Breastfeeding and Infant Feeding

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Breastfeeding and Infant Feeding

• Nelly Schottel, MD

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Breastfeeding

• AAP recommends that infants be exclusively
  breastfed through 6 months, continued up to 1
  year and beyond if mutually desired

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Advantages of Breastfeeding

• More bioavailable, easily digestible
• Decreased incidence of infectious disease,
  allergies, celiac disease, IBD, SIDS, diabetes,
  obesity
• Improved neurodevelopmental outcomes
• Maternal infant bonding

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• Maternal health advantages
• Reduces incidence of ovarian cancer and
  premenopausal breast cancer
• Earlier return to pre-pregnancy weight, decreased
  incidence of Type 2 DM, osteoporosis and PP
  depression
• Ovulation suppression 98 protection from
  pregnancy with full time breastfeeding in first 6
  months

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• Economic advantage
• Estimated that if 90 of US mothers complied with
  the recommendation to breastfeed exclusively for
  6 months -savings of 13 billion per year1

1 Bartick M, Reinhold A. The burden of suboptimal
breastfeeding in the United States a pediatric
cost analysis. Pediatrics. 2010125(5).
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• Exclusively breastfeeding mothers eligible to
  receive enhanced WIC food package and longer
  duration of benefits than mothers who formula
  feed
• WIC also offers breast pumps, nipple shields and
  supplements to breastfeeding mothers

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Breastfeeding Basics

• Newborns should breastfeed q 2-3 hrs (about 8-12
  times per day)
• 10 minutes per breast provides 90 of the
  available milk
• Important to have proper latch and position
• Place newborn to breast as soon as possible after
  birth
• Avoid bottles/pacifiers as much as possible
• Recognize early signs of hunger increased
  alertness, activity, mouthing, rooting

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• Prolactin increases milk production
• Oxytocin causes myo-epithelial cells to contract
• Both primarily stimulated by suckling
• May diminish after as little as 16-24 hours
  without nursing
• Emptying of the breast also affects milk
  production, prolactin levels decline if breast
  not regularly emptied

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Good latch

• Entire areola into babys mouth with nipple
  against posterior palate and tongue under areola
• Babys top and bottom lip should be everted
• Babys chin should be pressed into the breast
• Nose should also be resting on the breast

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• Sucking on tip of nipple causes frustration for
  both mother and baby
• Use rooting reflex
• Stimulate baby to stay awake after first few
  minutes of feeding

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Troubleshooting

• Flat or inverted nipples
• Previous breast surgery
• No change in breast size during pregnancy
• Medications or medical conditions
• Lack of support

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Sore/cracked nipples

• One of the major causes of terminating breast
  feeding in the first week post-partum
• Generally caused by improper technique
• Assess position, latch and suckling process
• Check for ankyloglossia
• Remedies
• Expressed breast milk
• Lanolin cream
• Warm moist compress
• Hydrogel pads
• Wet tea bags

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Flat or inverted nipples

• Nipple shield temporary solution for difficult
  latch
• Small or preterm infants
• Flat or inverted nipples

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Vitamin supplementation

• Trivisol (Vit A, C, D) for all exclusively
  breastfed infants
• Most formula-fed infants do not receive 400 IU of
  Vitamin D/day so generally recommend for all
  infants
• Need 1L (33 ounces) per day to receive 400 IU of
  Vitamin D

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• Essential that breastfeeding be discussed during
  office visits
• Early involvement of lactation specialists
• www.lalecheleague.com
• www.breastfeeding.com

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Contraindications to Breastfeeding

• Infant with galactosemia
• Mother with active, untreated tuberculosis
• Maternal exposure to radioactive isotopes
• Maternal exposure to chemotherapeutics and/or
  drugs of abuse (and other contraindicated meds)
• HSV lesion of breast
• HIV (in developed countries)

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Breastfeeding History

• How often do you breastfeed?
• Does the baby latch on well?
• Do you hear frequent sucking and swallowing?
• How many minutes per breast?
• Any complications? (sore nipples, mastitis, etc)

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Formula Feeding

• If breastfeeding is not possible, then an
  iron-fortified infant formula should be used
• Low iron formula not adequate (need 12mg/L iron)

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Formula Diet History

• How do you prepare the formula?
• How much per feeding?
• How often does the baby feed?
• How many total bottles per day?

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Routine Diet History

• How many wet diapers/BMs does the baby have
  each day?
• Does the baby drink any thing else besides
  formula/breastmilk? (water, juice)
• Have you started solid foods?

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Pediatric Formulas

• Standard formulas 20 kcal/oz (Enfamil Lipil and
  Similac Advance)
• Extensively hydrolyzed Nutramigen, Alimentum,
  Pregestimil
• Amino-acid based formulas Elecare, Neocate
• Soy Isomil

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Extensively hydrolyzed/AA based

• Intended for use by infants with milk-protein
  allergy (MPA) or at high-risk for allergy
• MPA can manifest as
• IgE mediated urticaria, wheezing, vomiting,
  anaphylaxis
• Non-IgE mediated pulmonary hemosiderosis,
  eosinophilic proctocolitis, enterocolitis,
  esophagitis
• Expensive! Require approval from insurance.

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Pediatric Formulas Soy-Based

• Free of cow-milk protein and lactose
  (carbohydrate is corn or tapioca starch)
• Use in disorders of carbohydrate metabolism (ex.
  Galactosemia)
• Use in acute diarrhea and secondary lactase
  deficiency
• Can try for infants with IgE assoc allergy
  symptoms (urticaria, eczema) to cows milk
  formulas (10-15 will have soy protein allergy
  and need hydrolyzed formula)

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Pediatric Formulas

• Come in a variety of formulations
• Ready to feed, concentrated liquid, or powder
• Concentrate dilute 11 with water
• Powder one scoop to 2 oz of water
• Only warm in tepid water, not in microwave
• Only infants 6 mos or older who receive
  exclusively ready to feed formula or formula made
  with well water or are exclusively breastfed need
  flouride supplementation

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How do I know my baby is getting enough??

• Wet diapers approximately 6-8 per day by the
  end of the first week of life
• Stooling will vary usually 4-8 per day
• Initial stool is meconium dark green to black,
  thick
• Stools change to a yellow, seedy composition

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Infant Growth Patterns

• Infants lose weight in the first few days of life
• By DOL 14, should regain birth weight
• Initial weight gain is 20-30 grams/day
• Doubles birth weight by 4-6 months
• Triples birth weight by 12 months

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How much?

• Infants need 100-120kcal/kg/day
• Equivalent to 150-180ml/kg/day
  100kcal30ml/20kcal
• Birth - 1 week
• 1-3 ounces
• 1 week - 1 month
• 2-4 ounces
• 3 - 6 months
• 6-7 ounces
• 6 - 12 months
• 7-8 ounces

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Routine Diet History

• Solids
• What solids does your baby eat?
• Have you started self-feeding/finger foods?
• Review allergy and choking risks

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Introduction of Solids

• Infant is eating 32 ounces of formula/breastmilk
  in a day and still wants more
• Look for developmental readiness to determine
  when to give solids
• Sitting supported, loss of extrusion reflex, good
  head control
• Solids should not be introduced before 4-6 months
  of age

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Introduction of Solids

• Start with iron-fortified single grain cereals -
  always use a spoon (not in the bottle)
• Then progress to single fruits, vegetables, and
  meats
• Introduce 1 new food every 3-5 days
• May have to offer food several times before
  infant accepts it

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• Fruit juices can be introduced, but limit to 4-6
  oz/day
• No need for water before 6 mos
• Introduce soft finger foods by 6-8 months
• Solid foods must be mashed or pureed in 1st year
  of life to avoid aspiration
• No honey until after 1 year
• Limit milk to 16-24 oz per day

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• No cows milk before 1 year
• Low bioavailability, risk for IDA
• Skim or low fat milk after 2 years of age
• Lack essential fatty acids needed for myelin
  production before 2 years
• Soy milk is adequate over 1 year only if
  pasteurized and vitamin fortified

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• Lactose intolerance
• Congenital carbohydrate enzyme deficiencies are
  extremely rare
• Acquired lactose intolerance may begin by 2
  years of age
• Dose dependent phenomenon
• Allergy to cows milk or soy protein (prevalence
  1-8)
• Vomiting, diarrhea, bloody stools, eczema,
  urticaria, wheezing, rhinitis, congestion

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• Wean to cup at 15 months
• Make bottle uninteresting
• Fill with water
• Make child sit while having bottle
• Put a toy in the bottle

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Babies Know How Much to Eat

• Houston anthropologist Linda Adair followed a
  demand fed boys intake 1 wk - 9 mo of age
• Although he ate three times as much some days as
  others, his growth was consistent and his size
  was average
• When he started solids, he took less formula and
  continued to regulate well

Adair, L.S. The Infants Ability to
Self-Regulate Caloric Intake A Case Study.
JADA, 1984.
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Kids Want to Eat

• Innate
• Imitate adults why role-modeling good eating
  behavior is important!
• However
• Children who are pressured, eat less well, not
  better
• It can take 10-15 exposures to a new food for a
  child to eat it

Birch, Johnson, and Fisher. Appetite and Eating
Behavior in Children. Pediatric Clinics of North
America. 1995
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Kids Know How Much to Eat

• Instinctive regulators of hunger and fullness
• Desire to control intake can undermine natural
  process
• In a study of healthy infants, infants grew less
  well with mothers who force fed1
• Internal regulation of satiety becomes blunted in
  those with food insecurity they eat as much as
  they can, whenever its available2

1Crow, Fawcett, and Wright, Maternal Behavior
During Breast and Bottle Feeding. JBM,
1980. 2Birch, Fisher, and Davison, Learning to
Overeat. AJCN, 2003
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What makes a meal?

• 4 or 5 food groups
• Protein source (chicken, tofu, beans, eggs,
  peanut butter)
• 2 grains or starchy foods (rice, potato, bread,
  pasta, tortilla, biscuit)
• Fruit, vegetable, or both
• MILK
• Fat source (olive oil, butter, salad dressing,
  cheese sauce)

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What makes a snack?

• Two to three food groups starch and fat, starch
  and protein
• Cheese and crackers
• Half a peanut butter and jelly sandwich
• Yogurt and fruit
• Hummus and vegetable

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Why are Family Meals Important?

• Support food regulation and appropriate growth
• Meals reassure children they will be fed
• Meals teach children to like a variety of food

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Family Meals

• Children who have family meals (5 or more per
  week) achieve more, behave better, and do better
  nutritionally
• Time spent with family members at meals is more
  related to psychological and academic success
  than time spent in any other activity

Videon, T.M. and C.K. Manning. Influences on
Adolescent Eating Patterns The Importance of
Family Meals. Journal of Adolescent Health, 2003.
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Family Meals

• In recent years, the trend is away from family
  meals
• Between the ages of 9 and 14, the fraction of
  children who eat a daily family dinner decreases
  from one-half to one-third

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Infant Andy

• Healthy 10 month old. He is growing well, but is
  a picky eater. His mother is eager to wean him
  off breastfeeding and start milk. She read about
  a particular brand of goats milk in the New York
  Times and plans to start this.
• What do you tell her?

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Infant

• Folate deficiency
• Continue formula until 1 year of age
• Will continue to need the fat in whole milk for
  brain development until 2 years of age
• Multivitamin

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Toddler Pamela

• Healthy, playful 21 month old who is meeting all
  of her developmental milestones. Her parents
  report having to force her to eat, and have
  several questions about feeding. Her growth
  curve shows a decrease in weight and length
  measurements for the past two visits.
• What questions do you ask?

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Toddler Pamela

• Does she drink milk? What kind? How much?
• Does she drink water or juice?
• What is offered at mealtime?
• When, where, and with whom are meals eaten?

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Toddler Pamela

• Drinks about 16 oz whole milk most days.
• Loves plain water, and will tote a sippy cup
  around all day.
• Parents offer a variety of foods Pamela will
  take a few bites and complain of being full she
  throws a fit if fed.
• Mom gives her cereal in a baggie to tote around
  because she wont eat her meals.

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Toddler Pamela

• She is drinking an appropriate amount of milk for
  her age, and her parents are offering a variety
  of food groups.
• Its likely her constant drinking of plain water
  is causing her to be too full when its time to
  eat.
• Toddlers need the security of structured meals
  and snacks at the table, as well as the
  opportunity to exercise independence dont
  force feed.

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Toddlers

• There is a natural slow down in the the rate of
  growth
• Tend to be skeptical about new foods
• Parents shouldnt expect
• Predictablility
• Eat a certain amount
• Eat a new food two days in a row
• Eat only three meals a day need 1-2 snacks

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Toddlers

• Family meals structured meals and snacks with a
  time limit no grazing
• Parents need to provide a variety of healthy
  foods no short-order cooks
• Role modeling by parents and older siblings can
  encourage toddlers to try new foods

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Summary of Key Points

• Breastfeeding is the preferred method of
  nutrition in infants exclusively for the first 6
  months of life.
• Infants have typical growth milestones that
  should be documented.
• Introduction of solids should NOT occur before
  4-6 months.

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Take Home Points

• Parents are responsible for providing healthy,
  safe foods
• Encourage family meals
• Children know intuitively how to eat and grow
  dont force!
• Parents are role models
• Infants need to be fed on demand and be exposed
  to a wide variety of textures and flavor
• Toddlers need structure at meals

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PREP

• During a prenatal visit with expectant parents
  they report that they are strict vegans. They ask
  you to advise them on a healthy diet and any
  required supplements. The mother plans to
  breastfeed the newborn exclusively for the first
  6 months. Of the following you are MOST likely to
  tell them that the newborn may require
  supplemental
• A Calcium
• B Folate
• C Iron
• D Vitamin B6
• E Vitamin B12

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PREP

• You are addressing a group of expectant mothers
  who are due to deliver their infants in the next
  few weeks. You discuss the benefits of
  breastfeeding and explain that is the best
  nutrition for most babies. One woman asks you if
  it acceptable to breastfeed if she has had
  hepatitis in the past. You explain that there are
  only a few infections that would prevent a mother
  from being able to breastfeed her baby. Of the
  following breastfeeding is MOST likely to be
  contraindicated of a mother
• A Has active untreated pulmonary TB
• B Has genital herpes without breast lesions
• C Is a CMV carrier
• D Is hepatitis B surface antigen positive
• E Is a hepatitis C antibody positive

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PREP

• You are counseling the mother of a 3 month old
  breastfed infant whose family has been urging her
  to introduce cereals to her babys diet. She asks
  your advice. Of the following the MOST likely
  outcome of introducing solid foods at this age is
  to
• A Accelerate the development of oral motor
  skills
• B Helps the infant sleep through the night
• C Increase the risk of food allergies
• D Increase the risk of GE reflux
• E Increase the risk of GI infections

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PREP

• The mother of a 5 month old boy has come to your
  office seeking nutritional advice. She
  exclusively breastfed the infant for the first 4
  months then weaned the baby to a standard
  formula. One week after weaning she noted that
  the baby strained with stool. Because of her
  concerns regarding the development of
  constipation, the mother switched him to a
  formula containing 2mg/L of iron. Of the
  following the MOST important dietary
  recommendation for this infant is to
• A Add pureed vegetables to the diet
• B Changed to a cow milk protein based formula
  containing 12mg/L of iron
• C Change to a soy protein based formula
• D Continue the present regimen and supplement
  with 4 oz/day dilute apple juice
• E Substitute oatmeal for rice cereal in the diet

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PREP

• During the 1 week health supervision visit a
  mother who is exclusively breastfeeding asks
  about vitamin and iron supplementation for her
  healthy term infant. She explains that her
  previous child who was born at 30 weeks was
  discharged with an oral iron supplement and
  vitamins. Of the following the most appropriate
  oral supplement to initiate for this infant at
  this visit is
• A Calcium
• B Folic acid
• C Iron
• D Vitamin D
• E Vitamin K

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PREP

• You are seeing a healthy newborn in the nursery
  on the 2nd day of life. The babys birth weight
  was 3.43kg, the weight today is 3.29kg. She is
  being exclusively breastfed and has voided and
  passed meconium. Her physical exam is completely
  normal and there is no jaundice. Her mother tell
  you the baby is latching well but shes concerned
  about the babys weight loss and would like to
  give the child formula. What do you tell her?
• A The weight loss means the breastfeeding is
  not working and she should give formula instead
• B Some weight loss is expected but her babys
  weight loss is excessive and she should give a
  bottle with every other feed until the baby gains
  weight
• C The weight loss is normal and there is no
  immediate need to supplement with formula. You
  discuss proper latching and advise that you would
  like to have the baby weighed in two days
• D The weight loss is normal but all babies need
  to be supplemented with formula starting at two
  days and she should start supplementing today

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PREP

• You are seeing a two week old in the office.
  His birth weight was 3.27 kg and his weight now
  is 3.17 kg. His mother tells you that nursing
  generally last an hour and is quite painful, and
  that her baby will frequently want to feed again
  30 minutes after nursing. He voids 6 times a day
  and has one soft bowel movement every other day.
  The physical exam is normal and the baby is not
  jaundiced. What do you advise?
• A The frequent nursing and pain is normal for a
  first time breastfeeding mother, and babies are
  not expected to regain weight until 3 weeks of
  age
• B The likely source of pain, frequent feeds, and
  infrequent bowel movements is a poor latch, and
  that you would like to have her latch examined by
  direct observation or by a lactation consultant
• C The frequent nursing and pain is normal but
  the infrequent bowel movements mean the baby is
  constipated so you recommend extra water be given
  to the baby
• D The frequent nursing and poor weight gain mean
  her milk supply is low and she should pump for 5
  minutes after every feed to increase her milk
  supply

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PREP

• You are seeing a 3 month old girl who has been
  doing well on cows milk formula since birth,
  with normal parameters and normal exam at her 2
  month visit. Today she is in your clinic because
  her parents have noticed some increased fussiness
  and diarrhea in the past two weeks. Yesterday
  and today they noticed spots and streaks of blood
  in her stool. Her physical exam is normal and
  there are no anal fissures. What would you
  recommend?
• A Change to soy formula
• B Change to lactose free formula
• C Change to a low iron formula
• D Change to a hydrolyzed protein formula
• E Reassure the parents and follow up at her 4 mo
  visit

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PREP

• The parents of a 5 week old girl ask about
  lactose intolerance. There is a strong family
  history of lactose intolerance on both sides of
  the family. Their daughter seems unusually gassy
  compared to their older child, although her
  stools are normal and her appetite is good. They
  wonder if they should switch to a lactose free
  formula. What advice is most reasonable?
• A Lactose intolerance is a heritable condition
  and this infant is likely to share her parents
  difficulty with lactose. The switch to lactose
  free formula makes good sense.
• B If this child had lactose intolerance, her
  symptoms would necessarily include constipation
  and emesis. She does not need a formula switch.
• C The common form of lactose intolerance is
  acquired and dose dependent. It does not present
  in infancy. This child does not need to switch
  formulas.
• D A stool study for giardiasis is indicated to
  identify the cause of her excess gas. Change to
  a lactose free formula pending test results.