lesion of breast
 HIV (in developed countries)
Breastfeeding History
How often do you breastfeed?
Does the baby latch on well?
Do you hear frequent sucking and swallowing?
How many minutes per breast?
Any complications? (sore nipples, mastitis, etc)
Formula Feeding
 If breastfeeding is not possible, then an
iron-fortified infant formula should be used
 Low iron formula not adequate (need
12mg/L iron)
Formula Diet History
How do you prepare the formula?
How much per feeding?
How often does the baby feed?
How many total bottles per day?
Routine Diet History
How many wet diapers/BM’s does the baby have
each day?
Does the baby drink any thing else besides
formula/breastmilk? (water, juice)
Have you started solid foods?
Pediatric Formulas
 Standard formulas 20 kcal/oz (Enfamil Lipil and Similac
Advance)
 Extensively hydrolyzed: Nutramigen, Alimentum,
Pregestimil
 Amino-acid based formulas: Elecare, Neocate
 Soy: Isomil
Extensively hydrolyzed/AA based
 Intended for use by infants with milk-protein allergy
(MPA) or at high-risk for allergy
 MPA can manifest as:
 IgE mediated: urticaria, wheezing, vomiting, anaphylaxis
 Non-IgE mediated: pulmonary hemosiderosis, eosinophilic
proctocolitis, enterocolitis, esophagitis
 Expensive! Require approval from insurance.
Pediatric Formulas: Soy-Based
 Free of cow-milk protein and lactose (carbohydrate is
corn or tapioca starch)
 Use in disorders of carbohydrate metabolism (ex.
Galactosemia)
 Use in acute diarrhea and secondary lactase deficiency
 Can try for infants with IgE assoc allergy symptoms
(urticaria, eczema) to cow’s milk formulas (10-15% will
have soy protein allergy and need hydrolyzed formula)
Pediatric Formulas
 Come in a variety of formulations
 Ready to feed, concentrated liquid, or powder
Concentrate – dilute 1:1 with water
Powder – one scoop to 2 oz of water
 Only warm in tepid water, not in microwave
 Only infants 6 mos or older who receive
exclusively ready to feed formula or formula
made with well water or are exclusively
breastfed need flouride supplementation
How do I know my baby is getting
enough??
 Wet diapers – approximately 6-8 per day by the end of
the first week of life
 Stooling will vary; usually 4-8 per day
 Initial stool is meconium; dark green to black, thick
 Stools change to a yellow, seedy composition
Infant Growth Patterns
 Infants lose weight in the first few days of life
 By DOL 14, should regain birth weight
 Initial weight gain is 20-30 grams/day
 Doubles birth weight by 4-6 months
 Triples birth weight by 12 months
How much?
 Infants need 100-120kcal/kg/day
 Equivalent to 150-180ml/kg/day
[100kcal*30ml/20kcal]
 Birth - 1 week
 1-3 ounces
 1 week - 1 month
 2-4 ounces
 3 - 6 months
 6-7 ounces
 6 - 12 months
 7-8 ounces
Routine Diet History
 Solids
What solids does your baby eat?
Have you started self-feeding/finger foods?
Review allergy and choking risks
Introduction of Solids
 Infant is eating 32 ounces of formula/breastmilk in a
day and still wants more
 Look for developmental readiness to determine when to
give solids
 Sitting supported, loss of extrusion reflex, good head
control
 Solids should not be introduced before 4-6 months of
age
Introduction of Solids
 Start with iron-fortified single grain cereals - always use
a spoon (not in the bottle)
 Then progress to single fruits, vegetables, and meats
 Introduce 1 new food every 3-5 days
 May have to offer food several times before infant
accepts it
 Fruit juices can be introduced, but limit to 4-6 oz/day
 No need for water before 6 mos
 Introduce soft finger foods by 6-8 months
 Solid foods must be mashed or pureed in 1st year of life
to avoid aspiration
 No honey until after 1 year
 Limit milk to 16-24 oz per day
 No cow’s milk before 1 year
 Low bioavailability, risk for IDA
 Skim or low fat milk after 2 years of age
 Lack essential fatty acids needed for myelin production
before 2 years
 Soy milk is adequate over 1 year only if pasteurized and
vitamin fortified
 Lactose intolerance
 Congenital carbohydrate enzyme deficiencies are
extremely rare
 Acquired lactose intolerance – may begin by 2 years of age
 Dose dependent phenomenon
 Allergy to cow’s milk or soy protein (prevalence 1-8%)
 Vomiting, diarrhea, bloody stools, eczema, urticaria,
wheezing, rhinitis, congestion
 Wean to cup at 15 months
 Make bottle uninteresting
 Fill with water
 Make child sit while having bottle
 Put a toy in the bottle
Babies Know How Much to Eat
 Houston anthropologist Linda Adair followed a demand fed
boy’s intake 1 wk - 9 mo of age
 Although he ate three times as much some days as others, his
growth was consistent and his size was average
 When he started solids, he took less formula and continued
to regulate well
Adair, L.S. “The Infant’s Ability to Self-Regulate Caloric Intake: A Case Study.”
JADA, 1984.
Kids Want to Eat
 Innate
 Imitate adults: why role-modeling good
eating behavior is important!
 However…
 Children who are pressured, eat less well, not
better
 It can take 10-15 exposures to a new food for a
child to eat it*
*Birch, Johnson, and Fisher. “Appetite and Eating Behavior in Children.”
Pediatric Clinics of North America. 1995
Kids Know How Much to Eat
 Instinctive regulators of hunger and fullness
 Desire to control intake can undermine natural process
 In a study of healthy infants, infants grew less well with
mothers who force fed1
 Internal regulation of satiety becomes blunted in those with
food insecurity: they eat as much as they can, whenever it’s
available2
1Crow, Fawcett, and Wright, “Maternal Behavior During Breast and Bottle Feeding”. JBM, 1980.
2Birch, Fisher, and Davison, “Learning to Overeat”. AJCN, 2003
What makes a meal?
 4 or 5 food groups
 Protein source (chicken, tofu, beans, eggs, peanut
butter)
 2 grains or starchy foods (rice, potato, bread, pasta,
tortilla, biscuit)
 Fruit, vegetable, or both
 MILK
 Fat source (olive oil, butter, salad dressing, cheese
sauce)
What makes a snack?
 Two to three food groups – starch and fat, starch and
protein
 Cheese and crackers
 Half a peanut butter and jelly sandwich
 Yogurt and fruit
 Hummus and vegetable
Why are Family Meals Important?
 Support food regulation and appropriate growth
 Meals reassure children they will be fed
 Meals teach children to like a variety of food
Family Meals
• Children who have family meals (5 or more per week)
achieve more, behave better, and do better
nutritionally
• Time spent with family members at meals is more
related to psychological and academic success than
time spent in any other activity*
*Videon, T.M. and C.K. Manning. “Influences on Adolescent Eating Patterns: The
Importance of Family Meals”. Journal of Adolescent Health, 2003.
Family Meals
• In recent years, the trend is away from family meals
• Between the ages of 9 and 14, the fraction of children
who eat a daily family dinner decreases from one-half
to one-third
Infant: Andy
 Healthy 10 month old. He is growing well, but is a picky
eater. His mother is eager to wean him off
breastfeeding and start milk. She read about a
particular brand of goat’s milk in the New York Times
and plans to start this.
 What do you tell her?
Infant
 Folate deficiency
 Continue formula until 1 year of age
 Will continue to need the fat in whole milk for brain
development until 2 years of age
 Multivitamin
Toddler: Pamela
 Healthy, playful 21 month old who is meeting all of her
developmental milestones. Her parents report having
to force her to eat, and have several questions about
feeding. Her growth curve shows a decrease in weight
and length measurements for the past two visits.
 What questions do you ask?
Toddler: Pamela
 Does she drink milk? What kind? How much?
 Does she drink water or juice?
 What is offered at mealtime?
 When, where, and with whom are meals eaten?
Toddler: Pamela
 Drinks about 16 oz whole milk most days.
 Loves plain water, and will tote a sippy cup around all day.
 Parents offer a variety of foods; Pamela will take a few bites
and complain of being full; she throws a fit if fed.
 Mom gives her cereal in a baggie to tote around because she
won’t eat her meals.
Toddler: Pamela
 She is drinking an appropriate amount of milk
for her age, and her parents are offering a
variety of food groups.
 It’s likely her constant drinking of plain water is
causing her to be too full when it’s time to eat.
 Toddlers need the security of structured meals
and snacks at the table, as well as the
opportunity to exercise independence – don’t
force feed.
Toddlers
 There is a natural slow down in the the rate
of growth
 Tend to be skeptical about new foods
 Parents shouldn’t expect:




Predictablility
Eat a certain amount
Eat a new food two days in a row
Eat only three meals a day – need 1-2 snacks
Toddlers
 Family meals; structured meals and snacks with a time
limit; no grazing
 Parents need to provide a variety of healthy foods; no
“short-order cooks”
 Role modeling by parents and older siblings can
encourage toddlers to try new foods
Summary of Key Points
 Breastfeeding is the preferred method of nutrition in
infants; exclusively for the first 6 months of life.
 Infants have typical growth milestones that should be
documented.
 Introduction of solids should NOT occur before 4-6 months.
Take Home Points
 Parents are responsible for providing healthy, safe
foods
 Encourage family meals
 Children know intuitively how to eat and grow:
don’t force!
 Parents are role models
 Infants need to be fed on demand and be exposed
to a wide variety of textures and flavor
 Toddlers need structure at meals
PREP
During a prenatal visit with expectant parents they report that
they are strict vegans. They ask you to advise them on a healthy
diet and any required supplements. The mother plans to
breastfeed the newborn exclusively for the first 6 months. Of
the following you are MOST likely to tell them that the newborn
may require supplemental:
A Calcium
B Folate
C Iron
D Vitamin B6
E Vitamin B12
PREP
You are addressing a group of expectant mothers who are due to
deliver their infants in the next few weeks. You discuss the
benefits of breastfeeding and explain that is the best nutrition
for most babies. One woman asks you if it acceptable to
breastfeed if she has had hepatitis in the past. You explain that
there are only a few infections that would prevent a mother
from being able to breastfeed her baby. Of the following
breastfeeding is MOST likely to be contraindicated of a mother:
A Has active untreated pulmonary TB
B Has genital herpes without breast lesions
C Is a CMV carrier
D Is hepatitis B surface antigen positive
E Is a hepatitis C antibody positive
PREP
You are counseling the mother of a 3 month old
breastfed infant whose family has been urging her to
introduce cereals to her baby’s diet. She asks your
advice. Of the following the MOST likely outcome of
introducing solid foods at this age is to:
A Accelerate the development of oral motor skills
B Helps the infant sleep through the night
C Increase the risk of food allergies
D Increase the risk of GE reflux
E Increase the risk of GI infections
PREP
The mother of a 5 month old boy has come to your office seeking
nutritional advice. She exclusively breastfed the infant for the first
4 months then weaned the baby to a standard formula. One week
after weaning she noted that the baby strained with stool. Because
of her concerns regarding the development of constipation, the
mother switched him to a formula containing 2mg/L of iron. Of the
following the MOST important dietary recommendation for this
infant is to:
A Add pureed vegetables to the diet
B Changed to a cow milk protein based formula containing 12mg/L of
iron
C Change to a soy protein based formula
D Continue the present regimen and supplement with 4 oz/day dilute
apple juice
E Substitute oatmeal for rice cereal in the diet
PREP
During the 1 week health supervision visit a mother who is
exclusively breastfeeding asks about vitamin and iron
supplementation for her healthy term infant. She explains that
her previous child who was born at 30 weeks was discharged
with an oral iron supplement and vitamins. Of the following the
most appropriate oral supplement to initiate for this infant at
this visit is:
A Calcium
B Folic acid
C Iron
D Vitamin D
E Vitamin K
PREP
You are seeing a healthy newborn in the nursery on the 2nd day of life.
The baby’s birth weight was 3.43kg, the weight today is 3.29kg. She is
being exclusively breastfed and has voided and passed meconium. Her
physical exam is completely normal and there is no jaundice. Her
mother tell you the baby is latching well but she’s concerned about the
baby’s weight loss and would like to give the child formula. What do you
tell her?
A The weight loss means the breastfeeding is not working and she should
give formula instead
B Some weight loss is expected but her baby’s weight loss is excessive and
she should give a bottle with every other feed until the baby gains
weight
C The weight loss is normal and there is no immediate need to supplement
with formula. You discuss proper latching and advise that you would like
to have the baby weighed in two days
D The weight loss is normal but all babies need to be supplemented with
formula starting at two days and she should start supplementing today
PREP
You are seeing a two week old in the office. His birth weight was 3.27
kg and his weight now is 3.17 kg. His mother tells you that nursing
generally last an hour and is quite painful, and that her baby will
frequently want to feed again 30 minutes after nursing. He voids 6
times a day and has one soft bowel movement every other day. The
physical exam is normal and the baby is not jaundiced. What do you
advise?
A The frequent nursing and pain is normal for a first time breastfeeding
mother, and babies are not expected to regain weight until 3 weeks of
age
B The likely source of pain, frequent feeds, and infrequent bowel
movements is a poor latch, and that you would like to have her latch
examined by direct observation or by a lactation consultant
C The frequent nursing and pain is normal but the infrequent bowel
movements mean the baby is constipated so you recommend extra
water be given to the baby
D The frequent nursing and poor weight gain mean her milk supply is low
and she should pump for 5 minutes after every feed to increase her milk
supply
PREP
You are seeing a 3 month old girl who has been doing well on
cow’s milk formula since birth, with normal parameters and
normal exam at her 2 month visit. Today she is in your clinic
because her parents have noticed some increased fussiness and
diarrhea in the past two weeks. Yesterday and today they
noticed spots and streaks of blood in her stool. Her physical
exam is normal and there are no anal fissures. What would you
recommend?
A Change to soy formula
B Change to lactose free formula
C Change to a low iron formula
D Change to a hydrolyzed protein formula
E Reassure the parents and follow up at her 4 mo visit
PREP
The parents of a 5 week old girl ask about lactose intolerance.
There is a strong family history of lactose intolerance on both
sides of the family. Their daughter seems unusually gassy
compared to their older child, although her stools are normal and
her appetite is good. They wonder if they should switch to a
lactose free formula. What advice is most reasonable?
A
Lactose intolerance is a heritable condition and this infant is likely
to share her parents’ difficulty with lactose. The switch to
lactose free formula makes good sense.
B
If this child had lactose intolerance, her symptoms would
necessarily include constipation and emesis. She does not need a
formula switch.
C
The common form of lactose intolerance is acquired and dose
dependent. It does not present in infancy. This child does not
need to switch formulas.
D
A stool study for giardiasis is indicated to identify the cause of her
excess gas. Change to a lactose free formula pending test results.