Newborn Nutrition and Feeding

Newborn Nutrition and Feeding

Kathryn Rhodes Alden

Key Terms and Definitions

Web Resources

Additional related content can be found on the companion website at image

G ood nutrition in infancy fosters optimal growth and development. Infant feeding is more than the provision of nutrition; it is an opportunity for social, psychologic, and even educational interaction between parent and infant. It can also establish a basis for developing good eating habits that last a lifetime.

Through preconception and prenatal education and counseling, nurses play an instrumental role in assisting parents with the selection of an infant feeding method. Scientific evidence is clear that human milk provides the best nutrition for infants, and parents should be strongly encouraged to choose breastfeeding (American Academy of Pediatrics [AAP] Section on Breastfeeding, 2012). Although many health care providers and the general public may consider artificial baby milk (infant formula) to be equivalent to breast milk, this belief is erroneous. Human milk is species specific, uniquely designed to meet the needs of human infants. The composition of human milk changes to meet the nutritional needs of growing infants. It is highly complex, with antiinfective and nutritional components combined with growth factors, enzymes that aid in digestion and absorption of nutrients, and fatty acids that promote brain growth and development. Infant formulas are usually adequate in providing nutrition to maintain infant growth and development within normal limits, but they are not equivalent to human milk.

Whether the parents choose to breastfeed or to give their infant artificial baby milk (formula), nurses provide support and ongoing education. Parent education is necessarily based on current research findings and standards of practice.

This chapter focuses on meeting nutritional needs for normal growth and development from birth to age 6 months, with emphasis on the neonatal period, when feeding practices and patterns are established. Both breastfeeding and formula feeding are addressed.

Recommended Infant Nutrition image

The AAP recommends exclusive breastfeeding or human milk feeding for the first 6 months of life and that breastfeeding or human milk feeding continue as the sole source of milk for the first year. During the second 6 months of life, appropriate complementary foods (solids) are added to the infant diet. If infants are weaned from breast milk before 12 months of age, they should receive iron-fortified infant formula, not cow’s milk (AAP Section on Breastfeeding, 2012). According to the Global Strategy for Infant and Young Child Feeding, endorsed by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), infants should be exclusively breastfed for 6 months, and breastfeeding should continue for up to 2 years and beyond (WHO/UNICEF, 2003).

Breastfeeding Rates image

Breastfeeding rates in the United States have risen steadily over the past decade. The Centers for Disease Control and Prevention (CDC, 2012) reported that the U.S. breastfeeding initiation rate in 2009 was 76.9%, which is the highest ever reported. Despite increases in breastfeeding rates, the U.S. continues to fall short of the Healthy People 2020 goals (USDHHS, 2010). Trends remain unchanged in breastfeeding rates among minority groups in the United States. The lowest rates are among non-Hispanic black women, although the overall percentage has increased in recent years. The minority group most likely to breastfeed is Hispanic women (Scanlon, Grummer-Strawn, Li, et al, 2010).

Benefits of Breastfeeding image

Numerous research studies have identified the beneficial effects of human milk for infants during the first year of life. Long-term epidemiologic studies have shown that these benefits do not cease when the infant is weaned; instead, these benefits extend into childhood and beyond. Breastfeeding has many advantages for mothers, for families, and for society in general (AAP Section on Breastfeeding, 2012; Lawrence & Lawrence, 2011; Ip et al., 2009). In discussing the benefits of breastfeeding with parents, nurses and other health care professionals must have a thorough understanding of these benefits from both a physiologic and a psychosocial perspective. Table 18-1 lists the benefits of breastfeeding.

TABLE 18-1

Benefits of Breastfeeding


SIDS, Sudden infant death syndrome.

Sources: American Academy of Pediatrics Section on Breastfeeding. (2012). Breastfeeding and the use of human milk policy statement. Pediatrics, 129(3), e827-e841; Ip, S., Chung, M., Raman, G., Trikalinos, T.A., & Lau, J. (2009). A summary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries. Breastfeeding Medicine, 4(Suppl 1), S17-S30.

Choosing an Infant Feeding Method image

Breastfeeding is a natural extension of pregnancy and childbirth; it is much more than simply a means of supplying nutrition for infants. Women most often breastfeed their babies because they are aware of the benefits to the infant (Nelson, 2012). Many women seek the unique bonding experience between mother and infant that is characteristic of breastfeeding. Women tend to select the same method of infant feeding for each of their children. If the first child was breastfed, subsequent children will likely also be breastfed (Taylor, Geller, Risica, Kirtania, & Cabral, 2008).

The support of the partner and family is a major factor in the mother’s decision to breastfeed. Women who perceive their partners to prefer breastfeeding are more likely to choose this method of infant feeding. Women are more likely to breastfeed successfully when partners and family members are positive about breastfeeding and have the skills to support breastfeeding (Clifford & McIntyre, 2008).

Parents who choose to formula-feed often make this decision without complete information and understanding of the benefits of breastfeeding and the potential hazards of formula feeding. Even women who are educated about the advantages of breastfeeding may still decide to formula-feed. Cultural beliefs, as well as myths and misconceptions about breastfeeding, influence women’s decision making. Many women see formula feeding as more convenient or less embarrassing than breastfeeding. Some view formula feeding as a way to ensure that the father, other family members, and day-care providers can feed the baby. Some women lack confidence in their ability to produce breast milk of adequate quantity or quality. Women who have had previous unsuccessful breastfeeding experiences may choose to formula feed subsequent infants. Some women see breastfeeding as incompatible with an active social life, or they think that it will prevent them from going back to work. Modesty issues and societal barriers exist against breastfeeding in public. A major barrier for many women is the influence of family and friends.

Evidence-Based Practice

The Usefulness of Prenatal Breastfeeding Education

Critically Analyze the Evidence

After reviewing scientific literature indicating that health care provider attitude and ongoing support have a significant impact on the initiation and duration of exclusive breastfeeding, the Academy of Breastfeeding Medicine (2006) published a protocol calling for health care providers to discuss the benefits of breastfeeding, beginning with the first visit in the first trimester. The guidelines encourage an ongoing conversation with the patient and her family about feeding plans, attitudes, and previous experiences. Both parents are encouraged to attend prenatal breastfeeding classes before making a decision. Educational materials should include written, non–formula-advertising materials and may also include visual aids, books, and videos.

A Cochrane Database of Systematic Review of nine prenatal education trials totaling 2284 women found that the benefits and strategies of prenatal education are difficult to compare as a result of greatly differing interventions and outcome measures (Gagnon & Sandall, 2007). One particular challenge of studying this topic is the difficulty of randomizing women to the interventions or control, when randomization may contradict a woman’s choice. The reviewers were not able to determine benefits or best strategies for prenatal education.

However, a subsequent randomized controlled trial (RCT) of 450 healthy women in Singapore who were over 34 weeks of gestation demonstrated that breastfeeding initiation and duration were significantly improved if the women were given either a prenatal education session (video, individual instruction and written materials) or two postnatal support sessions (individual instruction in hospital and at 2 weeks, with written materials), when compared with women receiving usual care (Su et al., 2007).

Group prenatal education sessions may also be effective, as well as efficient for the health care provider. In a more recent RCT of 1047 pregnant women, participants who were randomized to receive weekly group educational and facilitated support sessions with their gestational peers from 18 weeks until term had significantly increased breastfeeding initiation, more prenatal knowledge, more readiness for labor and birth, and increased satisfaction compared with women receiving usual treatment. No differences in costs were noted, and birthweights remained similar. Interestingly, the women in the support group also had significantly fewer preterm births (Ickovics et al., 2007).


Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol no. 14: Breastfeeding-friendly physician’s office, part 1: Optimizing care for infants and children. Breastfeeding Medicine. 2006; 1(2):115–119.

Gagnon, A. J. & Sandall, J. (2007). Individual or group antenatal education for childbirth or parenthood, or both. In The Cochrane Database of Systematic Reviews, 2007, Issue 3, CD 002869.

Ickovics, J. R., Kershaw, T. S., Westdahl, C., Magriles, U., Massey, Z., Reynolds, H., et al. Group prenatal care and perinatal outcomes: A randomized, controlled trial. Obstetrics and Gynecology. 2007; 110(2 Pt 1):330–339.

Su, L. L., Chong, Y. S., Chan, Y. H., Chan, Y. S., Fok, D., Tun, K. T., et al. Antenatal education and postnatal support strategies for improving rates of exclusive breastfeeding: Randomized controlled trial. British Medical Journal. 2007; 335(7620):596.

Breastfeeding is contraindicated in a few situations. Newborns who have galactosemia should not be breastfed. Mothers with active tuberculosis or human immunodeficiency virus infection and those who are positive for human T-cell lymphotropic virus type I or type II should not breastfeed. Breastfeeding is not recommended when mothers are receiving chemotherapy or radioactive isotopes (e.g., with diagnostic procedures). Maternal use of drugs of abuse (“street drugs”) is incompatible with breastfeeding (AAP Section on Breastfeeding, 2012; Lawrence & Lawrence, 2011).

The key to encouraging mothers to breastfeed is education and anticipatory guidance, beginning as early as possible during pregnancy and even before pregnancy. Each encounter with an expectant mother is an opportunity to educate, dispel myths, clarify misinformation, and address personal concerns. Prenatal education and preparation for breastfeeding influence feeding decisions, breastfeeding success, and the amount of time that women breastfeed (Rosen, Krueger, Carney, & Graham, 2008). Prenatal preparation ideally includes the father of the baby, partner, or another significant support person, providing information about benefits of breastfeeding and how he or she can participate in infant care and nurturing.

Connecting expectant mothers with women from similar backgrounds who are breastfeeding or have successfully breastfed is often helpful. Nursing mothers’ support groups provide information about breastfeeding along with opportunities for breastfeeding mothers to interact with one another and share concerns (Fig. 18-1). Peer counseling programs, such as those instituted by Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs, are beneficial.

For women with limited access to health care the postpartum period may provide the first opportunity for education about breastfeeding. Even women who have indicated the desire to bottle-feed may benefit from information about the benefits of breastfeeding and the potential hazards of infant formula. Offering these women the chance to try breastfeeding with the assistance of a nurse may influence a change in infant feeding practices.

Promoting feelings of competence and confidence in the breastfeeding mother and reinforcing the unequaled contribution she is making toward the health and well-being of her infant are the responsibility of the nurse and other health care professionals. Women who are optimistic, with a sense of breastfeeding self-efficacy, and faith in breast milk as the best nutrition for the infant are likely to breastfeed longer (O’Brien, Buikstra, & Hegney, 2008). The most common reasons for breastfeeding cessation are insufficient milk supply, painful nipples, and problems getting the infant to feed. Early and ongoing assistance and support from health care professionals to prevent and address problems with breastfeeding can help promote a successful and satisfying breastfeeding experience for mothers and infants (Renfrew & Hall, 2008). Many health care agencies have lactation consultants on staff. These health care professionals who are usually nurses have specialized training and experience in assisting breastfeeding mothers and infants. Evidence-based guidelines for supporting breastfeeding are available for use by health care professionals (Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2007; International Lactation Consultant Association [ILCA], 1999).

Cultural Influences on Infant Feeding

Cultural beliefs and practices are significant influences on infant feeding methods. Although recognized cultural norms exist, one cannot assume that generalized observations about any cultural group hold true for all members of that group. Many regional and ethnic cultures can be found within the United States. Dealing effectively with these groups requires that nurses are knowledgeable and sensitive to the cultural factors influencing infant feeding practices.

In general, persons who have immigrated to the United States from poorer countries often choose to formula-feed their infants because they believe it is a better, more “modern” method or because they want to adapt to U.S. culture and perceive that bottle feeding is the custom. However, this notion is not always true. For example, Hispanic women born in the United States are less likely to breastfeed, whereas Hispanic women who have recently immigrated tend to choose the social norm of breastfeeding that is characteristic of their homeland (Ahluwalia, D’Angelo, Morrow, et al., 2012).

Breastfeeding beliefs and practices vary across cultures. For example, among the Muslim culture, breastfeeding for 24 months is customary. Before the first feeding, rubbing a small piece of softened date on the newborn’s palate is a ritual practice. Because of the cultural emphasis on privacy and modesty, Muslim women may choose to bottle-feed formula or expressed breast milk while in the hospital (Shaikh & Ahmed, 2006).

Because of beliefs about the harmful nature or inadequacy of colostrum, some cultures apply restrictions on breastfeeding for a period of days after birth. Such is the case for many cultures in Southern Asia, the Pacific Islands, and parts of sub-Saharan Africa. Before the mother’s milk is deemed to be “in,” babies are fed prelacteal food such as honey or clarified butter, in the belief that these substances will help to clear out the meconium (Laroia & Sharma, 2006; Shaikh & Ahmed, 2006). Other cultures begin breastfeeding immediately and offer the breast each time the infant cries.

A common practice among Latina women is to combine breastfeeding with formula feeding during the first week of life. This practice can potentially result in problems with milk supply and babies refusing to latch on to the breast, which can lead to early termination of breastfeeding (Bartick & Reyes, 2012).

Some cultures have specific beliefs and practices related to the mother’s intake of foods that foster milk production. Korean mothers often eat seaweed soup and rice to enhance milk production. Hmong women believe that boiled chicken, rice, and hot water are the only appropriate nourishments during the first postpartum month. The balance between energy forces, hot and cold, or yin and yang is integral to the diet of the lactating mother. Hispanics, Vietnamese, Chinese, East Indians, and Arabs often use this belief in choosing foods. “Hot” foods are considered best for new mothers. This belief does not necessarily relate to the temperature or spiciness of foods. For example, chicken and broccoli are considered “hot,” whereas many fresh fruits and vegetables are considered “cold.” Families often bring desired foods into the health care setting.

Nutrient Needs image


During the first 2 days of life the fluid requirement for healthy infants (>1500 g) is 60 to 80 ml of water per kilogram of body weight per day. From day 3 to 7 the requirement is 100 to 150 ml/kg/day and from day 8 to day 30, 120 to 180 ml/kg/day (Dell & Davis, 2011). In general, neither breastfed nor formula-fed infants need to be given water, not even those living in very hot climates. Breast milk contains 87% water, which easily meets fluid requirements. Feeding water to infants may only decrease caloric consumption at a time when infants are growing rapidly.

Infants have room for little fluctuation in fluid balance and should be monitored closely for fluid intake and water loss. Infants lose water through excretion of urine and insensibly through respiration. Under normal circumstances, infants are born with some fluid reserve, and some of the weight loss during the first few days is related to fluid loss. In some cases, however, infants do not have this fluid reserve, possibly because of inadequate maternal hydration during labor or birth.


Infants require adequate caloric intake to provide energy for growth, digestion, physical activity, and maintenance of organ metabolic function. Energy needs vary according to age, maturity level, thermal environment, growth rate, health status, and activity level. For the first 3 months the infant needs 110 kcal/kg/day. From 3 months to 6 months the requirement is 100 kcal/kg/day. This level decreases slightly to 95 kcal/kg/day from 6 to 9 months and increases to 100 kcal/kg/day from 9 months to 1 year (AAP Committee on Nutrition, 2009).

Human milk provides 67 kcal/100 ml or 20 kcal/oz. The fat portion of the milk provides the greatest amount of energy. Infant formulas simulate the caloric content of human milk. Usually a standard formula contains 20 kcal/oz, though the composition differs among brands.


According to the Institute of Medicine (IOM) (2005), the adequate daily reference intake (DRI) for carbohydrate in the first 6 months of life is 60 g/day and 95 g/day for the second 6 months. Because newborns have only small hepatic glycogen stores, carbohydrates should provide at least 40% to 50% of the total calories in the diet. Moreover, newborns may have a limited ability to carry out gluconeogenesis (the formation of glucose from amino acids and other substrates) and ketogenesis (the formation of ketone bodies from fat), the mechanisms that provide alternative sources of energy.

As the primary carbohydrate in human milk and commercially prepared infant formula, lactose is the most abundant carbohydrate in the diet of infants up to age 6 months. Lactose provides calories in an easily available form. Its slow breakdown and absorption also increase calcium absorption. Corn syrup solids or glucose polymers are added to infant formulas to supplement the lactose in the cow’s milk and thereby provide sufficient carbohydrates.

Oligosaccharides, another form of carbohydrates found in breast milk, are critical in the development of microflora in the intestinal tract of the newborn. These prebiotics promote an acidic environment in the intestines, preventing the growth of gram-negative and other pathogenic bacteria, thus increasing the infant’s resistance to GI illness.


The average recommended DRI of fat for infants younger than 6 months is 31 g/day (IOM, 2005). For infants to acquire adequate calories from human milk or formula, at least 15% of the calories provided must come from fat (triglycerides).

The fat content of human milk is composed of lipids, triglycerides, and cholesterol; cholesterol is an essential element for brain growth. Human milk contains the essential fatty acids (EFAs), linoleic acid, and linolenic acid, as well as the long-chain polyunsaturated fatty acids, arachidonic acid (ARA), and docosahexaenoic acid (DHA). Fatty acids are important for growth, neurologic development, and visual function. Cow’s milk contains fewer of the EFAs and no polyunsaturated fatty acids. Most formula companies are now adding DHA and ARA to their products. Studies of infants receiving supplements of DHA and ARA have shown mixed results in terms of visual acuity and cognitive function (Heird, 2007; Simmer, Patole, & Rao, 2008).

Modified cow’s milk is used in most infant formulas, but the milk fat is removed, and another fat source such as corn oil, which the infant can digest and absorb, is added in its place. If whole milk or evaporated milk without added carbohydrate is fed to infants, the resulting fecal loss of fat (and therefore loss of energy) may be excessive because the milk moves through the infant’s intestines too quickly for adequate absorption to take place. This circumstance can lead to poor weight gain.


High-quality protein from breast milk, infant formula, or other complementary foods is necessary for infant growth. The protein requirement per unit of body weight is greater in the newborn than at any other time of life. For infants younger than 6 months the average DRI for protein is 9.1 g/day (IOM, 2005).

Human milk contains the two proteins, whey (lactalbumin) and casein (curd), in a ratio of approximately 60 : 40, as compared with the ratio of 80 : 20 in most cow’s milk–based formula. This whey/casein ratio in human milk makes it more easily digested and produces the soft stools seen in breastfed infants. The whey protein lactoferrin in human milk has iron-binding capabilities and bacteriostatic properties, particularly against gram-positive and gram-negative aerobes, anaerobes, and yeasts. The casein in human milk enhances the absorption of iron, thus preventing iron-dependent bacteria from proliferating in the gastrointestinal tract (Lawrence & Lawrence, 2011).

The amino acid components of human milk are uniquely suited to the newborn’s metabolic capabilities. For example, cystine and taurine levels are high, whereas phenylalanine and methionine levels are low.


Human milk contains all of the vitamins required for infant nutrition, with individual variations based on maternal diet and genetic differences. Vitamins are added to cow’s-milk formulas to resemble levels found in breast milk. Although cow’s milk contains adequate amounts of vitamin A and vitamin B complex, vitamin C (ascorbic acid), vitamin E, and vitamin D must be added.

Vitamin D facilitates intestinal absorption of calcium and phosphorus, bone mineralization, and calcium reabsorption from bone. According to the AAP, all infants who are breastfed or partially breastfed should receive 400 international units of vitamin D daily, beginning the first few days of life. Nonbreastfeeding infants and older children who consume less than 1 quart per day of vitamin D–fortified milk should also receive 400 international units of vitamin D each day (Wagner, Grier, Section on Breastfeeding, & Committee on Nutrition, 2008).

Vitamin K, required for blood coagulation, is produced by intestinal bacteria. However, the gut is sterile at birth, and a few days are required for intestinal flora to become established and produce vitamin K. To prevent hemorrhagic problems in the newborn an injection of vitamin K is given at birth to all newborns, regardless of feeding method (AAP Section on Breastfeeding, 2012).

The breastfed infant’s vitamin B12 intake is dependent on the mother’s dietary intake and stores. Mothers who are on strict vegetarian (vegan) diets and those who consume few dairy products, eggs, or meat are at risk of vitamin B12 deficiency. Breastfed infants of vegan mothers should be supplemented with vitamin B12 from birth.


The mineral content of commercial infant formula is designed to reflect that of breast milk. Unmodified cow’s milk is much higher in mineral content than human milk, which also makes it unsuitable for infants during the first year of life. Minerals are typically highest in human milk during the first few days after birth and decrease slightly throughout lactation.

The ratio of calcium to phosphorus in human milk is 2 : 1, an optimal proportion for bone mineralization. Although cow’s milk is high in calcium, the calcium-to-phosphorus ratio is low, resulting in decreased calcium absorption. Consequently, young infants fed unmodified cow’s milk are at risk for hypocalcemia, seizures, and tetany. The calcium/phosphorus ratio in commercial infant formula is between that of human milk and cow’s milk. The average DRI for calcium is 210 mg/day for infants younger than 6 months and 270 mg/day for infants between 7 months and 1 year (IOM, 2005).

Iron levels are low in all types of milk; however, iron from human milk is better absorbed than iron from cow’s milk, iron-fortified formula, or infant cereals. Breastfed infants draw on iron reserves deposited in utero and benefit from the high lactose and vitamin C levels in human milk that facilitate iron absorption. Full-term infants have enough iron stores from the mother to last four months. After that time, exclusively breastfed infants are at risk for iron deficiency. They should receive an iron supplement until they are consuming complementary foods that contain iron (e.g., iron-fortified cereals). Formula-fed infants should receive an iron-fortified commercial infant formula until 12 months of age. Infants should not be fed low-iron formula (Baker, Greer, & AAP Committee on Nutrition, 2010).

Fluoride levels in human milk and commercial formulas are low. This mineral, which is important in the prevention of dental caries, may cause spotting of the permanent teeth (fluorosis) in excess amounts. Experts recommend that no fluoride supplements be given to infants younger than 6 months. From 6 months to 3 years, fluoride supplements are based on the concentration of fluoride in the water supply (AAP Section on Breastfeeding, 2012).

Anatomy and Physiology of Lactation image

Anatomy of the Lactating Breast

Each female breast is composed of approximately 15 to 20 segments (lobes) embedded in fat and connective tissues and well supplied with blood vessels, lymphatic vessels, and nerves (Fig. 18-2). Within each lobe is glandular tissue consisting of alveoli, the milk-producing cells, surrounded by myoepithelial cells that contract to send the milk forward to the nipple during milk ejection. Each nipple has multiple pores that transfer milk to the suckling infant. The ratio of glandular tissue to adipose tissue in the lactating breast is approximately 2 : 1 compared with a 1 : 1 ratio in the nonlactating breast. Within each breast is a complex, intertwining network of milk ducts that transport milk from the alveoli to the nipple. The milk ducts dilate and expand at milk ejection. Previous thinking held that the milk ducts converged behind the nipple in lactiferous sinuses, which acted as reservoirs for milk. New research based on ultrasonography of lactating breasts has shown that these sinuses do not exist, and, in fact, glandular tissue can be found directly beneath the nipple (Geddes, 2007; Ramsay, Kent, Hartmann, & Hartmann, 2005) (Fig. 18-3).

The size and shape of the breast are not accurate indicators of its ability to produce milk. Although nearly every woman can lactate, a small number of women have insufficient mammary gland development to breastfeed their infants exclusively. Typically, these women experience few breast changes during puberty or early pregnancy. In some cases, women may still be able to breastfeed and offer supplemental nutrition to support optimal infant growth. Devices are available to allow mothers to offer supplements while the baby is nursing at the breast (Fig. 18-4).

Because of the effects of estrogen, progesterone, human placental lactogen, and other hormones of pregnancy, changes occur in the breasts in preparation for lactation. Breasts increase in size corresponding to growth of glandular and adipose tissue. Blood flow to the breasts nearly doubles during pregnancy. Sensitivity of the breasts increases, and veins become more prominent. The nipples become more erect, and the areola darken. Nipples and areola may enlarge. Around week 16 of gestation the alveoli begin producing colostrum (early milk). Montgomery glands on the areola increase in size and secretion. Secretions from these glands help provide protection against the mechanical stress of sucking and invasion by pathogens. The odor of the secretions may be a means of communication with the infant (Geddes, 2007).


After the mother gives birth a precipitous fall in estrogen and progesterone levels triggers the release of prolactin from the anterior pituitary gland. During pregnancy, prolactin prepares the breasts to secrete milk and, during lactation, to synthesize and secrete milk. Prolactin levels are highest during the first 10 days after birth, gradually declining over time but remaining above baseline levels for the duration of lactation. Prolactin is produced in response to infant suckling and emptying of the breasts (NOTE: Lactating breasts are never completely empty; the alveoli constantly produce milk as the infant feeds) (Fig. 18-5, A). Milk production is a supply-meets-demand system; that is, as milk is removed from the breast, more is produced. Incomplete emptying of the breasts can lead to decreased milk supply.

Oxytocin is the other hormone essential to lactation. As the nipple is stimulated by the suckling infant the posterior pituitary is prompted by the hypothalamus to produce oxytocin. This hormone is responsible for the milk ejection reflex (MER), or let-down reflex (Fig. 18-5, B). The myoepithelial cells surrounding the alveoli respond to oxytocin by contracting and sending the milk forward through the ducts to the nipple. Many “let-downs” can occur with each feeding session. Thoughts, sights, sounds, or odors that the mother associates with her baby (or other babies), such as hearing the baby cry, can all trigger the MER. Many women report a tingling “pins and needles” sensation in the breasts as milk ejection occurs, although some mothers can detect milk ejection only by observing the sucking and swallowing of the infant. The milk ejection reflex also may occur during sexual activity because oxytocin is released during orgasm. The reflex can be inhibited by fear, stress, and alcohol consumption.

Oxytocin is the same hormone that stimulates uterine contractions during labor. Consequently, the MER may be triggered during labor, as evidenced by leakage of colostrum. This reflex readies the breast for immediate feeding by the infant after birth. Oxytocin has the important function of contracting the mother’s uterus after birth to control postpartum bleeding and promote uterine involution. Thus mothers who breastfeed are at decreased risk for postpartum hemorrhage. These uterine contractions, or “afterpains,” that occur with breastfeeding are often painful during and after feeding for the first 3 to 5 days, particularly in multiparas, although they resolve within 1 week after birth.

Prolactin and oxytocin have been called the “mothering hormones” because they affect the postpartum woman’s emotions, as well as her physical state. Many women report feeling thirsty or very relaxed during breastfeeding, probably as a result of these hormones.

The nipple-erection reflex is an important part of lactation. When the infant cries, suckles, or rubs against the breast, the nipple becomes erect, which assists in the propulsion of milk through the ducts to the nipple pores. Nipple sizes, shapes, and ability to become erect vary with individuals. Some women have flat or inverted nipples that do not become erect with stimulation; these women will likely need assistance with effective latch. However, babies are usually able to learn to breastfeed successfully with any nipple. These infants should not be offered bottles or pacifiers until breastfeeding is well established.

Uniqueness of Human Milk

Human milk is the ideal food for human infants. It is a dynamic substance with a composition that changes to meet the changing nutritional and immunologic needs of the infant as growth and development ensue. Breast milk is specific to the needs of each newborn; for example, the milk produced by mothers of preterm infants differs in composition from that of mothers who give birth at term.

Human milk contains immunologically active components that provide some protection against a broad spectrum of bacterial, viral, and protozoan infections. Secretory IgA is the major immunoglobulin in human milk; IgG, IgM, IgD, and IgE are also present. Human milk also contains T and B lymphocytes, epidermal growth factor, cytokines, interleukins, Bifidus factor, complement (C3 and C4), and lactoferrin, all of which have a specific role in preventing localized and systemic bacterial and viral infections (Lawrence & Lawrence, 2011) (Table 18-2).

TABLE 18-2

Summary of Immune Properties of Breast Milk

B lymphocytes Give rise to antibodies targeted against specific microbes
Macrophages Kill microbes outright in baby’s gut, produce lysozyme, and activate other components of the immune system
Neutrophils May act as phagocytes, ingesting bacteria in baby’s digestive system
T lymphocytes
Antibodies of secretory immunoglobulin A class Bind to microbes in infant’s digestive tract and thereby prevent them from passing through walls of the gut into body tissues
B12-binding protein Reduces amount of vitamin B12, which bacteria need to grow
Bifidus factor Promotes growth of Lactobacillus bifidus, a harmless bacterium, in infant’s gut; growth of such nonpathogenic bacteria helps crowd out dangerous varieties
Fatty acids Disrupts membranes surrounding certain viruses and destroys them
Fibronectin Increases antimicrobial activity of macrophages; helps repair tissues that have been damaged by immune reactions in infant’s gut
Gamma-interferon Enhances antimicrobial activity of immune cells
Hormones and growth factors Stimulates infant’s digestive tract to mature more quickly; once the initially “leaky” membranes lining the gut mature, infants become less vulnerable to microorganisms
Lactoferrin Binds to iron, a mineral many bacteria need to survive; by reducing the available amount of iron, lactoferrin thwarts growth of pathogenic bacteria
Lysozyme Kills bacteria by disrupting their cell walls
Mucins Adheres to bacteria and viruses, thus keeping such microorganisms from attaching to mucosal surfaces
Oligosaccharides Binds to microorganisms and bars them from attaching to mucosal surfaces


From Newman, J. (1995). How breast milk protects newborns. Scientific American, 273(6), 76-79.

Human milk composition and volumes vary according to the stage of lactation. In lactogenesis stage I, beginning at approximately 16 to 18 weeks of pregnancy, the breasts are preparing for milk production by producing colostrum. Colostrum, a clear yellowish fluid, is more concentrated than mature milk and is extremely rich in immunoglobulins. It has higher concentrations of protein and minerals but less fat than mature milk. The high protein level of colostrum facilitates binding of bilirubin, and the laxative action of colostrum promotes early passage of meconium. Colostrum gradually changes to mature milk; this transition is called “the milk coming in” or as lactogenesis stage II. By day 3 to 5 after birth, most women have had this onset of copious milk secretion. Breast milk continues to change in composition for approximately 10 days, when the mature milk is established in stage III of lactogenesis (Lawrence & Lawrence, 2011).

Composition of mature milk changes during each feeding. As the infant nurses, the fat content of breast milk increases. Initially, a bluish-white foremilk is released that is part skim milk (approximately 60% of the volume) and part whole milk (approximately 35% of the volume). It provides primarily lactose, protein, and water-soluble vitamins. The hindmilk, or cream (approximately 5%), is usually released 10 to 20 minutes into the feeding, although it may occur sooner. It contains the denser calories from fat necessary for ensuring optimal growth and contentment between feedings. Because of this changing composition of human milk during each feeding, breastfeeding the infant long enough to supply a balanced feeding is important.

Milk production gradually increases as the baby grows so that by the time her infant is 2 weeks of age the mother produces 720 to 900 ml of milk every 24 hours. Babies have fairly predictable growth spurts (at approximately 10 days, 3 weeks, 6 weeks, 3 months, and 6 months), when more frequent feedings stimulate increased milk production. These growth spurts usually last 24 to 48 hours, and then the infants resume their usual feeding pattern.

Care Management: The Breastfeeding Mother and Infant image

Effective management of the breastfeeding mother and infant requires that caregivers are knowledgeable about the benefits of breastfeeding, as well as about basic anatomic and physiologic aspects of breastfeeding. Caregivers also need to know how to assist the mother with feeding and interventions for common problems. Ongoing support of the mother enhances her self-confidence and promotes a satisfying and successful breastfeeding experience. During the time in the hospital the mother is encouraged to view each breastfeeding session as a “feeding lesson” or “practice session” that will foster her self-confidence and promote a satisfying breastfeeding experience for herself and her infant.

The mother needs to understand infant behaviors in relation to breastfeeding. When newborns feel hunger, they usually cry vigorously until their needs are met. Some infants, however, will withdraw into sleep because of discomfort associated with hunger. Babies exhibit feeding-readiness cues that a knowledgeable caregiver can recognize. Instead of waiting to feed until the infant is crying in a distraught manner or withdrawing into sleep, beginning a feeding when the baby exhibits some of these cues (even during light sleep) is preferable:

Babies normally consume small amounts of milk during the first 3 days of life. As the baby adjusts to extrauterine life and the digestive tract is cleared of meconium, milk intake increases from 15 to 30 ml per feeding in the first 24 hours to 60 to 90 ml by the end of the first week.

At birth and for several months thereafter, all of the secretions of the infant’s digestive tract contain enzymes especially suited to the digestion of human milk. The ability to digest foods other than milk depends on the physiologic development of the infant. The capacities for salivary, gastric, pancreatic, and intestinal digestion increase with age, indicating that the natural time for introduction of solid foods may be around 6 months of age.

Babies are born with a tongue extrusion reflex that causes them to push out of the mouth anything placed on the tongue. This reflex disappears by 6 months—another indication of physiologic readiness for solids.

Early introduction of solids may make the infant more prone to food allergies. Regular feeding of solids can lead to decreased intake of breast milk or formula and may be associated with early cessation of breastfeeding.

In the early days after birth, interventions focus on helping the mother and the newborn initiate breastfeeding and achieve some degree of success and satisfaction before discharge from the hospital or birthing center. Interventions to promote successful breastfeeding include basics such as latch and positioning, signs of adequate feeding, and self-care measures such as prevention of engorgement. An important intervention is to provide the parents with a list of resources that they may contact after discharge from the hospital.

Nursing Care Plan

Breastfeeding and Infant Nutrition

Nursing Diagnosis Ineffective breastfeeding related to knowledge deficit of the mother as evidenced by ongoing incorrect latch technique

Expected Outcomes Mother will demonstrate the correct latch technique. Infant will latch on and suck with gliding jaw movements and audible swallowing. Mother will report “tugging” but no nipple pain with infant suckling. Mother will express increased satisfaction with breastfeeding, and neonate will exhibit satisfaction of hunger and sucking needs.

Nursing Interventions/Rationales

• Assess the mother’s knowledge and motivation for breastfeeding to acknowledge the patient’s desire for effective outcome and to provide a starting point for teaching.

• Observe a breastfeeding session to provide a baseline assessment for positive reinforcement and problem identification.

• Describe and demonstrate ways to stimulate the sucking reflex, various positions for breastfeeding, and the use of pillows during a session to promote maternal and neonatal comfort and effective latch.

• Monitor the neonatal position of the mouth on the areola and position of the head and body to give positive reinforcement for correct latch position or to correct poor latch position.

• Teach the mother ways to stimulate neonate to maintain an awake state by diapering, unwrapping, massaging, or burping to complete a breastfeeding session thoroughly and satisfactorily.

• Give the mother information regarding lactation diet, expression of milk by hand or pump, and storage of expressed breast milk to provide basic information.

• Make sure the mother has written information on all aspects of breastfeeding to reinforce oral instructions and demonstrations.

• Refer to support groups, lactation consultant, or both, if needed, to provide further information and group support.

Nursing Diagnosis Ineffective infant feeding pattern related to inability to coordinate sucking and swallowing

Expected Outcome Neonate will coordinate sucking and swallowing to accomplish an effective feeding pattern.

Nursing Interventions/Rationales

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Oct 8, 2016 | Posted by in NURSING | Comments Off on Newborn Nutrition and Feeding

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