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Infant Feeding

Infant Feeding . Jillian Parekh, MD, FAAP July 8, 2010. Rates of breastfeeding:. In 2004 and 2003,70% of US women initiated breastfeeding Breastfeeding rates for Hispanic mothers are greater than total US population (79%) At 3 mos, only 39% and 41% still exclusively breastfeeding

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Infant Feeding

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  1. Infant Feeding Jillian Parekh, MD, FAAP July 8, 2010

  2. Rates of breastfeeding: • In 2004 and 2003,70% of US women initiated breastfeeding • Breastfeeding rates for Hispanic mothers are greater than total US population (79%) • At 3 mos, only 39% and 41% still exclusively breastfeeding • At 6 mos, only 36% of infants receiving any breast milk • 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

  3. 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.

  4. 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)

  5. Advantages of Breastfeeding - Mom: • Prevents postpartum hemorrhage (uterine contraction) • Facilitates postpartum weight loss • Reduces stress hormone levels • May provide contraceptive effect • If used exclusively for 4-6 months – not reliable • Amenorrhea also allows iron stores to be repleted • Increased child spacing • Decreases risk of breast cancer • Anovulation may also protect against ovarian cancer • Maternal-infant bonding

  6. Advantages of Breast Feeding - Infant: • Prevents or reduces severity of illnesses • GI, respiratory, OM • 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 • 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

  7. 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…

  8. Complications of Breast feeding: • Nipple pain • Engorgement • Plugged ducts • Mastitis

  9. 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

  10. Milk Supply: • Colostrum is made first • Provides all nutrients neonate needs in first few days • Higher in protein, lower in sugar, lower in fat • Transitional milk • “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

  11. 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

  12. 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

  13. 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

  14. 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

  15. Breast feeding positions: • Cradle hold: • Baby’s head supported by elbow • May put too much pressure on abdomen if post C-Section

  16. Cross-Cradle hold: • Works well for babies who need to be guided to latch • Hands support baby • Baby’s chest and abdomen face yours

  17. 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

  18. Reclining position: • Good for post C-section or feeding at night • Need to support self with pillows

  19. Twin positioning:

  20. Patterns: • Feeding one vs both breasts • Draining one breast – hindmilk has more fat • Both breasts drained – engorgement • Feedings should last 10 -15 minutes per breast • Allow infant to drain first breast before switching • Notice early hunger cues • 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

  21. 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

  22. Is my baby getting enough? • Monitoring weight • 20-40g/day (after initial losses in first week) • 6 or more wet diapers/day • 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

  23. 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

  24. Growth: • Birth weight doubles by 5 months • Birth weight triples by 1 year

  25. 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

  26. 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)

  27. 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)

  28. 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.

  29. 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

  30. 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

  31. 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

  32. Stages of solids: • Stage I: • Stage II: • Stage III:

  33. Home made solids: • Boil foods and puree • No added salts or spices • Can freeze in individual servings (ice cube trays)

  34. Introduction of cow milk: • After age 1 • Less easily digested • Contains increased minerals and proteins • Inadequate vitamins and iron

  35. 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)

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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."

  41. 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

  42. 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

  43. 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

  44. 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. • Other common offending agents: soy, wheat, eggs, corn, fish, nuts • Usually rectal bleeding resolves within 3 weeks after dietary restriction. • 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

  45. 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

  46. 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

  47. 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.

  48. 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

  49. Answer: • A. cow milk based formula • B. human milk • C. premature formula • D. protein hydrosolate formula • E. soy protein based formula

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