Feeding a Child: Issues & Solutions (Dr. S. Nishan Silva)

1. Feeding a child Dr.S.Nishan Silva (MBBS)

2. Issues…. • Energy requirement • Breast milk/ feeding • Contents • Technique • Physiology • Colostrum • Formula feeds • Weaning • IUGR • Nutrition of older children

3. Energy • Requirementskcal/kg/day • Basal metabolic rate 40 • Physical activity 4+ • Specific dynamic action of food (10%) • Thermoregulation variable • Growth 70 (To match in-utero growth of 15g/kg/day)

4. Exclusive breastfeeding • All healthy infants should be breastfed exclusively for the first six months of life • Exclusive breastfeeding is defined as "an infant's consumption of human milk with no supplementation of any type. (no water, no juice, no nonhuman milk, and no foods) • except for medications." NF-

5. Composition of Mature Milk

6. BREAST FEEDING Physiological Mechanisms 1- Maternal reflexes • Prolactin reflex : as the baby suckles, impulses pass from the areola up to the hypothalamus then to the anterior pituitary producing prolactin which makes the breasts produce milk. b-Oxytocin reflex (let-down reflex): suckling also stimulates the production of oxytocin by the posterior pituitary. Oxytocin causes contraction of the smooth muscles surrounding the alveoli, squeezing milk out.

7. Prolactin “milk secretion” reflex Enhancing factors Hindering factors Early initiation of breastfeeds Delay in initiation of breastfeeds, Pre-lacteal feeds, Bottle feeding, Incorrect positioning, Painful breast Good attachment & effective suckling Frequent feeds including night feeds Emptying of breast Sensory impulse from nipple Prolactin in blood Teaching Aids: ENC NF- 7

8. Oxytocin reflex Inhibited by Stimulated by • Thinks lovingly of baby • Sound of the baby • Sight of the baby • CONFIDENCE • Worry • Stress • Pain • Doubt Teaching Aids: ENC NF- 8

9. BREAST FEEDING Physiological Mechanisms 2- Infant`s reflexes a.Rooting reflex : If the circumoral area or cheek of the infant are touched by the nipple, leads to turning of the head to the side on which the nipple is felt and the infant draws it into his opend mouth. b. Suckling reflex: The tactile stimulus caused by the nipple and areolar tissues filling the mouth lead to milking action by the tongue against the hard palate.. c. Swallowing reflex: This enables the baby to ingest the milk that is obtained by suckling, and allows interruption of breathing to prevent choking during swallowing.

10. Feeding reflexes in the baby Rooting reflex Sucking reflex Swallowing reflex Teaching Aids: ENC NF- 10

11. Key points of positioning Mother: Make the mother sit in a comfortable and convenient position (she can feed in lying down position) Ensure that she is relaxed and comfortable Baby: Baby’s head and body are in a straight line Baby’s whole body is supported Baby’s face is opposite the nipple and the breast Baby’s abdomen touches mother’s abdomen Teaching Aids: ENC NF- 11

12. Good positioning Teaching Aids: ENC NF- 12

13. Baby’s mouth is wide open Baby’s chin touches the breast Baby’s lower lip is curled outward Usually the lower portion of the areola is not visible Key points of good attachment Teaching Aids: ENC NF- 13

14. Good attachment lower lip is curled outward baby’s mouth is wide open chin touches the breast lower portion of the areola is not visible Teaching Aids: ENC NF- 14

15. Good and poor attachment NF- 15

16. Breast Feeding Video

18. Adequacy of breastfeeding • Breastfeeding is considered adequate if the baby • Goes to sleep for 2-3 hrs after each feed • Passes urine 6-8 times in 24 hrs • Gains weight at 10-15 gm/kg/day • Crosses birth weight by 2 weeks NF-

19. Monitoring feeding • Maternal sensation of engorgement and emptying • Frequency of feeding • Wet nappies • Stools • Jaundice • Weight

20. Normal output

21. Problems in breastfeeding

22. DIFFICULTIES OF BREAST FEEDING 1- Suckling in a poor position. 2- Insufficient Breast Milk. 3- Delayed Appearance of Milk. 4- Inability to Suckle or Refusal of Breastfeeding. 5- Engorgement. 6- Fissured or Cracked Nipples. 7- Flat or Retracted Nipples. 8- Regurgitation after Breastfeeding. 9- Work and Breastfeeding:

23. Full vs. engorged breasts Full breasts = NORMAL Engorged breasts = ABNORMAL Teaching Aids: ENC NF- 23

24. Full breasts: 36/72 hours after birth. Hot, heavy, may be hard Milk flowing Fever uncommon Engorged breasts: can occur at any time during breastfeeding Painful; edematous Tight, especially nipple area Shiny May look red Milk NOT flowing Fever may occur May cause a decrease in milk supply if it happens often Full vs. engorged breasts Teaching Aids: ENC NF- 24

25. Sore nipple Inverted nipple NF- 25

26. Other Practical Problems

27. Mothers Health • Nutrition for breastfeeding women • Energy and protein • higher needs than pregnancy • Vitamins and minerals • Most are higher or same as pregnancy • Iron and folate needs are lower • Water • Food choices • Practices to avoid while breastfeeding • Alcohol, drugs, smoking, excess caffeine

28. Summary of differences between milks Adapted from: Breastfeeding counselling: A training course. Geneva, World Health Organization, 1993 (WHO/CDR/93.6). Slide 2.2

29. Property Antibody-rich Many white cells Purgative Growth factors Vitamin-A rich Importance protects against infection and allergy protects against infection clears meconium; helps prevent jaundice helps intestine mature; prevents allergy, intolerance reduces severity of some infection (such as measles and diarrhoea); prevents vitamin A-related eye diseases Colostrum Slide 2.5

31. Composition of Mature Milk and Colostrum

32. balance of nutrients with high bioavail. good hormones cognitive development less infections less diseases less food allergies contracts the uterus delays menstration conserves iron stores may protect against breast cancer convenient bonding time with baby Benefits of Breastfeedingbabies moms

33. Benefits of breastfeeding for the mother • Protects mother’s health • helps reduces risk of uterine bleeding and helps the uterus to return to its previous size • reduces risk of breast and ovarian cancer • Helps delay a new pregnancy • Helps a mother return to pre-pregnancy weight Slide 2.23

34. Risks of artificial feeding  Interferes with bonding  More allergy and milk intolerance  Increased risk of some chronic diseases  Overweight  Lower scores on intelligence tests  More diarrhoea and respiratory infections  Persistent diarrhoea  Malnutrition Vitamin A deficiency  More likely to die Mother  May become pregnant sooner  Increased risk of anaemia, ovarian and breast cancer Adapted from: Breastfeeding counselling: A training course. Geneva, World Health Organization, 1993 (WHO/CDR/93.6). Slide 2.26

35. Expressed breast milk Indications Sick mother, local breast problems Preterm / sick baby Working mother Storage Clean wide-mouthed container with tight lid At room temperature: 6 hrs Refrigerator: 24 hours; Freezer (20°C): for 3 months NF-

36. Teaching Aids: ENC

37. Absolute contraindications of breast feeding: Causes related to the infant: *Inborn errors of metabolism as galactosemia and phenylketonuria. *Errors of digestion as monosaccharides and disaccharides intolerance. Maternal causes: • Maternal hepatitis B: Unless the newborn receives Hepatitis B immune globulin and Hepatitis B vaccine at birth, and then completes the hepatitis B vaccination schedule. • Maternal HIV/AIDS: Breast-feeding is not recommended if a safe alternative is available. • Intake of dangerous toxic drugs which are secreted in milk in considerable amounts: -Anticoagulants, antineoplastics (cyclophosphamide, cyclosporine, etc.), thiouracil, ergotamine, phenindione and lithium, -Radioactive substances. -Cocaine, heroin, marijuana.

38. Temporary Contraindications: Causes related to the infant: -Severe cleft palate, microgenathia. -Infant infections: Oral herpes simplex. Maternal causes: *Psychosis, neurosis and epilepsy. *Eclampsia. *Maternal infections: • Herpes simplex lesions on the breast (until healed). • Chicken pox: Zoster immune globulin (ZIG) is given to non infected neonate. The neonate is separated from the mother until she is no longer infectious. • Active tuberculosis: Mother is treated. Infant receives INH and is repeatedly tested with tuberculin test. INH is discontinued if tuberculin is still negative after 3-4 months of age and the mother response to treatment is satisfactory. • Breast abscess: No feeding from the affected breast until healed. • Septicemia, typhoid fever, pneumonia until treated.

39. Supplementing breast milk • Should be unnecessary, but • Vitamin K levels are low • Vitamin D levels are low in areas of little sunlight • Iron levels are low (but very well absorbed)

40. Feeding small or preterm infants: Choices • Human milk • Mother’s own • Banked donor milk • Fortified • Artificial • Term formula • Preterm formula • Parenteral Nutrition

41. Artificial Feeds • Term formulas are broadly similar • May be whey or casein based • International agreed standards for constituents

42. General guidelines for the choice of a particular formula: -For a normal baby: Better use an adapted "humanized" dry milk formula. The amount of formula needed is calculated according to weight as follows: Daily needs = 150ml formula/kg of body weight/ day, then The calculated amount is divided by the number of feeds per day (usually 6 feeds). Amount feed (ml):- 150 ml x Body weight in Kg Number of feeds per day Example: For a baby weighing 4 kgs. the daily needs is: 150 x 4 = 600 ml/day. So if we give 6 feeds/day, the amount given in each feed = 600 / 6= 100ml.

44. Short term risks of IUGR • Paediatric • Hypoglycaemia • Necrotising enterocolitis • Increased risk of problems of prematurity • (hypothermia) • (polycythaemia)

45. ‘Failure to Thrive’ • Term first used to describe delayed growth and development, • also called maternal deprivation syndrome. • “A failure of expected growth and well being” • Only growth can be objectively measured

46. Human milk shortcomings if preterm • Human milk may not provide enough • Protein • Energy • Sodium • Calcium, phosphorus and magnesium • Trace elements (Fe, Cu, Zn) • Vitamins (B2,B6,Folic acid, C,D,E,K)

47. Breast milk fortifiers • Improved • short term growth • nutrient retention • bone mineralisation • Concerns • trend towards increased NEC

48. Catch-up Growth • Enhanced nutritional intake sufficient to allow ‘catch-up’ growth improves long term neurodevelopmental outcome

49. Weaning in SL • At 6 months - started • Don’t give water / watery – give semisolid • Start with rice and breast milk • Small quantities, multiple meals • Energy densed • Add – Oil, Dhal, Sprats (powdered) • No salt or sugar till 1 year, No eggs till measles vaccine • Gradually introduce other vegetables, delay green leaves • Fish and then meat • Increase size of particles and quantity • Ensure hygene • No bottles/ tits. Cup and spoon preferred. • Continue breast feeding – up to 2 years • By 1 year – adult food

50. Assignment on Weaning • Describe the different recipes and food types that can be used for weaning. • Describe the relationship between introduction and progression of weaning and the child’s normal development.