Chapter 22: Infant Feeding

Question 1

how many calories does a full term newborn need?

Answer 1

• breast fed: 39-45 calories/per pound of body weight
• bottle fed: 45-50 cal/lb of body weight

Question 2

how many calories are in each ounce of breast milk and formula?

Answer 2

20 calories/oz

Question 3

how much weight can an infant lose? why does this happen?

when is the infant evaluated for weight loss?

Answer 3

• during early days, infants may lose up to 10% of birth weight.
  
  • result of normal excretion of extracellular water and meconium and newborns consuming fewer calories than needed
• infants should be evaluated for feeding problems if weight loss exceeds 7%, if weight loss continues beyond 3 days of age, or if birth weight is not regained w/in 10 days

Question 4

why are complex carbs and fats not well digested by the newborn?

Answer 4

• because they are lacking pancreatic amylase and lipase

Question 5

water needs of a newborn

Answer 5

• newborn needs larger amounts of fluid in relation to size than an adult, b/c they lose more water thru the skin, kidneys, and intestines
• they need approx 27-45 mL/lb during first 3-5 days
  
  • then gradually inc to 68-80 mL/lb a day
• breast milk and formula supply the infant’s water needs

Question 6

composition of breast milk

Answer 6

• lactogenesis: is the production of milk
  
  • lactogenesis I: starts during pregnancy and continues to early days after giving birth
    
    • breasts secrete colostrum
  • lactogensis II: begins 2-3 days after birth
    
    • transitional milk comes in
    • amount of milk inc as milk “comes in”
  • lactogenesis III: mature milk replaces traditional milk
    
    • breast milk is bluish and thin

Question 7

Colostrum

Answer 7

• made during lactogenesis I
• higher in protein and some vitamins and minerals than mature milk
  
  • lower in carbs, fat, lactose
• rich in IgA (good for GI infection protection)
• helps establish normal flora of intestines
• has a laxative effect to help pass meconium

Question 8

Transitional Milk

Answer 8

• made during lactogenesis II
• appears over about 10 days
• inc in amount as the milk comes in
• immunoglobulins and proteins decrease
  
  • lactose, fat, and calories increase
• vitamin content is the same as colostrum

Question 9

mature milk

Answer 9

• present during lactogenesis III
• appears during 2nd week of lactation
• bluish and thin
• easily digestible
• species specific
• contains approx 20 kcal/oz and nutrients sufficient to meet the infant’s needs
• provides immunoglobulins
• low in iron and vitamin D, but absorbed well

Question 10

protein in breast milk

Answer 10

• breast milk is high in taurine which is important for bile conjugation and the brain
• tyrosine and phenylalanine are low to correspond to low level of enzymes to digest them
• casein and whey are proteins in milk
  
  • breast milk is easily digestible b/c made mostly of whey which does not form the insoluble curd like casein does
• antigens in foods the mother has eaten may pass int obreast milk and may cause an allergy (including cow’s milk, milk products, chocolate, cola, corn, citrus, wheat, peanuts_

Question 11

how to protect against food allergies in the infant

Answer 11

• infant should be exclusively breast fed for at least 4 months and allergic foods should be avoided by the mother if her infant under 6 weeks of age has colic

Question 12

carbs in breast milk

Answer 12

• lactose is the major carb
  
  • improves absorption of calcium and provides energy for brain growth
• other carbs inc intestinal acidity and impede growth of pathogens

Question 13

fat in breast milk

Answer 13

• provides 50% of calories in breast milk
• hindmilk: milk produced at the end of the feeding
  
  • produces satiety and helps the infant gain weight
• triglycerides form the majority of fat content
  
  • cholesterol and long chain DHA and arachidonic acid are present to help with vision and growth of brain and nervous system

Question 14

vitamins in breast milk

Answer 14

• vitamin A, E, and C are in high levels
• vitamin D is low
  
  • may need daily supplementation during first few days of life of 400 IU
  • breastfeeding infants who are not exposed to sun or have dark skin may need supplement
  • formula fed infants who drink less than 1 qt of vit D fortified milk per day should supplement

Question 15

minerals in breast milk

Answer 15

• iron is in low levels, but it absorbs well so infant’s that are breast fed are not usually deficient
  
  • if breastfed exclusively, the infant will maintain iron stores for the first 6 mos of life until they start eating solids
  • preterm and formula fed infants need iron supplementation
• Na, Ca, and phosphorus are higher in cow’s milk than human milk, so if formula not diluted properly this could place a high solute load on immature kidneys

Question 16

what components of breast milk help prevent infection?

Answer 16

• bifidus factor: promotes the growth of lactobacilllus bifidus which is important to intestinal flora
• leukocytes
• macrochages: secrete
  
  • lysozyme: protects against gram + and enteric bacteria
  • lactoferrin: which binds iron in iron dependent bacteria to prevent their growth
• immunoglobulins

Question 17

does a mother’s diet effect breast milk composition?

Answer 17

• fatty acid content and levels of water soluble vitamins are influenced by the mother’s diet
• total fat, protein, carbs, and most minerals are not effected

Question 18

cow’s milk

Answer 18

• unmodified: not recommended for infants under 12 mos
  
  • it contains too much protein, potassium, chloride, and sodium
  • it lacks fatty acids, vit E, iron, zinc
• modified: is the source of most commercial formulas
  
  • formulate it for infants by reducing protein content to dec renal solute load
  • saturated fat is removed and replaced with vegetable fats
  • vitamins are added

Question 19

soy formula

Answer 19

• can be used for infants with galactosemia or lactase deficiency and for those whose families are vegetarians
• but many infants are also allergic to this

Question 20

what are the best formulas for infants with allergies?

Answer 20

• protein hydrolysate formula
  
  • protein is treated to make it less allergenic
• can also be used if infant has a malabsorption disorder

Question 21

breastfeeding recommendations

Answer 21

• AAP recommends infants only receive breast milk for first 6 mos after birth
  
  • then, breastfeeding should continue until infant is 12 mos old with the addition of foods

Question 22

benefits of breastfeeding for the infant

Answer 22

• less allergies
• immunologic properties to prevent infection
• dec incidence of respiratory tract, ear, urinary tract, and GI tract infections
• lower incidence of diabetes, asthma, obesity, SIDS, cancers
• composition meets infant’s needs
• easily digested
• unlikely to be contaminated
• less likely to result in overfeeding or constipation

Question 23

benefits of breastfeeding for the mother

Answer 23

• oxytocin release enhances uterine involution
• less blood loss b/c of delayed return of menses
  
  • delayed resumption of ovulation
• reduction in cancer risk
• increases attachment
• convenient and always available
• economical
• infant less likely to be ill
• easier to travel

Question 24

why would a mother choose to feed the baby formula?

Answer 24

• some women are embarrassed
• lack of social support
• anxiety about not being able to tell how much milk the baby gets with BF
• partner not supportive
• taking medications that may harm the baby
• lack of understanding or education

Question 25

factors influencing how women choose to feed their babies

Answer 25

• support from others
• father feeling “left out” if choose BF
• culture
  
  • most likely to BF if Asian, Pacific Islander, or Hispanic
  • least likely to BF if non-hispanic black
  • many times, colostrum is not valued in certain cultures, so they wait to breast feed until after going home
• employment:
  
  • returning to work is often a reason women choose to stop breastfeeding
• staff knowledge
• past experience
• feelings on modesty
• time intensive

Question 26

breast changes during pregnancy

Answer 26

• changes start early in pregnancy
  
  • ducts, lobules, and alveoli develop in response to estrogen, progesterone, hCS, an dprolactin
  • prolactin is high but estrogen and progesterone prevent milk production
• colostrum present at 16 weeks gestation
• women should see an increase in breast size during gestation

Question 27

milk production

Answer 27

• produced by the alveoli of the breasts
• milk is ejected from the secretory cells of the alveoli into the lumen by contraction of the myoepithelial cells
  
  • then, it travels thru the lactiferous ducts to the nipple
  • infant compresses the areola to move a stream of milk thru pores in the nipple

Question 28

hormonal changes at birth in relation to lactation

Answer 28

• at birth, loss of placental hormones results in inc prolactin which activates milk production
  
  • suckling and the removal of colostrum cause continued inc levels of prolactin
    
    • prolactin secreted in highest levels with suckling and at night
• oxytocin inc in response to nipple stimulation and causes the milk ejection/let down reflex–>the release of milk from the alveoli into the ducts
  
  • this reflex can occur any time oxytocin is released which occurs when a mom sees, hears, or thinks about her baby

Question 29

continued milk production

Answer 29

• amount of milk produced depende on adequate stimulation of the breast and removal of the milk by suckling/breast pump which causes production of prolactin
  
  • “supply and demand” effect
• early and frequent suckling causes prolactin to be released which makes more milk
• if milk is not removed from the breast, this causes a feedback to decrease prolactin and dec milk production

Question 30

preparation of breasts for breastfeeding

Answer 30

• do not apply soap to the nipples b/c it removes protective oils
• inverted or flat nipples make it harder for an infant to latch

Question 31

hunger cues in infants

Answer 31

• licking or sucking movements
• lip smacking
• rooting
• hand to mouth movements
• sucking on hands
• increased activity
• crying (late sign)

Question 32

initial feeding

Answer 32

• should occur within 1 hour after birth as long as mom/baby are stable
  
  • baby should be placed skin to skin as soon as its born, b/c infant’s are in the first period of reactivity so they are alert and ready to nurse
• early BF
  
  • assoc with a higher BF rate at 2-4 weeks and 2-4 mos postpartum
  • provides stimulation for milk production
  • improves suckling
  • inc bonding
  • helps infant to excrete meconium
  • helps stabilize infant’s blood sugar and temp

Question 33

how often to breast feed

Answer 33

• should feed baby 8-12 times/24 hours
  
  • so about every 2-3 hours

Question 34

what occurs during the second period of reactivity

Answer 34

• cluster feeding: 5-10 feedings are done over about a 2-3 hour period

Question 35

position of mother and infant with breastfeeding

Answer 35

• most common positions:
  
  • cradle
  • football or clutch
  • cross cradle
  • side lying
• help increase mom’s comfort by getting her pain meds, prop her up with pillows, and make sure her shoulders are relaxed.
  
  • use blankets/pillows to elevate infant to the level of the nipple
• infant’s head and body should directly face the bresat w/ the infant’s nose, cheeks, and chin lightly touching
  
  • neck should be flexed b/c hyperextension makes swallowing difficult
• mother makes C shape with hand to hold her breast by placing her thumb on the top and fingers under her breast

Question 36

eliciting latch on

Answer 36

• baby should always be awake and hungry
• position the infant to face the breast and instruct the mother to hold her nipple so it brushes against the infant’s lips
  
  • do not insert the breast until the mouth is widely opened

Question 37

position of infant’s mouth while breast feeding

Answer 37

• the infant’s lip should be positioned on the areola about 1-1.5 in form the base of the nipple to allow the nipple to be drawn toward the back of the mouth
  
  • this prevents the nipple from sucking only on the nipples whic hcan cause sore nipples
• the infant’s tongue should be forward, cupped under the breast, and over the top of the lower gums
  
  • the lips should be flared outward

Question 38

removal of infant from breast

Answer 38

• teach mother to remove infant from breast when sucking becomes non-nutritive
  
  • avoid trauma to the breast by inserting her little finger into the corner of the infant’s mouth b/w the gums to break the suction
  • then remove breast quickly

Question 39

suckling pattern

Answer 39

• during nutritive suckling (sucking), the infant sucks with smooth, continuous movement with occasional pauses to rest
  
  • infant may swallow after each suck or may suck several times before swallowing
• during non-nutritive suckling, little or no milk flow is obtained, and often occurs when infant is falling asleep
  
  • the infant’s jaw is moving in a fluttery, choppy motion and is not accompanied by swallowing

Question 40

length of feedings

Answer 40

• it may take as long as 5 min for milk ejection reflex to ccur during early days after birth, so often it is a good idea to allow the infant to set the length of feeding
  
  • when non-nutritive sucking occurs, remove infant, burp, and try on other breast
• feeding should start at about 10-15 min in length
• if you switch back and forth on the breasts during a feeding, this will inc amount of foremilk an infant gets but dec amount of hindmilk

Question 41

foremilk vs. hindmilk

Answer 41

• foremilk: watery first milk that quenches the infant’s thirst
• hindmilk: comes at the end of a feeding
  
  • richer in fat, more satisfying, leads to weight gain
    
    • if feeding is too short, the infant will not get this milk and will lose weight

Question 42

signs of letdown

Answer 42

• cramping
• increased lochia
• milk leaking from other breast
• tingling feeling in breast
• feeling of relaxation
  
  • pressure, pain, anxiety will inhibit letdown

Question 43

how to assess the position and the latch

Answer 43

• is the baby tummy to tummy with mom?
• do the nose and chin touch the breast?
• do the lips both flare out?
• is the neck straight?
• head slightly higher?
• wide mouth open?

Question 44

signs of milk transfer to baby

Answer 44

• audible swallowing
• absence of clicking noises or cheeks pulling inward
• milk in baby’s mouth
• breasts soft after feeding
• milk leaking from opposite breast
• infant’s stools are yellow and seedy
• infant is urinating at least 6-10 times per day at 1 week old

Question 45

insufficient milk supply

Answer 45

• one of the major reasons for early weaning to formula
• teach the parents how to assess swallowing and nutritive sucking
• suggest mom count the wet/dirty diapers
• commonly caused by:
  
  • ineffective suckling
  • infrequent or short feedings
  • maternal fatigue
  • low maternal thyroid function
  • preterm/late preterm infants
  • some meds like oral contraceptives

Question 46

how much weight should an infant gain per day

Answer 46

• gain on average 0.7-1 oz each day during the early months

Question 47

signs an infant is having trouble breastfeeding

Answer 47

• falling asleep after feeding for 5 min or less
• refusal to BF
• tongue thrusting
• smacking or clicking sounds
• dimpling of cheeks
• failure to open mouth widely
• lower lip turned in
• short, choppy motions of jaw
• no audible swallowing
• use of formula

Question 48

jaundice and breastfeeding

Answer 48

• an infant can normally be removed from phototherapy lights for feedings, but the concern is with adequate intake
• insensible water loss is increased thru the skin due to lights/heat so worried about dehydration
  
  • need to have frequent feedings to keep hydrated and inc stools to get rid of bilirubin

Question 49

prematurity and breastfeeding

Answer 49

• if baby can’t breastfeed after birth immediately, teach mom to use a breast pump to establish her supply
• late preterm infants may also have difficult breastfeeding b/c they are immature
  
  • may have problems with coordination of sucking, swallowing, and breathing and they are sleepier than full term infants

Question 50

engorgement of the breasts

Answer 50

• many women experience a temporary swelling/fullness to the breasts which peaks at 72-96 hours after birth when production of milk begins to increase
• normal temporary engorgement occurs due to congestion, inc vascularity, accumulation of milk, and edema–>does not interfere with BF
• may be a problem if feedings are delayed, too short, infrequent
  
  • breasts may become edematous and hard and making feedings painful
  • may lead to nipple trauma, mastitis, or d/c BF
• prevent by feeding early and often, BF at night, do not use formula
• treat by feeding frequently, hot showers, and massage

Question 51

nipple pain w/ BF

Answer 51

• common during early breastfeeding, esp during first week
  
  • peaks at 3-6 days, and resolves after
• but nipple trauma can sustain pain
  
  • the nipples appear red, cracked, blistered, or bleeding
  • redness, purulent drainage, and fever indicate mastitis and requires and abx
• caused by improper positioning or latch, exposure to soap/prolonged moisture/creams may cause sore nipples

Question 52

maternal signs of breastfeeding problems

Answer 52

• hard, tender breasts
• painful, red, cracked, blistered, bleeding nipples
• flat or inverted nipples
• localized edema or pain in breasts
• fever, generalized aching, malaise (mastitis)

Question 53

breastfeeding contraindications

Answer 53

• mother:
  
  • breast cancer
  • HIV positive
  • cytomegalovirus (CMV)
  • untreated gonorrhea or syphilis
  • active TB
  • active drug dependency
  • some meds (chemo)
• infant:
  
  • metabolic disorders (ie. galactosemia)

Question 54

milk storage

Answer 54

• room temp: 4-6 hours at 66-78 deg F
• cooler with 3 frozen ice packs: 24 hours at 59 deg F
• refridgerator: 3-8 days at 39 deg F or lower
• freezer: 6-12 mos at 0-4 deg F
• thawed breast milk: use within 24 hours

Question 55

using a breast pump

Answer 55

• can use electric, battery, or manual pumps
  
  • these can be rented or purchased
  • electric are more efficient and are indicated when mother plans to pump for a long time
• double pump: allows mother to pump both breasts at once, saving time and inc milk production
• should start using ASAP if cannot breastfeed infant
  
  • should pump at least 8 times per day for 15-20 min each
• breast massage and application of heat help initiate flow of milk
• relaxation during pumping increases volume

Question 56

teaching with breastfeeding

Answer 56

• avoid dieting: eat as you did in pregnancy to lose weight
• should have 8 glasses of non-caffeinated beverages daily
• avoid smoking, drugs, alcohol and undue stress
• 10 min on first side and finish until satisfied on 2nd side

Question 57

nipple confusion

Answer 57

• may occur when an infant who has been fed by a bottle confuses the tongue movements necessary for bottle feeding with the suckling of breastfeeding
  
  • some infants may refuse to BF or push the breast out of the mouth
• discourage use of formula in BF infants b/c it reduces breastfeeding time, which dec prolactin secretion, and, therefore, milk production
  
  • formula takes longer to digest (about 4 hours) so infant not hungry again for a while and may lead to inc times b/w feedings, so breasts may become engorged.
• also should limit pacifiers, b/c it may be associated with suckling problems if used to early

Question 58

types of formulas

Answer 58

• infants should receive iron fortified formulas
• can be purchased in 3 preparations:
  
  • ready to use formula: should not be diluted
    
    • shake container and pour into bottle
    • good for traveling
    • refridgeration is not necessary unless open, and then use in 48 hours
  • concentrated liquid formula: use equal parts concentrated formula and water and pour into bottle
    
    • store in fridge and use in 48 hours
  • powdered formula: use 1 level scoop and add to 2 oz of water
    
    • not sterile, so not recommended for preterm or immunocompromised infants
    • refridgerate for no more than 48 hours if prepared
    • can use a can of the powdered formula for 4 weeks once opened

Question 59

formula preparation

Answer 59

• need to have proper dilution of formula to provide proper nutrition to infant
• if water supply is safe, sterilization of milk and equipment is not necessary
  
  • however, all water mixed with formula should be boiled for 1 min
• use hot, sudsy water and a brush to clean, rinse, and air dry
  
  • can also use dishwasher, but nipples are weakened in dishwasher
• cleanliness is important
• no honey
• can prepare 1 bottle at a time or prep a 24 hour supply

Question 60

teaching with formula feeding

Answer 60

• hold in semi recumbent position (cradle hold)
• check nipple hole to make sure it is a drip not a stream
  
  • make sure bottle is held so nipple is full of formula at all times
  • point nipple directly into mouth
• burp at middle and end of feeding
• feed infant every 3-4 hours
  
  • do not overfeed–>regurgitation is common
• never microwave bottles of formula
• do not prop the bottle b/c it inc likelihood of regurgitation and eliminates holding/cuddling that should accompany feeding
• small risk of allergic reaction