Newborn Nutrition and Feeding Chapter 25 Newborn Nutrition and Feeding Copyright © 2016 by Elsevier Inc. All rights reserved.

Learning Objectives Describe current recommendations for infant feeding. Explain the nurse’s role in helping families choose an infant feeding method. Discuss benefits of breastfeeding for infants, mothers, families, and society. Describe nutritional needs of infants. Describe anatomic and physiologic aspects of breastfeeding.

Learning Objectives (Cont.) Recognize newborn feeding-readiness cues. Explain maternal and infant indicators of effective breastfeeding. Examine nursing interventions to facilitate and promote successful breastfeeding. Analyze common problems associated with breastfeeding and interventions to help resolve them.

Learning Objectives (Cont.) Compare powdered, concentrated, and ready- to-use forms of commercial infant formula. Develop a teaching plan for the formula-feeding family.

Recommended Infant Nutrition Scientific evidence is clear that human milk provides the best nutrition for infants. Human milk is the gold standard for infant nutrition. AAP recommends exclusive breastfeeding of human milk for the first 6 months and continued breastfeeding for at least 12 months. During the second 6 months, appropriate complementary solid foods are added to the diet.

Breastfeeding Rates Healthy People 2020 goals Infants ever breastfed, 81% Six months, 60.6% 12 months, 34.1% U.S. rates from 2010 (CDC Report, 2013) Infants ever breastfed, 77% 6 months, 49% 12 months, 27% Exclusive BF 46% at 3 months, 25% at 6 months Trends have not changed in breastfeeding rates among minority groups in the United States

Benefits of Breastfeeding The evidence supporting breastfeeding as the ideal form of infant nutrition is so strong that health care professionals may need to present information about it from two perspectives: Benefits of breastfeeding and Risks of not breastfeeding Long-term health benefits for both mom and baby Enhanced bonding and attachment Convenient, inexpensive Environmental benefits

Choosing an Infant Feeding Method The decision to breastfeed Natural extension of pregnancy and childbirth Women tend to select the same feeding method for all their children. Support by family and partner is a major factor in feeding choice. Cultural factors Mother’s knowledge about the health benefits to the infant and her comfort level with breastfeeding in social settings

Choosing an Infant Feeding Method (Cont.) Barriers to breastfeeding Lack of broad social support for breastfeeding Widespread marketing by infant formula companies Lack of prenatal breastfeeding education Insufficient training and education of health care professionals about breastfeeding Employment and the need to return to work after birth Pain, lifestyle incompatibility

Choosing an Infant Feeding Method (Cont.) Formula feeding Parents who choose to formula feed often make this decision without complete information and understanding of the benefits of breastfeeding. Cultural beliefs, myths, misconceptions Some view formula feeding as a way to ensure that the father, other family members, and daycare providers can feed the baby.

Choosing an Infant Feeding Method (Cont.) Breastfeeding contraindicated in a few circumstances Newborns with galactosemia Mothers who are positive for human T cell lymphotropic virus types I or II Mothers with untreated brucellosis Mothers with active tuberculosis Mothers with active herpes simplex lesions on the breasts Mothers with HIV infection Considered a contraindication in the United States In developing countries where HIV is prevalent, the benefits of breastfeeding for infants outweigh the risk of contracting HIV from infected mothers

Choosing an Infant Feeding Method (Cont.) Cultural influences on infant feeding Immigrants to the United States from poorer countries often choose formula to appear more “modern” or to adapt to U.S. culture and customs Breastfeeding beliefs and practices vary across cultures Beliefs about the harmful nature or inadequacy of colostrum Combining breastfeeding and commercial infant formula: las dos cosas Specific food intake to foster milk production

Nutrient Needs Fluids Energy Carbohydrates Fat Protein Vitamins Minerals

Anatomy and Physiology of Lactation Anatomy of lactating breast 15 to 20 segments (lobes) Alveoli Milk-producing cells within lobes Myoepithelial cells Contract to send milk to ductules Complex, intertwining network of milk ducts that transport milk from the alveoli to the nipple The size and shape of the breast are not accurate indicators of its ability to produce milk.

Anatomy and Physiology of Lactation (Cont.)

Anatomy and Physiology of Lactation (Cont.)

Anatomy and Physiology of Lactation (Cont.) Lactogenesis Prolactin prepares the breast to secrete milk. Supply-meets-demand system Oxytocin Milk ejection reflex (MER): let-down reflex Same hormone that stimulates uterine contractions during labor Mothers who breastfeed are at decreased risk for postpartum hemorrhage Nipple-erection reflex

Anatomy and Physiology of Lactation (Cont.)

Anatomy and Physiology of Lactation (Cont.) Human milk is the ideal food for human infants. Uniqueness of human milk Contains many immunologically active, protective components: Main immunoglobulin: IgA IgG, IgM, IgD, and IgE are also present. Colostrum: more concentrated than mature milk and extremely rich in immunoglobulins Higher concentrations of protein and minerals but less fat than mature milk

Anatomy and Physiology of Lactation (Cont.) Uniqueness of human milk (Cont.) Composition of mature milk changes during each feeding Stage I lactogenesis: begins 16 to 18 weeks of gestation Stage II lactogenesis: begins with delivery of placenta Stage III lactogenesis: mature milk is established, about 10 to 14 days after birth

Anatomy and Physiology of Lactation (Cont.) Uniqueness of human milk (Cont.) Composition of mature milk changes during each feeding. The composition of human milk changes over time as the infant grows and develops. Fat is the most variable component of human milk. Milk production gradually increases as the baby grows. Fairly predictable growth spurts (at about 10 days, 3 weeks, 6 weeks, 3 months, and 6 months)

Uniqueness of human milk (cont’d) Colostrum, a clear yellowish fluid More concentrated than mature milk Extremely rich in immunoglobulins Higher concentration of protein and minerals Less fat than mature milk

Uniqueness of human milk (cont’d) Composition changes during each feeding Fat content of breast milk increases Initially, foremilk is released that: Is part skim milk: about 60% of volume Is part whole milk: about 35% of volume Provides primarily lactose, protein, and water-soluble vitamins

Uniqueness of human milk (cont’d) Composition changes during each feeding Hindmilk, or cream (about 5%), usually let down 10 to 20 minutes into feeding Contains denser calories from fat for ensuring optimal growth and contentment Changing composition of human milk during each feeding requires breastfeeding long enough to supply balanced feeding

Care Management: The Breastfeeding Mother and Infant Supporting breastfeeding mothers and infants Care providers with knowledge, skills, and attitudes to promote and support breastfeeding Birthing environment in which breastfeeding is promoted and supported Baby-Friendly Hospital Initiative (BFHI)

Care Management: The Breastfeeding Mother and Infant (Cont.) Feeding readiness cues Hand-to-mouth or hand-to-hand movements Sucking motions Rooting reflex—infant moves toward whatever touches the area around the mouth and attempts to suck Mouthing

Care Management: The Breastfeeding Mother and Infant (Cont.) Positioning Latch Milk ejection or let-down Frequency of feedings Duration of feedings Indicators of effective breastfeeding

Frequency of Feedings Frequency of Feedings Newborns need to breastfeed 8 to 12 times in a 24 hour period Newborns should breastfeed every 3 hours during the day and every 4 hours at night Feeding frequency is determined by counting from the beginning of one feeding to the beginning of the next feeding

Care Management: The Breastfeeding Mother and Infant (Cont.)

Care Management: The Breastfeeding Mother and Infant (Cont.) Supplements, bottles, pacifiers Special considerations Sleepy baby Fussy baby Slow weight gain Jaundice Preterm and late preterm infants Breastfeeding multiple infants

Slow Weight Gain Newborns typically lose about 5 to 6 % of body weight before they begin to show a weight gain Weight loss of 7 % in a breastfeeding infant during the first three days of life should be investigated Infants should show a weight gain of 110 to 200 g per week or 20 to 28 g per day for the first three months Breastfeed infants usually do not gain weight as quickly as formula-fed infants

Jaundice Jaundice Hyperbilirubinemia Early onset or breastfeeding jaundice- usually occurs after 24 hours and peaks by the third day Breastfeeding infant may be associated with insufficient feeding and infrequent stooling Bilirubin is excreted from the body primarily through the intestines Infrequent stooling allows bilirubin in the stool to be reabsorbed into the infant system

Preterm Infants Human milk is the ideal food Breast milk enhances retinal maturation in the preterm infant and improves neurocognitive outcomes Decreasing the risk of necrotizing enterocolitis Mothers unable to breastfeed their preterm infant should begin pumping their breast as soon as possible

Breastfeeding Twins Breastfeeding Twins Mothers breastfeeding twins needs extra nourishment -200 to 500 kcal per day for each baby Each baby feeds from one breast per feeding usually for 20 to 30 minutes Modified demand feeding schedule

Care Management: The Breastfeeding Mother and Infant (Cont.) Expressing and storing breast milk Hand expression Mechanical milk expression (pumping) Types of pumps Storing breast milk Maternal employment Weaning Milk banking and milk sharing For infants who cannot be breastfed but who also cannot survive except on human milk, banked donor milk is critical.

Storage of Milk Breast milk can be safely stored in any clean glass or plastic container Freshly expressed milk can stored at room temperature for up to 8 hours Refrigerated safely for up to 8 days Milk can be frozen for 6 months in the freezer section of a refrigerator with a separate door

Weaning Infants can be weaned directly from the breast to a cup Bottles are usually offered to infants younger than 6 months Infant is weaned before 1 year, formula should be fed to the infant instead of cow’s milk

Care Management: The Breastfeeding Mother and Infant (Cont.) Care of the mother Nutrition Rest Breast care

Care Management: The Breastfeeding Mother and Infant (Cont.) Care of the mother (Cont.) Breastfeeding and contraception Breastfeeding during pregnancy Breastfeeding after breast surgery Breastfeeding and obesity Medications, alcohol, smoking, and caffeine Herbal preparations

Care Management: The Breastfeeding Mother and Infant (Cont.) Common concerns of the breastfeeding mother Engorgement Sore nipples Insufficient milk supply Plugged milk ducts Mastitis Follow-up after discharge

Formula Feeding Parent education Readiness for feeding Feeding patterns Feeding technique Common concerns Bottles and nipples

Formula Feeding (Cont.) Parent education (Cont.) Infant formulas (commercial formulas) Cow’s milk–based formulas Soy-based formulas, commonly used for children who are lactose or cow’s milk–protein intolerant Casein- or whey-hydrolysate formulas, used primarily for children who cannot tolerate or digest cow’s milk– or soy-based formulas Amino acid formulas, used for infants with multiple food protein intolerances

Positions for burping an infant.

Formula Feeding (Cont.) Parent education (Cont.) Formula preparation Powdered formula: least expensive Concentrated formula Ready-to-feed: most expensive Vitamin and mineral supplementation Weaning Introducing solid foods Complementary feedings

Question Benefits to the mother associated with breastfeeding include all except which of the following? There is a decreased risk of breast cancer. It is an effective method of birth control. It increases bone density. It may enhance postpartum weight loss.

Key Points Human breast milk is species specific and is the recommended form of infant nutrition. It provides immunologic protection against many infections and diseases. Breast milk changes in composition with each stage of lactogenesis, during each feeding, and as the infant grows. During the prenatal period, expectant parents should be informed of the benefits of breastfeeding for infants, mothers, families, and society.

Key Points (Cont.) Infants should be breastfed within the first hour after birth and at least 8 to 12 times every 24 hours thereafter. Parents should be taught to recognize the signs of effective breastfeeding.

Key Points (Cont.) Breast milk production is based on a supply- meets-demand principle: the more the infant nurses, the greater the milk supply. Infants go through predictable growth spurts. Sore nipples are most often caused by incorrect latch.

Key Points (Cont.) Commercial infant formulas provide satisfactory nutrition for most infants. Infants should be held for feedings. Parents should be instructed about the types of infant formulas, proper preparation for feeding, and correct feeding technique.

Key Points (Cont.) Solid (complementary) food should be started at about 6 months of age. Unmodified cow’s milk is inappropriate for infants younger than 1 year of age. Nurses must be knowledgeable about feeding methods and provide education and support for families.