Breastfeeding and Infant Feeding

Nelly Schottel, MD

Breastfeeding

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

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

Maternal health advantagesReduces incidence of ovarian cancer

and premenopausal breast cancerEarlier 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

Economic advantageEstimated 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. 2010;125(5).

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

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

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

Good latchEntire areola into

baby’s mouth with nipple against posterior palate and tongue under areola

Baby’s top and bottom lip should be everted

Baby’s chin should be pressed into the breast

Nose should also be resting on the breast

Sucking on tip of nipple causes frustration for both mother and baby

Use rooting reflexStimulate baby to stay awake after

first few minutes of feeding

Troubleshooting

Flat or inverted nipplesPrevious breast surgeryNo change in breast size during

pregnancyMedications or medical conditionsLack of support

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

Flat or inverted nipples

Nipple shield: temporary solution for difficult latch

Small or preterm infants

Flat or inverted nipples

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

Essential that breastfeeding be discussed during office visits

Early involvement of lactation specialists

www.lalecheleague.comwww.breastfeeding.com

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)

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)

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)

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?

Routine Diet History

How many wet diapers/BM’s does the baby have each day?

Does the baby drink any thing else besides formula/breastmilk? (water, juice)

Have you started solid foods?

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

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,

anaphylaxisNon-IgE mediated: pulmonary hemosiderosis,

eosinophilic proctocolitis, enterocolitis, esophagitis

Expensive! Require approval from insurance.

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 cow’s milk formulas (10-15% will have soy protein allergy and need hydrolyzed formula)

Pediatric Formulas

Come in a variety of formulationsReady to feed, concentrated liquid, or

powder

Concentrate – dilute 1:1 with water

Powder – one scoop to 2 oz of waterOnly warm in tepid water, not in microwaveOnly 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

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

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

How much?

Infants need 100-120kcal/kg/day

Equivalent to 150-180ml/kg/day [100kcal*30ml/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

Routine Diet History

Solids

What solids does your baby eat?

Have you started self-feeding/finger foods?

Review allergy and choking risks

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 solidsSitting supported, loss of extrusion reflex, good head

control

Solids should not be introduced before 4-6 months of age

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

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

No cow’s milk before 1 yearLow bioavailability, risk for IDA

Skim or low fat milk after 2 years of ageLack essential fatty acids needed for myelin

production before 2 years

Soy milk is adequate over 1 year only if pasteurized and vitamin fortified

Lactose intoleranceCongenital carbohydrate enzyme deficiencies are

extremely rareAcquired lactose intolerance – may begin by 2 years

of age Dose dependent phenomenon

Allergy to cow’s milk or soy protein (prevalence 1-8%) Vomiting, diarrhea, bloody stools, eczema, urticaria,

wheezing, rhinitis, congestion

Wean to cup at 15 monthsMake bottle uninteresting

Fill with waterMake child sit while having bottlePut a toy in the bottle

Babies Know How Much to EatHouston anthropologist Linda Adair followed a demand

fed boy’s 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 Infant’s Ability to Self-Regulate Caloric Intake: A Case Study.” JADA, 1984.

Kids Want to Eat

Innate

Imitate adults: why role-modeling good eating behavior is important!

However…Children who are pressured, eat less well,

not betterIt 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

Kids Know How Much to EatInstinctive 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 it’s available2

1Crow, Fawcett, and Wright, “Maternal Behavior During Breast and Bottle Feeding”. JBM, 1980.2Birch, Fisher, and Davison, “Learning to Overeat”. AJCN, 2003

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 bothMILKFat source (olive oil, butter, salad dressing,

cheese sauce)

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

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

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.

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

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 goat’s milk in the New York Times and plans to start this.

What do you tell her?

InfantFolate 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

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?

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?

Toddler: PamelaDrinks 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 won’t eat her meals.

Toddler: PamelaShe is drinking an appropriate amount of

milk for her age, and her parents are offering a variety of food groups.

It’s likely her constant drinking of plain water is causing her to be too full when it’s time to eat.

Toddlers need the security of structured meals and snacks at the table, as well as the opportunity to exercise independence – don’t force feed.

ToddlersThere is a natural slow down in the the

rate of growth

Tend to be skeptical about new foods

Parents shouldn’t expect:PredictablilityEat a certain amountEat a new food two days in a rowEat only three meals a day – need 1-2 snacks

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

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.

Take Home Points

Parents are responsible for providing healthy, safe foods

Encourage family meals

Children know intuitively how to eat and grow: don’t 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

PREPDuring 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

PREPYou 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

PREPYou are counseling the mother of a 3 month old breastfed infant whose family has been urging her to introduce cereals to her baby’s 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

PREPThe 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

PREPDuring 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

PREPYou are seeing a healthy newborn in the nursery on the 2nd day of life. The baby’s 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 she’s concerned about the baby’s 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 baby’s 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

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

PREPYou are seeing a 3 month old girl who has been doing well on cow’s 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

PREPThe 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.