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Fall 2015 – PEC – Infant Feeding

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Infant Feeding: the Healthy, Term Infant

Donnianne Noble

RN, IBCLC

Objectives

1) Discuss the AAP Committee on Nutrition recommendations on infant feeding in the first year of life.

2) List two health benefits of breastfeeding for mother and infant.

3) Describe how to assess whether the newborn is breastfeeding effectively.

4) List two considerations for parents when choosing formula feeding.

History of Infant Feeding

• For thousands of years, breastfeeding

• Wet nurses

• Milk from different animals (goats, cows, donkeys)

• Before bottles-- spoons, horns, cups, cloths

• Late 1800s-additives to cow’s milk

• 1900s- MDs take over, complex or simple formulas (evaporated milk, syrups, pasteurization, oils, vitamins) – Proprietary formulas—easy to prepare and affordable,

grew in popularity

– “Niche” formulas- soy, preemie, lactose-free, pre-digested, modifiers

Parents Are Confused

Many parents lack understanding of digestion and have questions about formula

One study shows that 26% of new parents think juice is a component of baby’s diet

Information from healthcare professionals can be influenced by aggressive formula marketing

Safe Bottle Feeding:

Which Formula?

• Cow’s milk based—first choice

• Iron fortified

• May be: ready-to- feed liquid, liquid

concentrate, or powered infant formula

• Liquid is recommended for the neonate as

the powdered is not sterile

• WIC clients will receive powdered infant

formula

Soy Formula

• Recommended for: – Infants with galactosemia

• Inability to digest the simple sugar, galactose • Occurs in 1 in 30,000 – 60,000 infants

– Term formula fed infant with secondary lactose intolerance – Term formula fed infant whose family has chosen a vegan diet

• NOT recommended for: – Infants born less than 1800 GMS – To prevent colic or allergy

• Concerns about: – Bio-availability of amino acids, calcium, iron, zinc (less than in

breastmilk and cows milk formula) – High levels of phyto-estogens – AAP would like soy formula to be by prescription only


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Additives in Formula

DHA & ARA (found in breastmilk) No studies on benefits May cause more GI side effects Higher cost (10-15% more) Extensive promotion to healthcare workers

Prebiotics (found in breastmilk) Non-digestible food ingredients, to stimulate growth

and/or activity of bacteria in the colon No studies-some started by the formula companies

Lutein (found in breastmilk) Claims to support eye development but no studies However, Lutein is also a dye and brightens food

color to make them look more appealing

Formula Marketing

“Restfull” added to Mead Johnson formulas (Enfamil)

Designed to sedate baby, make her sleep longer, solve sleep problems

A special PM formula before naps and bedtime

Longer sleep patterns not normal and may increase SIDS

What about the FDA

FDA categorizes formula as GRAS (generally regarded as safe)

Part of “food” division not “drug” FDA does not have to approve formula before if

can be marketed Formulas must meet federal nutrient guidelines Formula companies only have to register a product

with the FDA but no testing/studies need to be completed

Essentially, new additives and products are tested on newborns

Which brand?

• Studies show no great benefit of one particular brand over another – All babies are gassy, burpy, cry, are

fussy, spit up, and get rashes

– Specialty pre-digested formulas cause less allergy but are expensive

– All result in stools that are hard to runny, brown to green

• “Iron fortified” recommended for the first year (RDA)

Formula Prep • Check can isn’t dented or bulging

• Clean top of can with hot soapy water

• Note expiration date and batch number in log book

• Wash hands

• Store formula is cool dry place (not in garage or car)

• Sterilize before first use

• Choose a slow flow nipples – Even the hospital “yellow ring” nipples may be too fast for newborns to

handle

– Flow rates vary by brand

• Choose BPA free

• Room temperature is fine. Never warm bottles

in the microwave

Bottle Prep

Expiration Date

• Check the infant formula’s expiration date

on the label, lid, or bottom of the can. If the

expiration date has passed, then the infant

formula has expired and should not be

used.


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Log the Batch Number

• Keep track of all the formula used

• Regularly check for recalls of formula on

the internet • Recalls are not uncommon

• “FDA -Infant formula recall list”

WHO Recommendations

• To reconstitute powered formula:

• Water for powdered formula should be boiled first

• Then cooled to 70C (158F), and used at that temperature to prepare the formula

• Lower temperatures do not kill Enterobacter sakasakii or cronobacter or other bacterial contaminants

• The idea is to kill the intrinsic bacteria in the formula not to sterilize the water—it’s not the water that’s contaminated, it’s the formula

How to bottle feed

• Enjoy the baby’s mealtime

• Hold the baby in a semi-erect position

• Expect slow flow and relaxed feedings

• Burp ½ way through or as needed

• Never prop a bottle due to the risk of choking

• Never lay baby down with a bottle due to risk of tooth decay and increased risk of ear infections

• Discard any remaining formula

Remember baby’s tummy is small!

Day 1

1-2 teaspoons

Day 3

1/2 to 1 oz

Day 10

2+ ounces

• How much the tummy holds

Remember to look at the baby

• Don’t force your baby to finish because

there is more in his bottle

• If the baby spits up in the beginning days,

use smaller volumes, and feed them

slower

• The baby is expecting small amounts

frequently in the beginning days

• Switch arms to allow for eye development

Hazards in Infant Formula

Incorrect labeling Contaminants, toxins, pollutants

Salmonella, vitamin deficiencies, bacteria (E. Sakazaki) Glass, lead Water, bottle, nipple contamination, BPA

Recent serious contamination with E. sakazaki in powdered formula (infant deaths) 2011 – Walmart pulled over 3000 cans of Enfamil from

its shelves after 2 infant deaths of Cronobacter in Missourri

Recent recall for beetles in Similac Black market is big business ($35 billion annually

according to the FBI) Poorly absorbed nutrients It is cow’s milk


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Formula Contamination: China

September, 2008 6 babies died and 300,000 sickened so

far from contaminated formula Milk powder was found to have

melamine As China has become more prosperous,

breastfeeding has dropped off and formula feeding has increased

Melamine has also been found in American formula

http://www.fda.gov/Food/FoodSafety/Product-SpecificInformation/InfantFormula/AlertsSafetyInformation/default.htm

To check for recalls

“ Imagine that the world had invented a new

“dream product” to feed and immunize everyone born on earth.

Imagine also that it was available everywhere, required no storage or delivery--and it helped mothers to plan their families and reduce the risk of cancer. Then imagine that the world refused to use it. Towards the end of this century of unprecedented discovery and invention, even as scientists discover the origins of life itself, this scenario is not, alas, a fiction. The “dream product” is human breastmilk, available to us all at birth and yet we are not using it.” UNICEF 1991

UNICEF

UNICEF estimates that 1.5 million babies die each year worldwide-because they were not breastfed

Baby-Friendly Hospital Initiative

• Global program launched in 1991 by WHO & UNICEF to encourage hospitals to give optimal care for infant feeding and mother/baby bonding

• Recognizes hospitals that implement the “10 Steps to Successful Breastfeeding” and abide by the “International Code of Breastmilk Substitutes”

www.babyfriendlyusa.org

Ten Steps to Successful Breastfeeding

1. Write breastfeeding policy

2. Train all healthcare staff

3. Inform all pregnant women

4. Initiate breastfeeding within an hour of birth

5. Show mothers how to breastfeed

6. Give infants nothing but breastmilk

7. Practice “rooming in”

8. Encourage breastfeeding on demand

9. Give no artificial teats or pacifiers

10.Establish breastfeeding support groups

Baby-Friendly Hospital Initiative • Currently, 19,000 birthing sites in 134 countries

throughout the world have received the “Baby-Friendly” Award

• 199 “Baby-Friendly” hospitals in USA – 6 in Washington state

• Evergreen Hospital Medical Center Kirkland

• Tacoma General –Tacoma

• University of Washington Medical Center

• Okanogan-Douglas District Hospital -Brewster

• Providence St Mary's Hospital, Walla Walla

• Group Health Central - Seattle

• Represents less than 8% of US births


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Does Baby-Friendly Practice Work?

• Several large studies reveal;

– More mothers initiate breastfeeding

– More are exclusively breastfeeding

– More breastfeed for extended periods of time

– Fewer GI infections and atopic eczema

– Less supplementation

– Higher breastfeeding initiation among African-American women

2014 CDC Breastfeeding Report Card

@ birth – 79.2% (up 2 % from last year) @ 6 months – 49.4% (same as last year) @ 12 months – 26.7% (about the same as last

year) Exclusively breastfeeding at 3 months – 40.7% Exclusively breastfeeding at 6 months – 18.8%

WASHINGTON STATE: @ birth – 91.8% Exclusively breastfeeding at 6 months – 20.3%

http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf

Bio-specificity of Human Milk

• All mammalian milk is species specific • Human milk is ideally suited to meet

the specific needs of the human infant • Humans are “carrying” mammals

“Living” Properties

• Human milk is alive – Lipids, proteins, carbohydrates, vitamins

and minerals, growth factor, hormones, omega-3 fatty acids, anti-infective properties--macrophages, lymphocytes, phagocytes, immune globulins, interferon, antibodies, more….

• Protects against some diseases for a lifetime – Diabetes, lymphoma, all childhood

cancers, cardiovascular disease (lower BP, cholesterol), obesity

American Academy of Pediatrics

Recommendations: • Human milk is preferred for all infants

• Breastfeeding should begin within first hour of birth, baby not removed from mother until it begins

• Babies should be fed on demand

• No supplements unless medically indicated

• Follow up with healthcare practitioner at 2-4 days

• Exclusive breastfeeding for first 6 months, and continue for at least 12 months, with the addition of solids after 6 months

• Breastfeeding should be maintained during separations, such as hospitalization of mother or baby

Additional

AAP Recommendations

Mothers and babies should sleep in close proximity

Babies stay skin-to-skin with the mother after the birth until the 1st feeding

No pacifiers until breastfeeding well established

Evaluation of breastfeedings in hospital twice a day

No upper limit to age of weaning


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Vitamin D and

Breastfeeding

• AAP recommendations

• Breastfed infants in the first days, should receive vitamin drops with vitamin D to prevent rickets

– Sunscreens prevent vitamin D absorption

– Sunlight from normal activities for ½ hour a week is usually sufficient to prevent rickets

– Babies with more skin pigment, or in climates without much sunlight or who are always covered or kept inside are more at risk

• Not a breastfeeding issue, a sunlight issue

Immunity

Breastfeeding is the major source of active and passive immunity in the vulnerable early months and years of life

Breastfeeding is considered the most effective

means of reducing death rates of children under 5 years

Every single day, an estimated 3500-5000 unnecessary child deaths occur

Breastfeeding Myths/ Misconceptions

& How you can help

• Many ideas about breastfeeding; regarding diet, how to prepare breasts, how milk is made, how long to breastfeed, schedules, etc.

• Friends and relatives share scary stories (just like birth stories)

• Parents deserve accurate information, • Evidenced based information is helpful • A little knowledge about how breasts work

can empower the woman to feed her baby successfully – Most women don’t know how the breast works and

what’s inside – When they know a little about how their breasts

work, it increases confidence

Breast Anatomy

Develops from the galactic streak during fetal development

2-6% of humans have accessory glands along the milk streak

Montgomery glands produce lubricating and bacteriostatic secretions

Breast is composed of: Lobes (15-25), lobuli (20-40), alveoli -acinius

cells (10-100) Milk made in the cells in the alveoli flows to

alveolar ductslactiferous ductsnipple openings (4-10)

Breast Anatomy

• Many variations • Prenatal

assessment helpful • Flat or inverted

nipples-more or a challenge

• History of surgery important – Reduction,

augmentation, lift, placement of incisions

New Information on Anatomy

• Dr. Peter Hartman-Perth, Australia

• Ultrasound shows no evidence of the sinuses

• Milk duct system is more complex and convoluted than thought


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Breast Changes in Pregnancy

• Increase in size of breast and areola

• Increase tenderness of breasts and nipples

• Darkening of the areola

• Increased veining

• Begin colostrum production usually in 2nd trimester

Oxytocin: Milk-ejection Reflex

Released with:

– Tactile stimulation of the areola

– Psychological stimuli

– Baby’s crying

– Familiar “nest”

– Thoughts about baby

– Effects every body system

Prolactin

• Made by the hypothalamus, stored in the anterior pituitary

• For the production of milk

• Baseline levels similar in male and non-pregnant female

• Helps women respond to stresses in perinatal period

– Combats stress hormones

Secretory Activation (previously called Lactogenesis II)

After birth, and the removal of the placenta, falling estrogen and progesterone levels trigger the increase in milk production

(Placental fragments that remain can significantly prohibit milk production)

Lactogenesis III

(Autocrine Control)

• The ongoing process of milk production

• Continues as long as milk is removed from the breast

Factors in Milk Synthesis

(Ice machine analogy)

• Milk secretion is continuous and stored in alveoli and ducts

• Rate of milk production is related to breast emptiness

• The emptier the breast the faster the milk synthesis

• The fuller the breast the slower the milk synthesis


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Colostrum

–20-100 ml /24 hours in the 1st 3 days

–Beta-carotene, antibodies, prostaglandins

– Protein, sodium, potassium, chloride, minerals and fat-soluble vitamins than mature milk

–18 calories per oz.

Mature Milk

–After 10 days (until then, transitional milk)

–20-25 calories/ oz.

–Renal solute ideal for infants

–Hormones

–High water content

–Fat content varies

Fat Content of Mother’s Milk

Foremilk

– Comes in the first minutes of feeding or pumping

– Higher water content

– Looks thinner--like skim milk

Hind milk

– Comes after foremilk, after baby has been sucking for several minutes

– Has a higher fat content

– Looks more like cream

Let the baby finish the first side first, then offer the second side. Many will not take the second in the 1st days

SKIN TO SKIN!!

Colonized with mothers skin flora

Skin to skin raises blood sugars by 11%

Decreases infant cortisol levels which decrease stress

Enhances thermoregulation

Improved motor function and rhythmic sucking behaviors

Decreases pain response

Promotes uterine contractions and may help decrease risk of PP hemorrhage

Getting Started: Timing

• Quiet alert state after birth

• Feeding cues

• Infant self-attachment

“Right after birth, within the first hour of life, normal infants have a prolonged period of quiet alertness…., during which they look directly into their mother’s and father’s faces and eyes and can respond to voices. It is as though newborns had rehearsed the perfect approach to the first

meeting with their parents.”

Marshall Klaus, MD

Environment

• Privacy; who else is in the room?

• Remove nightgown or put gown on backwards

• Un-swaddled baby--Skin-to-Skin

• Warm blanket around mother and baby


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The Quiet Alert State

Expected Behaviors

• Calm

• Gazing at parents

• Subtle, slow feeding cues

• Some babies may crawl to the breast and self-attach

• Goal: A feeding initiated in the first hour of life

Education

• Feeding cues

• Latch and positioning

The Sleepy Phase

Expected Behaviors

• Baby moves through sleep stages

• Decreased feeding cues

Education

• Infant sleep stages – Quiet (deep) sleep

• Nearly still

• No eye movement

• Difficult feedings

– Active (REM) sleep

• Precedes waking

• Eye movement under lids

• Increased body movements

• May latch and feed well

• Importance of skin-to-skin

Mother’s position

• Start with mothers position

• Semi-reclined position

• Knees higher than hips

Baby’s position

• Baby in good alignment.

– Ear, shoulder, hip lined up.

• Baby lying on his tummy.

• Baby’s arms on either side of the breast.

– “Like he’s hugging the breast.”

Big Tip – The Tuck!! • Tuck the baby’s bum under the mothers

opposite breast.

– “His diaper should touch your ribs.”

• This ensures baby’s chin will be to the breast

Asymmetrical Latch

• Gums should land deeper below the nipple

• Ideal latch

• Nipple toward roof of mouth


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Settling in • Teach mom how to move her arm around

to support baby so she has a hand free

• Show mom how to roll baby’s lower shoulder to allow more room near his nose.

Positions

• Learning process for mom and baby

• May take 100 times in each position to feel comfortable

• Gets easier in home

environment (nest)

• Mothers and babies work it out

Clutch, Football Hold – Mom can see attachment better

– Allows good head control

– Keeps baby from C/S incision

– Make room behind mom's back for baby

– Good after birth and at night

– Moms get more rest

Side-Lying

When the Baby

Doesn’t Latch

• Is there something going on with the baby? – Infant condition, prematurity – Abnormalities of face and/or mouth – Baby is drugged, over-stimulated, in deep sleep – Baby is still spitting up amniotic fluid

• Are mother’s breasts are difficult to grasp? – Flat, inverted, large nipples – Breast tissue which seems to move away from

the baby – Mother unable to position well – Slow or low milk flow

Hospital Routines and Their Effect

on the Neonate

• Limited or infrequent feedings

– Slowed gut motility

– Reduced stooling

– Greater weight loss

– Higher bilirubin levels

– Greater frequency, volume of supplemental feeds

• Missed feeding cues, scheduled feedings • Hospital routines

– PKU, blood sugars – Circumcision – Separation from mother

• Effects of maternal medications, IV fluids

• Negative early feeding experience – Gastric suctioning

• Supplementation • Immaturity

Sleepy, Lethargic Babies


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The Sleepy Baby

Put the baby skin-to-skin , or at least unwrap

Express colostrum for the baby to smell

Try a new position

Body massage

Change the diaper

Be assertive but kind

Talk to the baby

Breast compression after the baby latches

Effects of “just one bottle” of Formula

on the Neonate

• Increased likelihood of serious allergy to cow’s milk protein

• Increased chance of bowel infection and diarrhea by changing the PH of the bowel

• Cause of nipple or flow preference

• Affects delicate supply and demand balance

• Increases engorgement

• Decreases mother’s confidence

• Reduces the duration of breastfeeding

The Early Days

• Feedings may be long and eager or may be a short visit and relaxed

• Not clear beginnings or endings to feeds

• First feedings are often followed by long periods of deep sleep in the first 24 hours

• Offer first breast for as long as the baby is interested, then offer second breast

• Many don’t take the second breast at the same feeding for a few days

Potential Problems • Sore nipples

• Flat/inverted nipples

• Engorgement

• Insufficient milk supply

Sore Nipples: Prevention

• Prenatal assessment

• Correct latch-on, good positioning, varied

• Keep nipples dry, or use colostrum

• Avoid soaps or lotions on nipples, areola

• Release suction before removing baby

• Avoid pacifiers or bottles for first 4-6 weeks

Sore Nipples: Causes

• Poor positioning/poor latch

• Slow milk flow

• Infant oral anatomy (ankyloglossia, low muscle tone)

• Maternal breast anatomy (flat/inverted nipples, non-elastic areolae)

• Bacterial or yeast infection


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Flat or Inverted Nipples

• Antepartum – Anticipatory guidance-may be a

challenge

– May be difficulty with latch/sore nipples

– Lactation consultant referral

• Postpartum – Nipple massage or pump before feeds

– Modified syringe or nipple everter

– Nipple shield with close follow-up

– Breast shells between feedings

Treatment of Sore Nipples

• #1 = good latch and positioning!

• Observe feeds and ask mothers how it feels

• Watch for early feeding cues

• Hand express colostrum before feeding

• Use tools when appropriate

• Use wound healing when appropriate

Sore Nipples: Treatment

Lanolin, oils, peppermint water, medi-honey

Moist wound healing, hydrogel dressings, moist soaks before or after feedings

For breaks in the skin, topical antibiotics and /or low strength topical steroids and/or anti-fungal treatment (APNO-RX)

Breast shells to keep clothing off of sore nipples

In severe cases, discontinue breastfeeding for 24-48 hours, with double electric pumping to maintain supply

If condition persists, culture for bacteria and yeast

Refer to LC/OT/PT, or dermatologist

Engorgement Causes

• Breast fullness caused by:

– Inefficiently drained breast

– Edema

– Inflammation

Engorgement Prevention

Proper latch-on and position Feed frequently (8-12 times in 24

hours) Avoid supplements or water If a feeding is missed, express milk

(hand or pump) Avoid all bottles and pacifiers If weaning, go gradually

Engorgement Treatment

Treatment:

Reverse pressure softening

Good latch and positioning

Breast shaping

Tincture of time. Edema usually subsides by 2 weeks postpartum


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Engorgement: General Treatment

• #1 = Frequent feeds and good latch

• Warmth before

• Massage during

• Ice after

Insufficient Milk Supply: Causes

Mismanagement of breastfeeding or ineffective breastfeeding

Abnormalities of maternal anatomy or physiology

Retained placenta Breast surgery (reduction) Breast injury (burns, surgery, radiation) Effects of illness (anemia, sepsis,

postpartum hemorrhage) Pumping only with a poor quality pump

Insufficient Milk Supply:

Management

Careful history to determine cause Repair mismanagement / increase

numbers of feedings at the breast Increased skin-to-skin time

Determine intake by ac/pc weight on electronic scale

Bilateral pumping after breastfeeding

Galactogogues Reglan, Domperidone, fenugreek

Supplementation in the First Days

• First observe and evaluate latch

• Look for S&S of hypoglycemia, sepsis, excessive weight loss

• If medically indicated, supplement with: – 1st choice- colostrum, or expressed milk, then donor

milk, last choice formula

• Consider cup, finger feed, supplemental nursing system, spoon, tube and syringe

• Always document, why, what and what method used for supplementation

The Importance of Parent Education

“How do you know baby is getting enough?” Wet/poopy diapers Frequency of feedings Nutritive vs. non-nutritive sucking

Marathon/frenzy feeding Warning signs When to get help Follow up

“Is baby getting enough?”

• Wet/poopy diapers

– 1 wet diaper per days old (3 on day 3) until day 5, then 6-8/day

– After 1st day 2-3+ stools/day yellow by day 4-5

– Education about normal stool color change


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“Is baby getting enough?” Feeding cues Nutritive vs. non-nutritive sucking Expected patterns of feeding and

behavior Feedings at least 8-12 times in 24 hours Satisfied after feedings Breast feels softer

The 2nd & 3rd Nights

• Marathon / Frenzy feeding • Baby wants to be on breast constantly

• Falls asleep at breast and cries if removed or put down

• Not about – Hunger, starving, not enough milk

– Using mom “as a pacifier”

– Baby being manipulative or spoiled

• Is about baby coping with an over-stimulated immature nervous system

• More prolactin released with night feeds

Discharge Education

• Warning signs to report to care provider

• When and where to get help

• Feeding plans and close follow-up for “problem feeders”

• When to be seen next by HCP

Barriers to Breastfeeding • Early discharge / lack of follow-up

• Conflicting messages/lack of consistent information

• Free formula/ aggressive marketing of formula

• Failing to provide support

• Lack of breastfeeding friendly workplaces

• Lack of confidence

• Embarrassment

• Loss of freedom

• Influence of family and friends

Your Words

Are Powerful

• Health care provider words are powerful

• Praise and encourage at every possibility

• Words of doubt create doubt

– “What a nice job you are doing.”

– “The baby is so happy to with you and feeding.”

– “Isn’t your baby amazing?”

What Does “Support” Mean?

Help mothers-when you don’t know the answer—find out the answer Give research based information rather than personal information Create an environment where women can be successful Know available resources Refer: use IBCLCs and other trained professionals

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