Transcript Newborn Feeding

Infant Feeding
Jillian Parekh, MD, FAAP
July 8, 2010
Rates of breastfeeding:

In 2004 and 2003,70% of US women initiated breastfeeding



At 3 mos, only 39% and 41% still exclusively breastfeeding
At 6 mos, only 36% of infants receiving any breast milk


Breastfeeding rates for Hispanic mothers are greater than total US
population (79%)
Only 14% were exclusively breastfeeding
In all ethnicities: married, older and highly educated women
not working outside of the home were more likely to initiate
and sustain breastfeeding for longer periods
Federal laws on breastfeeding:






President Obama signed the Patient Protection and Affordable Care Act,
H.R. 3590, on March 23rd and the Reconciliation Act of 2010, H.R.
4872, on March 30, 2010.
Requires an employer to provide reasonable break time for an employee
to express breast milk for her nursing child for one year after the child's
birth each time such employee has need to express milk.
The employer is not required to compensate an employee
receiving reasonable break time for any work time spent for such
purpose.
The employer must also provide a place, other than a bathroom, for the
employee to express breast milk.
If these requirements impose undue hardship, an employer that employs
less than 50 employees is not subject to these requirements.
Furthermore, these requirements shall not preempt a state law that
provides greater protections to employees.
NYC and breastfeeding:





N.Y. Civil Rights Law § 79-e (1994) permits a mother to breastfeed her child
in any public or private location. (SB 3999)
N.Y. Labor Law § 206-c (2007) states that employers must allow
breastfeeding mothers reasonable, unpaid break times to express milk and
make a reasonable attempt to provide a private location for her to do
so. Prohibits discrimination against breastfeeding mothers.
N.Y. Penal Law § 245.01 et seq. excludes breastfeeding of infants from
exposure offenses.
N.Y. Public Health Law § 2505 provides that the Maternal and Child Health
commissioner has the power to adopt regulations and guidelines including,
but not limited to donor standards, methods of collection, and standards for
storage and distribution of human breast milk.
N.Y. Public Health Law § 2505-a creates the Breastfeeding Mothers Bill of
Rights and requires it to be posted in a public place in each maternal health
care facility. The commissioner must also make the Breastfeeding Mothers
Bill of Rights available on the health department's website so that health care
facilities and providers may include such rights in a maternity information
leaflet. (2009 N.Y. Laws, Chap. 292; AB 789)
Advantages of Breastfeeding - Mom:




Prevents postpartum hemorrhage (uterine contraction)
Facilitates postpartum weight loss
Reduces stress hormone levels
May provide contraceptive effect




Decreases risk of breast cancer


If used exclusively for 4-6 months – not reliable
Amenorrhea also allows iron stores to be repleted
Increased child spacing
Anovulation may also protect against ovarian cancer
Maternal-infant bonding
Advantages of Breast Feeding - Infant:

Prevents or reduces severity of illnesses







Reduces incidence of NEC in premature infants
Reduces frequency of UTI
Reduces death from botulism
Reduces risk of sepsis and meningitis
Reduces infant mortality
Decreases risk of chronic diseases





GI, respiratory, OM
Crohn’s, leukemia, lymphoma, DM, hypercholesterolemia,asthma, and atopic
conditions
Increases long term cognitive and motor skills
Provides analgesia
Increases visual acuity
Reduces obesity in adolescents and young adulthood
Keys to successful Breastfeeding:








Informing all pregnant women about the benefits
Help mothers initiate breastfeeding within the first hour
Allow rooming-in
Encourage breastfeeding on demand
Teach positions, provide access to lactation consultant
Teach how to pump
Avoid pacifier use until breastfeeding successfully initiated
Resources for support groups…
Complications of Breast feeding:




Nipple pain
Engorgement
Plugged ducts
Mastitis
Possible contraindications:



Breast surgery
Primary insufficient milk syndrome
ID:






HIV, HTLV, TB, VZV, HSV, Hep B, Hep C
Substance abuse
Alcohol
Cigarettes
Medications
Inborn errors of metabolism
Milk Supply:

Colostrum is made first



Transitional milk




Provides all nutrients neonate needs in first few days
Higher in protein, lower in sugar, lower in fat
“milk came in”
From day 2-5 up to 10-14 days
Supply is much greater – engorgement
Mature milk


Appears near the end of second week
Thinner and more watery/bluish than transitional milk
Latching:


Infant should be held so that the mouth is
opposite the mother’s nipple and neck is
slightly extended. Head, shoulders and hips
are in alignment
While learning to latch, helps to support
breast in the C-hold
Latch:

Elicit rooting reflex (nipple to lip)



Wait for infant to open mouth and pull baby
quickly to breast, aim nipple upperward toward
hard palate
Infant should grasp entire nipple as much of
aerola as comfortable
In correct latch, infants nose and chin are
against breast

Lips should be everted
Signs of incorrect latch:






Indentation of the infant’s cheeks during
suckling
Clicking noises
Lips curled inwards
Frequent movement of infant’s head
Lack of swallowing
Maternal pain
Flow:



Suckling begins with rapid bursts and
intermittent pauses – helps milk let down
Once milk flow established, approx 1 suckle
or swallow per second
Peristaltic action from tongue
Breast feeding positions:

Cradle hold:


Baby’s head supported by elbow
May put too much pressure on abdomen if post
C-Section
Cross-Cradle hold:



Works well for babies who need to be guided
to latch
Hands support baby
Baby’s chest and abdomen face yours
Football or clutch hold:



This hold also allows you to guide mouth to
nipple
Good for low BW or premature babies
Good for post C-Section as no pressure on
abdomen
Reclining position:


Good for post C-section or feeding at night
Need to support self with pillows
Twin positioning:
Patterns:

Feeding one vs both breasts





Feedings should last 10 -15 minutes per breast
Allow infant to drain first breast before switching
Notice early hunger cues


Draining one breast – hindmilk has more fat
Both breasts drained – engorgement
Increased alertness, flexion of extremities, mouth and
tongue movements, cooing sounds, rooting, fist to mouth,
sucking on hands
Crying is late sign of hunger – becomes more
difficult to get good latch
Frequency:




In first 24 hours: infants feed 8-12 times
Frequent feeds help reduce weight loss and
jaundice and establishes good milk supply
Average is every 1.5 – 3 hours
Breast milk empties from stomach faster than
formula
Is my baby getting enough?

Monitoring weight


6 or more wet diapers/day





20-40g/day (after initial losses in first week)
BF babies will pee less until full supply of milk arrives
Seem satisfied and happy for 1-3 hours after feed
BMs
Nurse at least 8-12 times in 24 hours
NO WATER

Bottle Feeding:






1 month: 2-4 oz/feed
2 months: 5 oz/feed
3 months: 5-6 oz/feed
4 months: 6-7 oz/feed
5-12 months: 8 oz/feed
Breast Feeding:




Birth -1 month: 6-8/day
2-6 months: 4-5/day
7-10 months: 3-4/day
11-12 months: 3/day
Growth:


Birth weight doubles by 5 months
Birth weight triples by 1 year
Pumping and Storage:



Establish good breastfeeding before start pumping –
usually around 4 weeks old
Start with pumping in morning – supply is best
Storage of pumped breast milk:






4-6 hours at room temperature
Up to 24 hours in a cooler with ice packs
5-8 days in a fridge (best in first 72 hours)
3-4 months in freezer
6-12 months in deep freezer
Don’t re-freeze milk
Breast Milk
Formula
-DHA and AA
-Levels decline as baby gets older
-best absorption
-has lipase to digest fats
-No DHA (now being added)
-incomplete absorption
-no lipase
-WHEY – easy to digest
-better absorbed
-lactoferrin and lysozyme – intestinal health
-rich in growth factors and sleep-inducing
proteins
-CASEIN – harder to digest
-incomplete absorption, harder on kidneys
-No lactoferrin or lysozyme
-Low in brain/body building proteins
-Deficient in growth factors
Carbs
-Rich in lactose
-rich in oligosaccharides
-+/- lactose
-deficient in oligosaccharides (promote
intestinal health)
Immunity
-rich in WBC
-rich in immunoglobulins
-No live WBCs
-few immunoglobulins
Vitamins/Minerals
-better absorbed (iron, zinc, calcium)
-iron 50-75% absorbed
-contains more selenium
-not absorbed as well
-Iron is 5-10% absorbed
-less selenium
Cost
-$600/year in extra food for mom
-$1,200/year
-$2500/year for hypoallergenic
-Cost of bottles and supplies
Enzymes/Hormone
s
-rich in digestive enzymes (lipase, amylase)
-Rich in hormones (prolactin, oxytocin,
thyroid…)
-Need to supplement Vitamin D
-Processing kills digestive enzymes
-processing kills hormones (not human to
begin with)
-Contains Vitamin D!
Fats
Protein
Types of formula:

Cow's milk-based formula - the type of formula that the average baby should be on if not
being breastfed (examples: Enfamil Lipil, Nestle Good Start Gentle Plus, Similac Advance)

“Gentle" formula with less lactose than regular milk based formula - for babies with some
gas or fussiness on milk-based formula (examples: Enfamil Gentlease Lipil and Nestle Good
Start Gentle Plus)

Lactose-free formula - for babies with lactose intolerance (examples: Enfamil LactoFree
Lipil and Similac Sensitive)

Added rice starch formula - for babies with acid reflux (examples: Enfamil A.R. Lipil and
Similac Sensitive R.S.)

Soy formula - for babies with galactosemia, lactose intolerance, and milk protein allergies
(examples: Enfamil Prosobee Lipil, Nestle Good Start Soy Plus, and Similac Isomil
Advance)
Types of formula cont’d:

Formula for premature babies - have more calories and other nutrients for
premature and low-birth weight babies (examples: Enfamil EnfaCare Lipil and
Similac Neosure)

Next-step or toddler formula - for older infants and toddlers between the ages of
9 and 24 months of age (examples: Enfamil Next Step Lipil, Nestle Good Start
Gentle Plus 2, and Similac Go & Grow)

Elemental formula - for babies with milk protein and soy allergies (examples:
Nutramigen Lipil, Pregestamil Lipil, and Similac Alimentum)

Amino acid based formula - for babies with milk protein and soy allergies who
don't tolerate an elemental formula (examples: Neocate and Nutramigen AA Lipil)
Correct Mixing of formula:







Ready-to-use : Most expensive, but no mixing is necessary.
Concentrated liquid : Less expensive , you mix the formula liquid with
an equal part of water.
Powder : least expensive formula. Mix one level scoop of powdered
formula with 2 ounces of water and stir well.
Not necessary to warm bottle – ok to be cool or room temperature
If baby prefers it warm: put the filled bottle in a container of warm water
and let it stand for a few minutes.
Do not use a microwave (uneven heating)
Always check temperature of milk on skin before feeding to the infant.
Pediatricians’ role in breastfeeding:

MVI (Vitamin D)





AAP recommends 200IU/day of Vitamin D
Not needed if getting 16 oz/day of formula
Encouragement
Support
Allowing them to stop when needed
Ready for solids?


Loss of tongue-thrust reflex
Signs of self-regulation




Able to tell you when you s/he is full
Ability to sit up and hold head unsupported
Interest in food
Usually around 4-6 months

AAP recommends exclusive breast feeding for 6
months
Solid food introduction:

Start with rice cereal – and continue it (iron)







Start with watery consistency
1 Tbsp cereal/4 Tbsp milk
No evidence about which foods to start first
Babies are born with sweet preference
Single ingredient cereals only
Wait 3-5 days before starting a new food
Limit milk to 28 oz/day to ensure adequate
nutritional intake
Stages of solids:

Stage I:

Stage II:

Stage III:
Home made solids:



Boil foods and puree
No added salts or spices
Can freeze in individual servings (ice cube
trays)
Introduction of cow milk:




After age 1
Less easily digested
Contains increased minerals and proteins
Inadequate vitamins and iron
4-6 months






Cereals and grains – rice, barley, oat
Fruits: avocado, apples, bananas, pears
Vegetables: Acorn/butternut squash, sweet
potatoes, green beans
Protein: None
Dairy: None
**Avocados and bananas never need to be
cooked (cook all others for < 8 mos)
6-8 Months:





Cereals/Grains: rice, barley, oat
Fruits: avocados, apples, bananas, mangos,
nectarines, peaches, pears, plums, prunes,
pumpkin
Veggie: Sweet potatoes, squash, carrots, green
bean, peas, zucchini, parsnips
Protein: chicken, turkey, tofu (estrogens)
Dairy: Plain whole milk yogurt
8-10 Months:






Cereals/Grains: Flax, graham crackers, quinoa,
millet, cheerios, wheat, toast
Fruits: blueberries, melons, cherries, cranberries,
dates, figs, kiwi, papayas
Veggies: asparagus, broccoli, cauliflower, eggplant,
potatoes,onions, peppers, mushrooms, parsnips
Protein: egg yoks, beans/legumes, beef, pork, ham
Dairy: cream cheese, cottage cheese, cheeses (not
soft)
Can start to add some spices, cook all proteins
10-12 Months:





Cereals/Grains: pastas, wheat cereals, bagels
Fruits: berries, cherries, citrus, dates, cut up
grapes
Veggies: artichokes, beets, corn, cucumbers,
spinach, tomatoes
Protein: Whole eggs (12 mos), fish
Dairy: whole milk after 12 mos, soft cheese
after 12 months
Dangerous table foods:


Don’t introduce finger foods until age 8-9
months old
Avoid hard and smooth foods that need to be
grinded




Grapes – unless cut up
Nuts
Popcorn
Hot dog – can cut up until small pieces
AAP Report in 2008:

"Although solid foods should not be introduced
before 4 to 6 months of age, there is no current
convincing evidence that delaying their introduction
beyond this period has a significant protective effect
on the development of atopic disease regardless of
whether infants are fed cow milk protein formula or
human milk. This includes delaying the introduction
of foods that are considered to be highly allergic,
such as fish, eggs, and foods containing peanut
protein."











Honey : >1 y/o
Peanut butter : age 1-2
Nuts– age 1-2
Citrus or acidic foods : >1 y/o
Raw strawberries,raspberries, blackberries : >1 y/o
Corn: > 1 y/o
Egg whites: > 1 y/o
Whole milk: > 1 y/o
Wheat: >8-10 months
Grapes: 10 mos-1 year
Shellfish: 1-2 years
Question:


A 2 month old exclusively breast-fed infant presents to your
office b/c mom thinks he is irritable. Has been passing loose
stools and cries with bowel movements. Generally, happy at
other times. PE is normal. Anal inspection reveals no
fissures. Stool specimen has redish flecks, guaiac is +.
Of the following the BEST next step is to:





A. begin therapy with oral Amox
B. institute trial of lansoprazole
C. Obtain an upper GI series
D. remove milk products from maternal diet
E. send stool for C. Diff toxin testing
Answer:





A. begin therapy with oral Amox
B. institute trial of lansoprazole
C. Obtain an upper GI series
D. remove milk products from maternal diet
E. send stool for C. Diff toxin testing
Explanation:


Infant is passing small amounts of blood in stool, but very
well appearing.
Most likely allergic colitis – first line treatment is dietary
restriction of milk protein from mother’s diet.


Usually rectal bleeding resolves within 3 weeks after dietary
restriction.


Other common offending agents: soy, wheat, eggs, corn, fish, nuts
Condition usually resolves by 1 year of age.
C. Diff is present in stool of 25% of healthy term infants –
but rarely cause of colitis
Question:


During your morning nursery rounds, you find you have a
new patient who was born to a mother infected with HIV.
The mother asks about any precautions she needs to take in
the care of her newborn.
Of the following, you are MOST likely to tell the mother that
she should:





A. add a teaspoon of liquid bleach to the infant’s bath water
B. avoid breastfeeding
C. avoid sharing utensils
D. take no specific action
E. wear gloves while changing diapers
Answer:





A. add a teaspoon of liquid bleach to the infant’s
bath water
B. avoid breastfeeding
C. avoid sharing utensils
D. take no specific action
E. wear gloves while changing diapers
Explanation:



Risk of transmission of HIV from infected
mother to infant without an intervention is
~15-25%.
Breastfeeding by an infected mother increases
the risk by 5-20%.
In countries where safe alternatives to
breastfeeding are readily available, feasible,
affordable – avoidance of all breastfeeding is
recommended.
Question:


You are evaluating an 8 week old infant whose BW was
1,000g and was delivered at 30 weeks gestation. Initially he
had early resp distress and sepsis, but now these problems are
resolved and he has moved from parenteral nutrition to full
enteral feeds.
Of the following the feeding that will provide the BEST
mineral content to ensure healthy bone development for this
infant is:





A. cow milk based formula
B. human milk
C. premature formula
D. protein hydrosolate formula
E. soy protein based formula
Answer:





A. cow milk based formula
B. human milk
C. premature formula
D. protein hydrosolate formula
E. soy protein based formula
Explanation:





VLBW preterm infants are at risk for delayed bone mineralization
due to constraints in delivering optimal nutrition to them while in
NICU.
Need to optimize Ca and Phosphorus balance (hard to do with
TPN). Demineralization of bone often happens after 4 weeks of
TPN (increased alk phos).
Term infant cow milk formula has insufficient calories, protein, Ca,
P, and other trace minerals and vistamins (same as human milk).
Preterm formulas contain higher calorie density, more readily
absorbed lipids, greater protein content, encriched Ca and Phos,
minerals and vitamins
Healthy bone development usually ensured by 44 weeks (post
conception)
Question:


You are addressing a group of new mothers regarding infant
feeding. One mom asks you when an infant can be switched
from formula to whole cow milk.
Of the following, you are MOST likely to respond that whole
cow milk:





A. Can be introduced at 6 mos of age if an infant has significant GER.
B. can be given at 9 mos if the infant is also taking a wide variety of
supplemental foods.
C. may be given as supplement at any age as long as infant also
receives human milk.
D. should be avoided until 12 mos of age because its iron content is
poorly absorbed.
E. should be avoided until 2 years of age because its caloric content is
inadequate for optimal growth.
Answer:





A. Can be introduced at 6 mos of age if an infant has
significant GER.
B. can be given at 9 mos if the infant is also taking a wide
variety of supplemental foods.
C. may be given as supplement at any age as long as
infant also receives human milk.
D. should be avoided until 12 mos of age because its
iron content is poorly absorbed.
E. should be avoided until 2 years of age because its
caloric content is inadequate for optimal growth.
Explanation:



Iron content of cow milk is 0.5mg/L – up to 10% is
absorbed – inadequate to prevent iron deficiency
even when iron rich foods added.
Iron fortified formulas contain 10-12mg/L of iron
and ~4% is absorbed. This is sufficient up to 6
months, then iron rich foods should be added (as
iron stores become depleted).
Cow milk also has a higher content of protein and
electrolytes (Na, K) – renal solute load is too high
for infant kidneys