Newborn Nutrition and Feeding



Newborn Nutrition and Feeding


Kathryn R. Alden



Good nutrition in infancy fosters optimal growth and development. Infant feeding is more than providing 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 helping parents make an informed decision about infant feeding. Scientific evidence is clear that human milk provides the best nutrition for infants, and parents should be strongly encouraged to choose breastfeeding (AAP Section on Breastfeeding, 2012). Although many consider commercial infant formula to be equivalent to breast milk, this belief is erroneous. Human milk is the gold standard for infant nutrition. It 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.


Breastfeeding is defined as the transfer of human milk from the mother to the infant; the infant receives milk directly from the mother’s breast. Exclusive breastfeeding means that the infant receives no other liquid or solid food (AAP Section on Breastfeeding, 2012). If the infant is fed expressed breast milk from the mother or a donor milk bank, it is called human milk feeding.


Whether the parents choose breastfeeding, human milk feeding, or formula feeding, nurses provide support and ongoing education. Parent education and care management are necessarily based on current research findings and standards of practice. Nurses and lactation consultants (who are most often nurses) provide education, assistance, and support for mothers, infants, and families. After hospital discharge nurses and lactation consultants in primary care and community health settings provide ongoing support and assistance to promote optimal feeding practices and positive health outcomes.


This chapter focuses on meeting nutritional needs for normal growth and development from birth to 6 months, with emphasis on the neonatal period when feeding practices and patterns are established. Breastfeeding and formula feeding are addressed. Information on breastfeeding is focused on the direct transfer of milk from mother to infant.



Recommended Infant Nutrition


The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first 6 months of life and that breastfeeding be continued as complementary foods are introduced. Breastfeeding should continue for 1 year and thereafter as desired by the mother and her infant (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 and UNICEF, 2003).


Exclusive breastfeeding for the first 6 months of life is also recommended by other professional health care organizations such as the American Academy of Family Physicians (AAFP, 2012), Academy of Breastfeeding Medicine (ABM Board of Directors, 2008), the American College of Obstetricians and Gynecologists (ACOG Committee on Health Care for Underserved Women and Committee on Obstetric Practice, 2007), and the American Dietetic Association (ADA, 2009). The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN, 2007) actively supports breastfeeding as the ideal form of infant nutrition and provides guidelines for nurses in promoting breastfeeding and supporting breastfeeding families.



Breastfeeding Rates


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. The 6-month breastfeeding rate was 47.2%, and the 12-month rate was 25.5%. The rate of exclusive breastfeeding at 3 months was 36% and at 6 months, 16.3%. In spite of the increases in breastfeeding rates, the United States continues to fall short of the Healthy People 2020 goals of 81% of infants ever breastfed, 60.6% breastfeeding at 6 months, and 34.1% at 12 months; goals for exclusive breastfeeding are 46.2% through 3 months and 25.5% through 6 months (USDHHS, 2010).


Trends remain unchanged in breastfeeding rates among minority groups in the United States. The lowest breastfeeding rates are among non-Hispanic black women (Jensen, 2012), although the overall percentage of non-Hispanic black women who breastfeed 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


Extensive evidence exists concerning the health benefits of breastfeeding and human milk for infants, with some of the benefits extending into adulthood (Table 24-1). These benefits are optimized when infants are breastfed exclusively and when the duration of breastfeeding is increased (Mass, 2011). The evidence supporting breastfeeding as the ideal form of infant nutrition is so strong that health care professionals may need to present information about it from two perspectives: benefits of and risks of not breastfeeding (Spatz and Lessen, 2011).



TABLE 24-1


BENEFITS OF BREASTFEEDING




image


SIDS, Sudden infant death syndrome.


Data from American Academy of Pediatrics Section on Breastfeeding: Breastfeeding and the use of human milk—policy statement, Pediatrics 129(3):e827-e841, 2012; Stuebe A: The risks of not breastfeeding for mothers and infants, Rev Obstet Gynecol 2(4):222-231, 2009; Ip S, Chung M, Raman G, et al: A summary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries, Breastfeed Med 4(suppl 1):S17-S30, 2009.


Breastfeeding is associated with health benefits for mothers (see Table 24-1). The benefits are increased with the number of children who were breastfed and the total length of time of lactation.


The psychologic benefits for mothers include enhanced bonding and attachment. For many women breastfeeding is associated with a sense of empowerment in the ability to provide nutrition for the infant.


Breastfeeding is convenient. The milk is ready to feed and at the proper temperature. In most cases there is no need for bottles or other equipment.


The economic benefits of breastfeeding affect families, employers, insurers, and the entire nation. Because infant formula is expensive, breastfeeding represents a significant savings for families. It reduces health care costs and decreases employee absenteeism. It has been estimated that the United States could save $13 billion dollars per year and more than 900 infant deaths could be prevented if 90% of infants were breastfed exclusively for 6 months (Bartick and Reinhold, 2010).


Breastfeeding has environmental benefits. It reduces the waste that is deposited in landfills, including formula packaging, bottles, nipples, and other equipment. There is no need for fuel to prepare or transport human milk, which saves energy resources (USDHHS, 2011).



Choosing an Infant Feeding Method


For most women there is a clear choice to either breastfeed or formula feed. In some cases women decide to combine breastfeeding and formula feeding. However, this practice may be associated with a shorter duration of breastfeeding (Holmes, Auinger, and Howard, 2011). In some instances women want their infants to receive breast milk but prefer not to feed directly from their breasts.



Choosing to Breastfeed


Women most often choose to breastfeed because they are aware of the benefits to the infant (Nelson, 2012). This reinforces the importance of prenatal education about the numerous benefits of breastfeeding.


Breastfeeding is a natural extension of pregnancy and childbirth; it is much more than simply a means of supplying nutrition for infants. 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.


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 breastfeed. Women are more likely to breastfeed successfully when partners and family members are positive about breastfeeding and have the skills to support it.


Cultural factors influence infant feeding decisions. For example, in the Hispanic culture breastfeeding is the norm, whereas formula feeding is more common among African-American families (see Cultural Competence box).



image Cultural Competence


Breastfeeding Among African-American Women


African-American women are least likely to breastfeed than other ethnic groups in the United States. Multiple factors are involved in this phenomenon. There may be a lack of knowledge or misinformation about benefits and management of breastfeeding. Support for breastfeeding may be lacking (Lewallen and Street, 2010). They may believe that formula is nutritionally superior to breastfeeding. African-American women tend to return to work earlier and are more likely to be employed in environments that are unsupportive of breastfeeding. Stereotypes about breastfeeding and the idea that breasts are primarily sexual objects can influence the decision to choose formula feeding over breastfeeding. Cultural traditions are an important factor (Philipp and Jean-Marie, 2007). Kuae Mattox, National President of Mocha Moms, Inc., an organization that supports African-American breastfeeding mothers, writes: “…African American women have a much steeper road to climb when it comes to breastfeeding, and some believe its roots go as far back as slavery, when our ancestors were ‘wet nurses’, forced to breastfeed the master’s children, often to the exclusion of their own. That created a negative breastfeeding cultural legacy that some believe still permeates our culture today” (Mattox, 2012, p. 2).


African-American women need information and support for breastfeeding. Many are surrounded by family and friends who advise them to formula feed (Nelson, 2012). A national, nonprofit organization called Mocha Moms, Inc. is reaching out to women in creative and unconventional ways. This group of stay-at-home mothers consists primarily of African- American professional women with college degrees who previously worked but have chosen to stay at home to be with their children. Mocha Moms offer support groups and provide information through Internet-based communications and peer-to-peer information sharing. Their website is www.mochamoms.org.



The decision to breastfeed exclusively is related to the mother’s knowledge about the health benefits to the infant and her comfort level with breastfeeding in social settings (Stuebe and Bonuck, 2011). The likelihood that women will breastfeed exclusively may be greater if they made the decision to do so during pregnancy (Tenfelde, Finnegan, and Hill, 2011).


There appears to be a relationship between maternal weight and infant feeding decisions. Women who are overweight or obese are less likely to breastfeed than women who are underweight or of average weight (Mehta, Siega-Riz, Herring, et al., 2011).


Other factors influence decisions about infant nutrition. Social and systemic factors create obstacles or barriers to breastfeeding among women in the United States. These include a lack of broad social support for breastfeeding and the widespread marketing by infant formula companies. In addition, there is a lack of prenatal breastfeeding education for expectant parents and insufficient training/education of health care professionals about breastfeeding. In some institutions the policies and practices do not support exclusive breastfeeding (Mass, 2011). There is a lack of support for breastfeeding mothers during the first 2 to 3 weeks after birth when they are most likely to encounter difficulties.


On a more personal level, a major obstacle for women is employment and the need to return to work after birth (Mass, 2011). A lack of support from the partner and family also creates obstacles to breastfeeding for many women. In a meta-synthesis of 14 qualitative studies about infant feeding decision making, Nelson (2012) reported common barriers to breastfeeding such as lack of comfort or uneasiness with breastfeeding, pain, lifestyle incompatibility, discomfort with public breastfeeding, and a lack of formal support.



Choosing to Formula Feed


Parents who choose to formula feed often make this decision without complete information and understanding of the benefits of breastfeeding. Even women who are educated about the advantages of breastfeeding may still decide to formula feed. Cultural beliefs and myths and misconceptions about breastfeeding influence women’s decision making. Many women see bottle-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 (Nelson, 2012).


Women who participate in the Supplemental Nutrition Program for Women, Infants, and Children (WIC) are more likely to formula feed (Jensen, 2012; Mass, 2011). Although in recent years WIC has improved food packages for breastfeeding families, many women on WIC decide to formula feed based on the perceived monetary value of infant formula as well as convenience and social factors (Jensen, 2012).



Contraindications to Breastfeeding


Breastfeeding is contraindicated in a few circumstances. Newborns who have galactosemia should not receive human milk. Breastfeeding is contraindicated for mothers who are positive for human T-cell lymphotropic virus types I or II and those with untreated brucellosis. Women should not breastfeed if they have active tuberculosis (TB) or if they have active herpes simplex lesions on the breasts. However, neither of these conditions precludes a mother expressing milk for her infant (AAP Section on Breastfeeding, 2012). Women with active TB can breastfeed when they have been treated for at least 2 weeks and are deemed noninfectious. Varicella that occurs 5 days before or 2 days after birth and acute H1N1 infection require temporary separation of mother and infant. In both instances it is safe for infants to receive expressed milk (AAP Section on Breastfeeding, 2012).


In the United States maternal human immunodeficiency virus (HIV) infection is considered a contraindication for breastfeeding (AAP Section on Breastfeeding, 2012). However, that is not true in other countries. In developing countries where HIV is prevalent, the benefits of breastfeeding for infants outweigh the risk of contracting HIV from infected mothers (WHO, UNICEF, UNFPA, and UNAIDS, 2010).


Breastfeeding is not recommended when mothers are receiving chemotherapy or radioactive isotopes (e.g., with diagnostic procedures). Maternal use of mood-altering drugs (“street drugs”) is incompatible with breastfeeding (AAP Section on Breastfeeding, 2012). Other maternal medications may also be incompatible with and require temporary or permanent cessation of breastfeeding.



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 are found within the United States. Dealing effectively with these groups requires that nurses be knowledgeable and sensitive to the cultural factors influencing infant feeding practices.


In general people 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 formula feeding is the custom. Hispanic women who are more acculturated may be less likely to breastfeed and, if they do, tend to breastfeed for a shorter duration (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. 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. 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 clear out meconium. Other cultures begin breastfeeding immediately and offer the breast each time the infant cries.


A common practice among Mexican women is las dos cosas (“both things”). This refers to combining breastfeeding and commercial infant formula. It is based on the belief that, by combining the two methods, the mother and infant receive the benefits of breastfeeding, and the infant receives the additional vitamins from infant formula (Bartick and Reyes, 2012; Rios, 2009). This practice can result in problems with milk supply and babies refusing to latch on to the breast, which can lead to early termination of breastfeeding.


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


Fluids


During the first 2 days of life the fluid requirement for healthy infants (more than 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; from day 8 to day 30 it is 120 to 180 mL/kg/day (Dell, 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 can decrease caloric consumption at a time when they are growing rapidly.


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



Energy


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 an average of 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, although the composition differs among brands.



Carbohydrates


According to the Institute of Medicine (IOM, 2005), the recommended adequate intake (AI) for carbohydrates 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 carbohydrate 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 gastrointestinal (GI) illness.



Fat


Fats provide a major energy source for infants, supplying as much as 50% of the calories in breast milk and formula. The recommended AI of fat for infants younger than 6 months is 31 g/day (IOM, 2005). 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 and 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 add DHA to their products, although there is a lack of evidence supporting the benefit (Lawrence and Lawrence, 2011b). 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) can be excessive because the milk moves through the infant’s intestines too quickly for adequate absorption to take place. This can lead to poor weight gain.



Protein


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 recommended AI for protein is 9.1 g/day (IOM, 2005).


Human milk contains the two proteins whey and casein in a ratio of approximately 70 : 30 compared with the ratio of 20 : 80 in most cow’s milk–based formula (Blackburn, 2013). This whey/casein ratio in human milk makes it more easily digestible and produces the soft stools seen in breastfed infants. The primary whey protein in human milk is α-lactalbumin; this protein is high in essential amino acids needed for growth. 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 GI tract (Lawrence and Lawrence, 2011a). 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.



Vitamins


With the exception of vitamin D, 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 vitamins A and 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 resorption 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, and AAP Section on Breastfeeding and 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 depends 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 for vitamin B12 deficiency. Breastfed infants of vegan mothers should be supplemented with vitamin B12 from birth.



Minerals


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/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.


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 for the first 4 months. After 4 months of age, infants who are exclusively breastfed are at risk for iron deficiency. The AAP recommends giving exclusively breastfed infants an iron supplement (1 mg/kg/day) beginning at 4 months and continuing until the infant is consuming iron-containing complementary foods such as iron-fortified cereals. Infants who are partially breastfed should receive the same iron supplement if more than half of their daily feedings consists of human milk and they are not consuming iron-rich foods (Baker, Greer, and the AAP Committee on Nutrition, 2010). Formula-feeding infants should receive an iron-fortified commercial infant formula until 12 months of age. Infants younger than 1 year should never be fed whole milk (Baker, Greer, and the AAP Committee on Nutrition, 2010).


Fluoride levels in human milk and commercial formulas are low. This mineral, which is important in preventing dental caries, can 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).



Breastfeeding


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. 24-1). 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 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. However, 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, et al., 2005) (Fig. 24-2).




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 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 they are still able to produce some breast milk, although the quantity is not likely to be sufficient to meet the nutritional needs of the infant. These mothers can 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.


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 areolae darken. Nipples and areolae enlarge. Around week 16 of gestation the alveoli begin producing prepartum milk or colostrum. Montgomery glands on the areola enlarge. The oily substance secreted by these sebaceous glands helps provide protection against the mechanical stress of sucking and invasion by pathogens. The odor of the secretions can be a means of communication with the infant.



Lactogenesis


After the mother gives birth a precipitous fall in progesterone 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 (Fig. 24-3, A). Milk production is a supply-meets-demand system (i.e., as milk is removed from the breast, more is produced). Incomplete removal of milk from the breasts can lead to decreased milk supply. Oxytocin is 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 (see Fig. 24-3, B). The myoepithelial cells surrounding the alveoli respond to oxytocin by contracting and sending the milk forward through the ducts to the nipple. The MER is triggered multiple times during a feeding session. Thoughts, sights, sounds, or odors that the mother associates with her baby (or other babies) such as hearing the baby cry can 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 MER also can 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 can be triggered during labor, as evidenced by leakage of colostrum. This reflex readies the breasts 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. Uterine contractions that occur with breastfeeding are often painful during and after feeding for the first 3 to 5 days. These “afterpains” are more common in multiparas and tend to resolve completely within 1 week after birth.


Prolactin and oxytocin have been called the mothering hormones because they affect the postpartum woman’s emotions and 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 aids 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 likely need assistance with effective latch. Their 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 growing infant. Breast milk is specific to the needs of each infant; 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 protozoal infections. The major immunoglobulin (Ig) in human milk is secretory IgA; 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 and Lawrence, 2011a).


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 prepartum milk or colostrum. Stage II of lactogenesis begins with birth as progesterone levels drop sharply when the placenta is removed. For the first 2 to 3 days after birth, the baby receives colostrum, a clear, yellowish fluid that is rich in antibodies and higher in protein but lower in 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 is important in the establishment of normal Lactobacillus bifidus flora in the infant’s digestive tract. It gradually changes to transitional milk. By 3 to 5 days after birth the woman experiences a noticeable increase in milk production. This is often referred to as the milk coming in. Breast milk continues to change in composition for approximately 10 days, when the mature milk is established. This is stage III of lactogenesis (Lawrence and Lawrence, 2011a).


The composition of human milk changes over time as the infant grows and develops. Fat is the most variable component of human milk with changes in concentration over a feeding, over a 24-hour period, and across time. Variations in fat content exist between breasts and among individuals (Lawrence and Lawrence, 2011a). During each feeding the concentration of fat gradually increases from the lower fat foremilk to the richer hindmilk. The hindmilk 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. Infants 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, after which the infants resume their usual feeding pattern as the mother’s milk supply increases.



Care Management




Supporting Breastfeeding Mothers and Infants


The key to encouraging mothers to breastfeed is education and anticipatory guidance, beginning as early as possible during and even before pregnancy. Each encounter with an expectant mother is an opportunity to educate, dispel myths, clarify misinformation, and address concerns. Prenatal education and preparation for breastfeeding influence feeding decisions, breastfeeding success, and the amount of time that women breastfeed. Prenatal preparation ideally includes the father of the baby, partner, or another significant support person and provides 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 such as La Leche League or Mocha Moms provide information about breastfeeding along with opportunities for breastfeeding mothers to interact with one another and share concerns (Fig. 24-4). Peer counseling programs such as those instituted by WIC 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 formula feed can benefit from information about the benefits of breastfeeding. Offering these women the chance to try breastfeeding with the assistance of a nurse or lactation consultant can 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. The first 2 weeks of breastfeeding can be the most challenging as mothers are adjusting to life with a newborn, the baby is learning to latch on and feed effectively, and the mother may be experiencing nipple or breast discomfort. This is a time when support is critical. Primiparous women are most likely to experience early breastfeeding problems, which often result in less exclusive breastfeeding and shorter duration of breastfeeding (Chantry, 2011). Anticipatory guidance during the prenatal period and especially during the hospital stay after birth can provide the mother with information and increase her confidence in her ability to successfully breastfeed her infant. New mothers need access to lactation support following discharge through primary care offices or outpatient lactation services. Peer support is also helpful.


The most common reasons for breastfeeding cessation are insufficient milk supply, painful nipples, and problems getting the infant to feed (Lauwers and Swisher, 2011; Lawrence and Lawrence, 2011a). 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. Many health care agencies have certified lactation consultants on staff. These health care professionals, who are usually nurses, have specialized training and experience in helping breastfeeding mothers and infants.


The U.S. Breastfeeding Committee (USBC, 2010a) has identified key competencies for health care professionals related to breastfeeding care and services. The competencies include knowledge, skills, and attitudes to promote and support breastfeeding. The USBC identifies specific competencies for those who provide more “hands-on” care (e.g., nurses and lactation consultants). The competencies are: “assist in early initiation of breastfeeding, assess the lactating breast, perform an infant feeding observation, recognize normal and abnormal infant feeding patterns, and develop and appropriately communicate a breastfeeding care plan” (USBC, 2010a, p. 5).


All parents are entitled to a birthing environment in which breastfeeding is promoted and supported. The Baby-Friendly Hospital Initiative (BFHI), sponsored by the WHO and UNICEF, was founded in 1991 to encourage institutions to offer optimal levels of care for lactating mothers. When a hospital achieves the “Ten Steps to Successful Breastfeeding for Hospitals,” it is recognized as a Baby-Friendly hospital (Box 24-1) (BFHI USA, 2010). In 2009 only 6.2% of live births in the United States occurred at Baby-Friendly facilities (CDC, 2012). More than 19,000 facilities worldwide have achieved Baby-Friendly status. As of May 2012 143 health care facilities in the United States were designated as Baby-Friendly (BFHI USA, 2012), although many hospitals and birthing facilities are working toward reaching that goal. Women are more likely to achieve their goals for exclusive breastfeeding if they give birth in facilities where all or most of the ten steps are in place (Declercq, Labbok, Sakala, et al., 2009; Perrine, Scanlon, Li, et al., 2012).



The Joint Commission (TJC) issued a set of Perinatal Core Measures that includes exclusive breast milk feeding. In implementing the core measures, hospitals strive to improve their adherence to evidence-based best practices that can result in increased rates of exclusive breastfeeding (TJC, 2012; USBC, 2010b).


Care management of the breastfeeding mother and infant requires that nurses and other health care professionals be knowledgeable about the benefits and basic anatomic and physiologic aspects of breastfeeding. They also need to know how to help the mother with feedings and discuss interventions for common problems. Ongoing support of the mother enhances her self-confidence and promotes a satisfying and successful breastfeeding experience. Mothers should be encouraged to ask for help with breastfeeding, especially while they are in the hospital. Primiparas are likely to need the most assistance and in many facilities are routinely seen by lactation consultants. The mother needs to understand infant behaviors in relation to breastfeeding and recognize signs that the baby is ready to feed. Infants exhibit feeding-readiness cues or early signs of hunger. Instead of waiting to feed until the infant is crying in a distraught manner or withdrawing into sleep, the mother should attempt to breastfeed when the baby exhibits feeding cues (see Evidence-Based Practice box):




Evidence-Based Practice


Maternal Feeding Styles and Childhood Obesity






Critically Analyze the Evidence




• Childhood obesity can have its roots in the feeding patterns established in infancy. This research field for primary prevention of obesity is new, and many infant feeding studies are currently in the pipeline.


• Overfeeding can impair the infant’s ability to self-regulate. Infants whose caregivers are responsive to an infant’s hunger and satiety (full) cues are significantly less likely to be overweight (DiSantis, Hodges, Johnson, et al., 2011).


• Discordant responsiveness occurs when the caregiver perceives that the infant cannot recognize hunger or satiety. Restrictive feeding style is associated with maternal fear of causing obesity. Pressuring feeding style is associated with caregiver concern that the infant has poor appetite and will be underweight (Gross, Mendelsohn, Fierman, et al., 2011).


• In a Latina population a pressuring feeding style emerges as a result of belief that all infant crying or hand sucking is caused by hunger and that babies should always finish their bottles. Pressuring style is more likely in foreign-born women and women with less than a high-school education (Gross, Fierman, Mendelsohn, et al., 2010).


• Low-income, food-insecure mothers are more likely to be discordant, either restrictive or pressuring, than food-secure mothers (Gross, Mendelsohn, Fierman, et al., 2012).



Apply the Evidence: Nursing Implications




• Parental education about infant hunger and satiety cues ideally should begin in antenatal education classes and be reinforced intensively during the postpartum period. The nurse should point out the infant cues and praise the parents for appropriate responsiveness.


• Videos and printed material and warm lines should be made available to new parents. Specific suggestions about how much formula to feed initially and how voiding and stool patterns and weight gain reflect adequate nutrition can provide education guidelines.


• Assessing for familial and cultural beliefs enables the nurse to address parental and extended family concerns. The nurse can address how the new mother might respond to well-meaning but incorrect comments from family and strangers.


• Education regarding the various newborn cries and their possible causes can reassure parents and their extended families that feeding should not be the first and only option.


• Breastfeeding is the gold standard for infant feeding because it is more difficult to overfeed.


• Nurses can advocate on a local and national level to eliminate food insecurity.



Quality and Safety Competencies: Evidence-Based Practice*







*Adapted from QSEN at www.qsen.org/.


Babies normally consume small amounts of milk with feedings 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.


In the postpartum period interventions focus on helping the mother and the newborn initiate successful breastfeeding. An important goal is to build maternal confidence in breastfeeding. Interventions to promote successful breastfeeding include educating and assisting mothers and their partners with basics such as latch and positioning, signs of adequate feeding, and self-care measures such as prevention of engorgement. It is important to provide the parents with a list of resources that they can contact after discharge from the hospital.


The ideal time to begin breastfeeding is within the first hour after birth (BFHI, 2010). Newborns without complications should be allowed to remain in direct skin-to-skin contact with the mother until the baby is able to breastfeed for the first time (AAP Section on Breastfeeding, 2012). This is true both for mothers who gave birth by cesarean and for those who gave birth vaginally. Early skin-to-skin contact is associated with higher rates of exclusive breastfeeding while in the hospital (Bramson, Lee, Moore, et al., 2010) and increased duration of breastfeeding (Moore, Anderson, Bergman, et al., 2012).


Routine procedures such as vitamin K injection, eye prophylaxis, weighing, and bathing should be delayed until the neonate has completed the first feeding (AAP Section on Breastfeeding, 2012).



Positioning


For the initial feedings it can be advantageous to encourage and assist the mother to breastfeed in a semireclining position with the newborn lying prone, skin-to-skin on the mother’s bare chest. Her body supports the baby. The mother is more relaxed, nipple pain is reduced or eliminated, and the mother has more freedom of movement to use her hands. The baby is able to use inborn reflexes to latch onto the breast and feed effectively. This approach to breastfeeding is based on the concept of “biological nurturing” (Colson, 2010, 2012).


The four traditional positions for breastfeeding are the football or clutch hold (under the arm), modified cradle or across-the-lap, cradle, and side-lying (Fig. 24-5). The mother should be encouraged to use the position that most easily facilitates latch while allowing maximal comfort. The football or clutch hold is often recommended for early feedings because the mother can see the baby’s mouth easily as she guides the infant onto the nipple.




Mothers who gave birth by cesarean often prefer the football or clutch hold. The modified cradle or across-the-lap hold works well for early feedings, especially with smaller babies. The side-lying position allows the mother to rest while breastfeeding. Women with perineal pain and swelling often prefer this position. Cradling is the most common breastfeeding position for infants who have learned to latch easily and feed effectively. Before discharge from the birth institution the nurse can help the mother try all of the positions so she will be confident in trying these positions at home.


During breastfeeding the mother should be as comfortable as possible. After arranging for privacy, the nurse might suggest that she empty her bladder and attend to other needs before starting a feeding session. The nurse who is assisting with breastfeeding should be at the mother’s eye level. The mother holds the infant securely at the level of the breast, supported by firm pillows or folded blankets, facing toward her. The baby’s mouth is directly in front of the nipple. The mother should support the baby’s neck and shoulders with her hand and not push on the occiput. The baby’s body is held in alignment (ears, shoulders, and hips are in a straight line) during latch and feeding.

Sep 16, 2016 | Posted by in NURSING | Comments Off on Newborn Nutrition and Feeding
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