Feeding 1: Breast and bottle

Chapter 39 Feeding 1


Breast and bottle



Carolyn Patchell



CHAPTER CONTENTS


Introduction 374
Learning outcomes 374

Rationale 374

Factors to note 375

Breastfeeding 375
Breast milk 375

Frequency and length of breastfeeds 376

Equipment 376

Method 376

Observations and complications 378

Expressing breast milk 379

Dos and don’ts 380

Eliminating 380

Artificial feeding 380
Preparing artificial feeds 382

Equipment 382

Method 382

Bottle-feeding an infant 382

Observations and complications 384

Dos and don’ts 384

Weaning 384

Toddler feeding 385
Equipment 385

Method 385

Observations and complications 386

Dos and don’ts 386


INTRODUCTION


A nutritionally balanced diet is essential to maximise a child’s growth and promote normal development. Children are dependent upon adults to feed them safely and appropriately when young and, later, to teach them how and what to provide for themselves as they become independent.



LEARNING OUTCOMES


By the end of this section you should be able to:


• Explain how feeding impacts on a child’s development

• Describe how to feed a baby and toddler

• List the benefits of breastfeeding

• Describe how to calculate a baby’s feed requirements.


RATIONALE


Feeding supplies an infant with food and fluids to promote growth and to enhance recovery when ill. It also plays a vital role in development. A children’s nurse must be fully aware of how, what and when to feed a child and be able to teach families, if necessary, how to feed their child.


Written guidance should be available on wards for families to support the advice they have been given. A number of publications are available from the Department of Health (DoH) and the Food Standards Agency (FSA), which give clear and easy to read guidance for families.



FACTORS TO NOTE



Assessment


The children’s nurse should be familiar with how to assess the child’s nutritional status. Being able to plot height and weight on a percentile chart and then interpret the results is an important skill. Children with abnormal nutritional status should be referred to a paediatric dietitian for assessment and advice. Local nutrition screening tools may be available to assist in this assessment, and if not advice should be sought from the dietetic department within the hospital.



Guidelines


Parental involvement in feeding is not just desirable, but essential. Feeding is one of the basic, vital life functions which parents undertake for their child and is an important part of the bonding process. Parents should always be included.



BREASTFEEDING


The ideal choice of feed for a healthy infant is breast milk. Breast milk is nutritionally the best feed for infants, and has been shown to promote optimum health, growth, development and immunity against illness (Heinig & Dewey 1996, 1997). There is significant evidence to support the existence of the significant advantages, both to the infant and the mother, of breastfeeding (British Paediatric Association Standing Committee on Nutrition 1994), which are summarised in Box 39.1. Despite the well-recognised advantages of breastfeeding, rates are low in the UK.



BOX 39.1 Advantages of breastfeeding



Advantages to the baby



Reduced risk of developing:



• Gastrointestinal illness and gastroenteritis in particular

• Middle ear infection

• Respiratory system infection

• Urinary tract infection

• Insulin-dependent diabetes mellitus

• Allergies, e.g. eczema.

For the pre-term baby:


• Optimum neurological development

• Reduced risk of necrotising enterocolitis.


Advantages to the mother



Reduced risk of:



• Premenopausal breast cancer

• Some forms of ovarian cancer.


Social gains:



• Ready availability for feeding baby

• Unique contact between mother and baby

• May help mother to lose weight naturally.

The Infant Feeding Survey, published in 2005 reported initial breastfeeding rates of 78% in England, a significant increase from the previous survey carried out in 2000. However, rates of breastfeeding reduced rapidly to only 22% of mothers exclusively breastfeeding their infant at 6 weeks of age; 8% at 4 months of age; and only a negligible number at 6 months of age. There is growing evidence of the lifetime benefits of exclusive breastfeeding and consequently, the World Health Organization (WHO 2003) recommend that all babies be exclusively breastfed until 6 months of age. This is supported by the UK government (DoH 2004).


A mother whose infant is sick should be given all the information to make a fully informed decision about breastfeeding. The benefits of breastfeeding offer particular advantages to sick infants and many sick infants can breastfeed successfully. If the infant is too sick to feed at the breast, the mother can express her milk and it can be given to the infant via a nasogastric tube, cup and spoon or by bottle.


The reasons why a mother stops breastfeeding vary, but a recurrent issue is the lack of help and support to continue when difficulties are encountered (Hamlyn et al 2002). Social and cultural factors, e.g. early return to work, can also influence a mother’s decision to cease breastfeeding. Lack of knowledgeable support can be a particular issue if the infant is admitted to a children’s ward, especially straight from a maternity unit, as education about breastfeeding for children’s nurses has been sketchy or non-existent in the past. The UNICEF Baby Friendly Initiative (1997) has supported specific guidance for good practice on paediatric units and these should be readily available for paediatric nurses on units where infants are admitted.



BREAST MILK


Breast milk is a unique fluid, which changes in nutritional composition over time from birth, to reflect the changing needs of a growing infant and also during an individual breastfeed. During the first 3 days after delivery, colostrum is produced, which is richer in electrolytes, protein and immunoglobulins and is lower in carbohydrate, fat and some vitamins than mature milk. The high levels of immunoglobulins found in colostrum confer the increased immunity seen in breastfed over formula-fed infants, and it is vital that infants, who are unable to feed directly from the breast in the first few days of life, receive this in an expressed form whenever possible. The first milk produced during a breastfeed is called foremilk. This milk is lower in fat and contains higher levels of maternal antibodies and immunoglobulins than the hindmilk which follows. Hindmilk is rich in fat and fat soluble vitamins and provides the bulk of calories in the feed. It is essential that infants receive a full breastfeed containing both foremilk and hindmilk for optimal growth.



FREQUENCY AND LENGTH OF BREASTFEEDS


Breastfeeding works on a supply and demand process, so the more the infant feeds the more milk is produced, and infant-led feeding is important for an adequate milk supply (Chadderton et al 1997). Many infants feed every 1–2 h in the first few days after birth, and many will feed for long periods, sometimes up to 1 hour. As breastfeeding becomes established, the frequency of feeds reduces to an average of eight feeds over 24 h (Hörnell et al 1999). If an infant continues to feed frequently and is unsettled after a feed, it is possible that the positioning or attachment to the breast is poor and a breastfeeding specialist should review breastfeeding techniques. As breastfeeding is infant-led, the baby should come off the breast of their own accord. If they are still hungry, the second breast should be offered. The sucking pattern of the infant is rhythmical during breastfeeding and changes from quick short sucks to slow deep sucks with short pauses from time to time (Stables & Rankin 2005).


Correct positioning and attachment should be assessed if the mother is suffering from complications such as sore and cracked nipples or engorgement.


Mothers with insufficient milk supply should be encouraged to feed or express at night as maternal prolactin levels are highest at this time, and to feed at least every 3 h throughout the day to promote increased supply.



EQUIPMENT



• The only ‘equipment’ necessary for breastfeeding will be a drink for the mother, close to hand.

• Breast pads or tissues may be required to clean any leakage from the breast from which the infant is not feeding.

• The mother must feel comfortable if she is to breastfeed well, so she may require a special chair or pillow in order to find her optimum position, and privacy, free from unnecessary interruptions.

• Nipple shields should be avoided as they can reduce the mother’s milk supply, and also may exacerbate nipple problems such as fissures (Chadderton et al 1997).


METHOD


This method is based on Chadderton et al (1997).


1. Ensure that the mother is comfortable with a drink close at hand. The mother can either be sitting (Fig. 39.1) or lying down (Fig. 39.2).

2. If the baby is calm and relaxed, feeding is more likely to progress well.

3. Position the baby to lie comfortably, close to the mother with the baby’s head and body in line and not twisted. The baby’s head should be well supported, but free to move; do not hold the baby’s head but support from the shoulders (Figs 39.3, 39.4). The baby’s nose and mouth should be in line with the nipple.

4. Depending on its size and shape, the mother’s breast may need support from her hand (Fig. 39.5). Place the mother’s hand with fingers flat against her rib cage so that the breast is supported by the angle of thumb and forefinger. The breast can also be supported with the hand underneath and thumb lightly on top well back from the areola so that the mother can form her breast into a good shape for the baby to latch on to.

5. Allow the baby to root for the breast, letting tongue and lips touch the nipple (Fig. 39.6). Allowing the baby’s head to tilt back slightly will encourage the baby to open the mouth wide. Then bring the baby back to the breast quickly, but smoothly, aiming the lower jaw at the base of the areola (Fig. 39.7). This brings the tongue over the lower lip to scoop up the areola, nipple and as much breast tissue as possible, ensuring that the tongue can reach the lactiferous ducts within the tissue behind the areola. The lactiferous ducts are small reservoirs of milk from which the milk is released.

6. Allow the baby to feed as long as desired from the first breast before moving on to the second, to ensure that both fore- and hindmilks are released. A baby should not have the feed stopped prematurely. While in hospital, any medical or nursing interventions should be timed around feeds and not be allowed to interrupt feeds.

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Figure 39.1 Breastfeeding in the sitting position.


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Figure 39.2 Breastfeeding in the lying position.


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Figure 39.3 Position of the infant during a feed.


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Figure 39.4 Supporting the baby during a feed.


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Figure 39.5 Supporting the breast during feeding.


(with approval from UNICEF UK Baby Friendly Initiative at: www.babyfriendly.org.uk)


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Figure 39.6 Infant rooting to the breast.


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Figure 39.7 Good infant attachment.



OBSERVATIONS AND COMPLICATIONS



Observations (Chadderton et al 1997)



• Observe that the mother and baby are comfortable and relaxed. The baby should be close to the mother with the head and body straight, chin touching her breast (and in the young infant <6 months, with the bottom supported).

• Observe the baby’s responses. Does the baby reach (root in the newborn) for the breast? Use the tongue to explore the breast? Stay attached? Are there signs of milk ejection (afterpains, milk leakage)?

• Is there evidence of emotional bonding (mother has a secure, confident hold, watches and touches her baby)? Does the baby watch her?

• Anatomy: Are the breasts soft and full? Are the nipples protractile? Is the skin healthy and breasts round during feeding?

• How does the baby suckle? Is the mouth wide, lower lip turned outward, tongue cupped around the breast? Are the cheeks round? Does the baby produce slow, deep sucks in bursts followed by short pauses? Can you see or hear the baby swallow?

• Note how long the baby feeds and record, if required.

• Observe for signs of possible difficulty (see below).


Complications/difficulties


There are no complications of breastfeeding as such, but there may be some difficulties in establishing effective breastfeeding. Examples are as follows:


• If the mother is tense and unrelaxed, give her time to talk through her worries and fears, and provide emotional and practical support. If the baby is uninterested at the start, try cuddling well into the breast, skin-to-skin between feeds. This will help the baby become used to the smell, feel and appearance of the breast (Chadderton et al 1997). Do not give dummies, bottles or pacifiers which can confuse a baby trying to learn how to breastfeed (Shore 1998).

• If the mother’s nipples become sore and/or cracked, this is usually due to poor positioning and attachment. Refer this complication to a breastfeeding specialist.

• Be aware that many drugs can be excreted in breast milk and therefore ingested by the baby (Hale 2004). Ask about any medication the mother is taking and check with the pharmacy about any possible contraindications.


EXPRESSING BREAST MILK


A mother may need to express her breast milk in order to:


• Help establish and maintain lactation

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Mar 7, 2017 | Posted by in NURSING | Comments Off on Feeding 1: Breast and bottle

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