W11 - Infant Nutrition Flashcards
1
Q
What are the WHO and UNICEF recommendations for breastfeeding duration?
A
Exclusive breastfeeding for the first 6 months.
Continued breastfeeding for at least 2 years and beyond, if mutually desired.
2
Q
What does “exclusive breastfeeding” mean?
A
Only breastmilk
no formula, water, or food
EXCEPT
400 IU of vitamin D daily.
3
Q
Important Supplement for Breastfeeding Infants
A
400 IU of vitamin D daily
4
Q
Why is breastmilk referred to as the “Gold Standard” for infant nutrition?
A
Because it promotes optimal growth, health, and development in infants and children, and health outcomes improve with longer duration.
5
Q
When and how should solid foods be introduced to an infant’s diet?
A
At 6 months, once developmental milestones are met.
Solids should be high in iron and protein.
Introducing solids too early can be harmful.
6
Q
When should dairy be introduced in an infant’s diet?
A
6-7 months: Yogurt and cheese can be introduced
9 - 12 months: Cow’s milk
homogenized milk preferred in the first 2 years.
7
Q
VERY Important thing that should be introduced in foods
A
IRON
8
Q
Breastfeeding: Natural Age of Weening
A
2 - 7 years
There are no upper limits for this duration and no apparent psychological ill effects from breastfeeding into the 3rd year and beyond.
9
Q
Infant Nutrition: Care Considerations for LGBTQ+ Patients
A
- Avoid assumptions
- Use appropriate pronouns
- Discuss expectations and goals
- Induced lactation
10
Q
What is induced lactation, and when might it be used?
A
Process of stimulating milk production without a recent pregnancy or birth.
It may be used by non-birthing parents, adoptive parents, or trans women who wish to feed their child.
Can involve:
- hormonal therapy
- mechanical stimulation
- medications like domperidone.
11
Q
Chest Feeding
A
Term used by many masculine-identified trans people to describe feeding their baby from their chest, regardless of whether they’ve had chest/top surgery.
12
Q
Colactation
A
Colactation refers to when more than one parent breastfeeds or chestfeeds their child
13
Q
True or False: Clients with small breasts produce less breastmilk than clients with larger breasts.
A
False.
Breast size is not indicative of milk-producing capability.
Milk supply is regulated by hormone response and infant demand, not breast volume.
14
Q
True or False: Clients with flat nipples cannot breastfeed.
A
False.
Flat nipples can be more difficult to latch initially, but the nipple elongates during feeding.
Many people with flat nipples breastfeed successfully.
15
Q
True or False: Clients who have had breast augmentation can still breastfeed.
A
True.
Milk production is often unaffected unless
Surgery involved removal of glandular tissue or damaged the nerve endings around the areola (especially relevant in breast reductions).
16
Q
How does tandem feeding affect milk composition during pregnancy?
A
Milk reverts to colostrum during pregnancy, which is rich in nutrients and has a laxative effect to help prevent neonatal jaundice.
Parents must balance feeding needs between the newborn and older child
17
Q
What are risks associated with breastfeeding during pregnancy?
A
Generally safe.
May be cautioned against TANDEM feeding in cases of threatened preterm labor or cervical insufficiency.
18
Q
Why is breastfeeding sometimes contraindicated?
A
If a patient is pregnant while breastfeeding another child
Breastfeeding stimulates the release of oxytocin
Oxytocin causes uterine contractions
In cases of threatened preterm labor, cervical insufficiency, or a history of preterm birth, even mild uterine contractions may increase the risk of:
Cervical dilation
Preterm rupture of membranes
Early onset of labor
19
Q
How do rising estrogen and progesterone levels during pregnancy affect breastfeeding?
A
These hormones suppress milk production and increase nipple sensitivity, which may reduce supply and make feeding uncomfortable.
20
Q
What determines breastmilk supply after the initial hormonal trigger?
A
Milk production becomes supply-and-demand based.
Effective and frequent infant feeding or pumping is key to maintaining supply.
21
Q
What three types of tissue make up the breast?
A
Glandular, fibrous, and adipose tissue
22
Q
How is the structure of the mammary gland organized?
A
Each mammary gland contains 15–20 lobes, which are subdivided into lobules made of alveoli.
23
Q
What are lobules and what do they do?
A
Lobules are clusters of alveoli that merge to form larger ducts which drain the lobe.
24
Q
What is the function of lactiferous ducts?
A
They transport milk from the lobules through the breast and out the nipple
25
What are myoepithelial cells and their function in lactation?
They are contractile epithelial cells that surround the alveoli and help eject milk into the ducts.
26
What do Cooper’s ligaments do?
They are connective tissue structures (collagen and elastin) that anchor the breast to the chest wall.
27
What anatomical and hormonal mechanisms regulate milk ejection?
Milk ejection is regulated by oxytocin, which stimulates the myoepithelial cells surrounding the alveoli in the mammary glands.
Milk is released through multiple openings on the nipple and areola.
28
What are Montgomery glands and what is their function?
Small bumps on the areola that secrete an antibacterial lubricant.
Also produce a scent that helps guide the infant to the breast for feeding.
29
What anatomical structures are involved in milk ejection and infant latching?
Nipple contains 15–20 openings from lactiferous ducts that release milk.
Myoepithelial cells surrounding the alveoli contract in response to oxytocin to expel milk.
Smooth muscle fibers in the areola contract to stiffen the nipple, which helps the infant latch.
30
Which breast structure contains the cells that secrete milk?
1. Lactiferous ducts
2. Lobules
3. Alveoli
4. Nipple
Alveoli
Alveoli are the functional units of the mammary glands where milk is secreted by specialized epithelial cells.
These cells are surrounded by myoepithelial cells, which contract in response to oxytocin, pushing milk through the ductal system.
31
In a lactating client, the milk ducts act as:
1. Secretory gland producing cleansing agent
2. Visual cue for the infant to latch on
3. Channels for the milk to flow to the nipple
4. Milk secreting gland
3. Channels for the milk to flow to the nipple
Milk ducts serve as the passageways that transport milk from the alveoli, where it is produced, through the breast tissue to the nipple, where it is expressed during breastfeeding.
32
Components of Breast Assessment
1. Inspection
A) Size
B) Symmetry
C) Shape
2. Palpitation
33
What is glandular insufficiency and how might it present in a postpartum breast assessment?
Glandular insufficiency is underdevelopment of glandular tissue, often presenting as:
**widely spaced, asymmetric breasts **
potentially limiting milk supply.
34
What changes to the nipples occur during pregnancy and postpartum?
Areolae darken during pregnancy.
Nipples typically protrude and elongate 2–3x during feeding due to smooth muscle contraction.
35
What tools can assist breastfeeding in clients with flat or inverted nipples?
A nipple shield (silicone device placed over the nipple) can assist with latching in cases of flat or inverted nipples.
36
What are the five stages of lactation and when do they occur?
1. Mammogenesis – Breast development (begins in utero, continues through puberty, completes with first pregnancy)
2. Lactogenesis Stage I
– Mid-pregnancy to Day 2 postpartum
(hormonal changes begin milk production)
3. Lactogenesis Stage II
- Day 3–8 postpartum (copious milk production begins (milk “comes in”))
4. Galactopoiesis
- Day 9 postpartum to end of lactation
(milk supply is maintained by supply and demand)
5. Involution
- Occurs ~40 days after last breastfeeding (milk-producing structures regress)
37
When does breast development begin?
Breast development begins early in the gestational period.
38
How does mammary gland development progress during childhood?
Limited to general body growth.
39
How does mammary gland development progress during puberty?
Primary and secondary mammary ducts grow and divide during puberty.
40
How do menstrual cycles affect mammary tissue?
Each menstrual cycle leads to proliferation and active growth of duct tissue.
41
When is mammary function considered fully developed?
Complete mammary function develops only during pregnancy.
42
When is Lactogenesis I initiated?
From mid-pregnancy
to
day 2 postpartum
43
What changes initiate Lactogenesis Stage I?
Hormonal changes
High levels of **estrogen, progesterone, and prolactin** during pregnancy
44
What 3 major processes begin during Lactogenesis Stage I?
Milk synthesis begins mid-pregnancy.
Differentiation of alveolar cells to secretory cells
Prolactin stimulates epithelial cells to produce milk
45
What hormone stimulates epithelial cells to produce milk during Lactogenesis Stage I?
Prolactin.
46
What early sign of lactogenesis I may be observed during pregnancy?
Leaking of colostrum
47
What happens to estrogen and progesterone levels after delivery?
Estrogen and progesterone **drop** rapidly following the delivery of the placenta
48
Why is the drop in estrogen and progesterone postpartum important?
It signals the start of milk synthesis and allows prolactin levels to rise.
(Estrogen/progesterone inhibit prolactin)
49
What hormone is essential for initiating and maintaining milk production?
Prolactin
50
What stimulates the release of prolactin postpartum?
** Mechanical stimulation of prolactin receptors around the areola**
- Through attachment, hand expression, or pumping.
51
Another important hormone in lactation (Not prolactin)
OXYTOCIN
52
What is the role of oxytocin in lactation and postpartum recovery?
It triggers the milk-ejection reflex (letdown) by contracting myoepithelial cells around alveoli
(also causes uterine contractions to reduce postpartum bleeding.)
53
How is oxytocin released during lactation?
Oxytocin is released from the posterior pituitary gland in response to mechanical stimulation of the nipple.
54
3 Major Processes of Lactogenesis Stage II
Lactogenesis Stage II is characterized by the onset of:
- copious milk production (triggered by a drop in progesterone after birth)
- Tight junctions in alveolar cells close, allowing milk to accumulate.
- control of milk production shifts from endocrine (hormonal) to autocrine (mechanical stimulation based on demand).
55
When does lactogenesis stage II begin?
Days 3 - 8 postpartum
56
What is the difference in milk production control before and after Lactogenesis Stage II?
Before Stage II, milk production is hormonally controlled (endocrine).
After Stage II, it shifts to autocrine control (regulated by supply and demand through breast stimulation)
57
What is the relevance of Lactogenesis Stage II for clients experiencing perinatal bereavement?
Despite the loss, clients may still experience Lactogenesis Stage II and lactate due to the physiological hormonal shifts postpartum.
58
Galactopoiesis
The stage of lactation responsible for:
- maintaining ongoing milk production through feedback from milk removal and demand.
59
What is the timeline for Galactopoiesis?
Day 9 postpartum until start of involution.
60
What is the major regulatory mechanism in Galactopoiesis?
It is regulated by **supply and demand**
Frequent and effective milk removal maintains milk production via **autocrine** control.
61
What physical changes occur during Galactopoiesis?
Between 6 and 9 months postpartum, breast size typically decreases as milk production declines due to reduced stimulation
62
How does Galactopoiesis differ from Lactogenesis Stage II?
Lactogenesis Stage II is **hormonally driven** and marked by the onset of copious milk production (day 3–8 postpartum)
Galactopoiesis relies on **mechanical stimulation and infant demand** to maintain milk supply.
63
Involution
Involution is the final stage of lactation
The breast returns to its pre-pregnancy state and milk production ceases.
64
When does involution occur?
On average, involution begins around **40 days after the last breastfeeding session**.
65
What triggers involution of the mammary glands?
Lack of regular stimulation, leading to a buildup of inhibitory peptides in the breast.
66
What changes occur in breast milk during involution?
Sodium levels in breast milk increase, making the taste less pleasant and aiding in natural weaning.
67
How does supplementation contribute to involution?
Introducing regular supplementation reduces breastfeeding frequency
Which decreases stimulation and accelerates the onset of involution.
68
What are the benefits of human milk for infants?
Reduced risk of diabetes
Protection from infections (e.g., ear infections, meningitis)
GI tract maturation and reduced risk of NEC in preterm infants
Lower incidence of allergies
Decreased risk of SIDS
Enhanced cognitive development
Analgesic effect
69
One important benefit of human milk that she emphasized in class
**REDUCED RISK OF DIABETES**
Possible mechanisms:
- Early exposure to cow’s milk proteins (via formula) has been associated with an increased risk of Type 1 diabetes.
Human milk delays or reduces this exposure, possibly preventing autoimmune responses that target pancreatic beta cells.
- Breastfeeding is associated with a lower risk of childhood obesity, a major risk factor for T2DM
- Human milk promotes development of the gut microbiome, which supports immune regulation and glucose metabolism
70
GI Benefit of Human Milk
**Reduced risk of necrotizing enterocolitis, particularly in preterm infants**
Human milk provides a protective coating to the gastrointestinal tract, reducing permeability and inflammation.
It contains immunoglobulins, growth factors, and anti-inflammatory agents that help mature and shield the gut lining, lowering the risk of NEC in preterm infants.
71
Maternal Benefits of Breastfeeding
- Stimulates oxytocin release --> increased uterine contractions --> reduced risk of PPH
- Oxytocin release also promotes uterine involution
- Basal MBR increases, requiring up to 500 additional calories per day --> return to pre-pregnancy weight --> reduced cardiovascular risk
- Bonding/ skin-skin contact
- Decreased risk of uterine/ovarian cancer (no mechanism given)
- Protects against osteoporosis (no mechanism given)
- Convenient and cost efficient
72
Potential downside of breastfeeding
Time commitment associated with breastfeeding
73
Increased caloric requirement during breastfeeding
500 cal/day
74
T/F: Formula feeding does not impact the risk of asthma
False
Formula feeding is associated with a higher risk of asthma compared to breastfeeding.
(Consider the high levels of immunoglobulin and anti-inflammatory cytokines present in human milk)
75
T/F: Breastfeeding reduces the risk of obesity
True
Breastfeeding is linked to a lower incidence of childhood and adult obesity.
76
T/F: Breastfeeding decreases the risk of breast cancer
True.
Breastfeeding offers a protective effect against the development of breast cancer.
77
T/F: Formula feeding reduces natural child spacing
True.
Formula feeding leads to an earlier return to ovulation (around 3 months)
Exclusive breastfeeding can delay ovulation to approximately 6 months, increasing natural spacing between pregnancies.
78
What are the most recent Canadian breastfeeding statistics?
91% of parents started out breastfeeding
69% breastfed for at least 6 months
38% exclusively breastfed for at least 6 months
93% of breastfed babies received vitamin D supplements
79
What are the most common reasons given for stopping breastfeeding before 6 months?
Before 1 month:
- Difficulty with breastfeeding (38.4%)
- Perceived low milk supply (33.2%)
- Medical condition (12.1%)
Between 1–6 months:
- Perceived low milk supply (47.5%)
- Difficulty with breastfeeding (23.5%)
80
What is the Baby Friendly Initiative?
An international program developed by WHO and UNICEF.
Aims to protect, promote, and support breastfeeding globally.
Recommends 10 integrated steps to improve breastfeeding support in hospitals and community settings.
Hospitals must avoid promoting formula, bottles, or pacifiers.
Breastfeeding care must be integrated into patient care programs.
81
What are the 10 steps of the WHO/UNICEF Baby-Friendly Initiative?
1. Create a written policy that protects breastfeeding (no formula/pacifier promotion).
2. Train all staff in breastfeeding support.
3. Provide antenatal education about breastfeeding.
4. Initiate skin-to-skin and first feed within 1 hour of birth.
5. Offer postpartum support for latch, positioning, and challenges.
6. Only recommend supplementation when medically necessary (e.g., dehydration, hypoglycemia).
7. Encourage rooming-in and parental presence at the bedside.
8. Teach responsive feeding and how to recognize feeding cues.
9. Educate on risks of early bottles/pacifiers before breastfeeding is established.
10. Ensure discharge plans include community supports like lactation consultants and peer groups.
82
After an unmedicated birth, how soon is a baby most likely to be able and ready to breastfeed?
Within the first 5 minutes
Within the first hour
Approximately 6 hours
By 12 hours
Within the first hour
83
Five Breastfeeding Positions
Football
Cradle
Cross-cradle
Side-lying
Laid back
84
Very important practice to promote
Skin to skin contact
85
Name the position
Football
86
Name the position
Side-lying
87
Name the position
Cross-cradle
88
Name the position
Cradle
89
When should the first feeding be?
First hour of life
90
How long should feedings be?
Should be unrestricted and based on the infant cues of readiness to feed
But also
20 - 30 minutes
91
How often should feedings be?
Frequency and duration should be infant driven
but also
8 - 12 feedings in 24 hours
92
Good or poor latch?
Poor Latch
Lips need to be flanged out. These baby's are curled in a little bit
Chin is tucked into the chest. It should be more in a stiffing position, where the neck is extended. **Not** flexed
Mouth is not all away around the nipple.
Looks like the baby is sleeping. If babies are actively feeding well they should be awake
Maternal hand is on the posterior. The hand should be placed on the upper part of the back. Can be painful and create an aversion. **Hand should be midline at the level of the scapulae.**
93
Good or poor latch?
Good latch and attachment
Awake and alert
Lips are flanged (fish lips)
Wide, around the entire nipple
Chin is close to breast
Good spacing between the nose and the nipple
94
Good or Poor Latch?
Bad latch
Chin is not tucked to breast
Nose is up against the nipple (not in the stiffing position)
Eyes closed
Not covering the entire nipple
Seal has been broken, appears to be unlatching.
This would create maternal skin breakdown
95
Good or poor latch?
Poor latch
Nose should not be against the breast tissue
96
What are the criteria for a good latch during breastfeeding?
Baby is awake and alert
Lips are flanged outward (“fish lips”)
Mouth wide and covering the entire nipple and areola
Chin is close to the breast
Nose is not pressed into the breast (a small space is visible)
Baby’s head and neck are extended (not flexed)
Baby is well-supported with hand placement at upper back (scapula level), not the posterior head
97
What are the three stages of human milk?
1. Colostrum
2. Transitional milk
3. Mature milk
98
What are the key characteristics of colostrum?
Thick, yellowish appearance
Rich in proteins and immunological factors
Lower in calories, fats, carbohydrates, and some vitamins
99
When is colostrum present in the breast?
At the end of pregnancy and during the first 2–3 days postpartum
100
What is a sufficient volume of colostrum per feed for a healthy term infant?
5–10 mL per feed
101
Why such a small volume of colostrum per feed?
Newborn's stomach is approximately the size of a chick pea. Cannot take a large volume.
Immature kidneys are not capable of processing large volumes of colostrum.
102
What are the characteristics of transitional milk?
Combination of colostrum and mature milk
Higher in fat, lactose, and calories than colostrum
Breasts become fuller, often described as “milk coming in”
103
When does transitional milk begin and how long does it last?
Begins around day 2–4 postpartum
Lasts approximately 1–2 weeks
104
What are the characteristics of mature milk?
Fat content is variable and influenced by breast fullness
Fat increases during the course of a feed
Supports infant growth and energy needs
105
When does mature milk come in and how long does it last?
Begins after the transitional milk phase, around 2 weeks postpartum
Continues for the duration of breastfeeding until involution
106
What determines the fat content of mature milk?
Degree of breast emptiness
Fat content increases as feeding progresses
107
How does the timing of feeds affect the fat content in mature milk?
When feedings are close together (breasts less full), higher fat content may be present at the start of the feed
When feedings are spaced further apart (breasts fuller), fat content gradually increases during the feed
108
The most variable component of human milk is
1. Protein
2. Fat
3. Lactose
4. Calcium
2. Fat
109
The parent of a 4 week old, exclusively breastfed baby who had 5-6 profuse, yellow, loose stools everyday is worried and asks for an explanation.
The most likely cause for stools of this kind is:
1 Diarrhea
2. Infection with an intestinal parasite
3. Maternal diet
4. Normal stool
4. Normal stool
Breastfed infants often have frequent, loose, yellow stools. This is a normal finding and not a sign of diarrhea or pathology.
110
Stools: Day 1
At least ONE wet diaper
AND
ONE dark green or black stool
111
Stools: Day 2
At least TWO wet diapers
AND
ONE dark green or black stool
112
Stools: Day 3
At least THREE wet diapers
AND
THREE brown, green, or yellow stools
113
Stools: Day 4
At least FOUR wet diapers
AND
THREE brown, green, or yellow stools
114
Stools: Day 5 to 3 Weeks
At least SIX heavy pale, or clear wet diapers
AND
THREE large, soft, yellow or brown stools
115
How big should a stool be in order to count as one stool?
At least the size of a toonie
116
Stool chart
117
A client 14 days postpartum informs you that she has bright red vaginal bleeding and that her infant seems constantly hungry. The most likely explanation for this is
1. Large for gestational age for baby
2. Early return of menses
3. Uterine infection
4. Retained placenta
Retained placenta
At 14 days postpartum, lochia should have transitioned to serosa.
Continued bright red bleeding may indicate retained placental fragments.
Retained placenta maintains estrogen and progesterone levels, which inhibit the action of prolactin. This restricts milk production and delays the onset of lactogenesis II.
118
What are some strategies to increase milk production?
Breastfeed on cue (8–16 sessions per day)
Ensure breasts are emptied completely
Avoid long periods without milk removal (>5 hours)
Gentle breast massage
Stop hormonal medications (e.g., contraceptives)
Assess endocrine function (e.g., PCOS, diabetes)
Use lactation-enhancing medications like domperidone only as a last resort
119
Domperidone MoA
D2 receptor antagonist
Blocks DA in the anterior pituitary, prevents DA-mediated inhibition of prolactin secretion --> increased prolactin secretion --> simulation of milk production
120
Hand Expression
Wash hands with soap and water
Use a clean container to collect milk
Gently massage breast in circular motion (outward to inward)
Use “C-hold” with thumb and fingers behind areola
Press straight back toward the chest wall, compress, and release
Reposition fingers and repeat rhythmically around the areola
Mimics baby’s natural feeding pattern
121
What are some common challenges that can interfere with breastfeeding?
Prematurity, illness, or birth injuries (e.g., nerve damage)
Drowsiness from epidural anesthesia or analgesia
Facial/jaw asymmetry or anomalies (e.g., tongue-tie, cleft lip/palate)
Nipple pain (often from poor latch)
Engorgement
Mastitis
Candidiasis
May require NG feeds if unable to coordinate suck-swallow-breathe reflex
122
Name the finding
Tongue tie
Tight frenulum restricts the movement of the tongue which impedes latching
123
Name the finding
Nipple Trauma
Clock used (1-3 o'clock) position used to document breast lacerations
Breast milk itself can promote healing.
OTC nipple creams can be prescribed.
'All purpose' ointment with a steroid, antifungal, antibacterial
124
Name the finding
Mastitis
Red streaking appearance related to a blocked milk duct
Requires antibiotics if febrile
125
Name the finding
Yeast
Both the baby and mother must be treated for candidiasis infections (Antifungals)
126
Breastfeeding recommendation for viral infections: HIV
Not recommended in Canada.
Depends on geographical location and access to safe alternatives to breastmilk.
127
Breastfeeding recommendation for viral infections: HTLV-1
Contraindicated for breastfeeding.
128
Breastfeeding recommendation for viral infections: Cytomegalovirus
Seropositive mothers may breastfeed.
Avoid breastmilk for preterm infants of mothers with acute CMV infections
129
Breastfeeding recommendation for viral infections: Hepatitis B
Breastfeeding permitted.
130
Breastfeeding recommendation for viral infections: Hepatitis C
Breastfeeding permitted if titer not high.
131
Breastfeeding recommendation for viral infections: Herpes Simplex
Breastfeeding permitted if no breast lesions.
132
Breastfeeding recommendation for viral infections: Rubella
Breastfeeding permitted.
133
What are the medical reasons to supplement breast milk?
Low birth weight, prematurity, illness
Excessive weight loss or dehydration
Hypoglycemia
Inborn error in metabolism
Insufficient milk supply
Use of a contraindicated medication
134
What factors should be considered when choosing an infant feeding method?
Make an informed decision (see resource on onQ)
Consider cultural influences
Take into account personal preference and support system
Know that commercial formulas are made from cow’s milk
Ensure formulas are iron-fortified
Provide parent education on feeding patterns and techniques
135
When is donor human milk recommended, and who has priority access?
Donor human milk is recommended when the mother’s own milk is unavailable.
Low birth weight and preterm infants are given priority access due to limited supply.
Donor milk is pooled, tested, pasteurized, and nutritionally analyzed according to HMBANA standards.
136
Location of Milk Banks in North America
Canada:
- Vancouver
- Calgary
- Toronto
United States
- 29 Active Milk Banks
137
