On completion of this chapter, the reader will be able to: • Describe current recommendations for infant feeding. • Explain the nurse’s role in helping families choose an infant feeding method. • Discuss benefits of breastfeeding for infants, mothers, families, and society. • Describe nutritional needs of infants. • Describe anatomic and physiologic aspects of breastfeeding. • Recognize newborn feeding-readiness cues. • Explain maternal and infant indicators of effective breastfeeding. • Examine nursing interventions to facilitate and promote successful breastfeeding. • Analyze common problems associated with breastfeeding and interventions to help resolve them. • Compare powdered, concentrated, and ready-to-use forms of commercial infant formula. 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 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). 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 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. 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). 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. 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). 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). 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. 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. 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. 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). 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). 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. 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). • Hand-to-mouth or hand-to-hand movements • Rooting reflex—infant moves toward whatever touches the area around the mouth and attempts to suck 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. 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). 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).
Newborn Nutrition and Feeding
Recommended Infant Nutrition
Breastfeeding Rates
Benefits of Breastfeeding
BENEFITS FOR THE INFANT
BENEFITS FOR THE MOTHER
BENEFITS TO FAMILIES AND SOCIETY
Enhanced neurodevelopmental outcomes, especially in preterm infants
Choosing an Infant Feeding Method
Choosing to Breastfeed
Choosing to Formula Feed
Contraindications to Breastfeeding
Cultural Influences on Infant Feeding
Nutrient Needs
Fluids
Fat
Protein
Minerals
Breastfeeding
Anatomy of the Lactating Breast
Lactogenesis
Care Management
Supporting Breastfeeding Mothers and Infants
Positioning
You may also need
Full access? Get Clinical Tree
Newborn Nutrition and Feeding
Only gold members can continue reading. Log In or Register to continue
