CHAPTER 17 NEWBORN NUTRITION

NEWBORN CUES

- However, if the newborn does not demonstrate signs of hunger, she should still offer the breast every 21/2 hours until breastfeeding has been established and she is more aware of her infant's cues. -Newborns indicate hunger by rooting, making hand-to-mouth movements, and making mouth and tongue movements while in an awake/ alert state

NIPPLE CONFUSION

- If the mother wants to avoid nipple confusion and be able to leave the baby with a bottle, she should first establish breastfeeding for at least 2 to 3 weeks before introducing a bottle.

ENGORGEMENT

-*Engorgement* can happen when the body is adjusting to the amount of milk to make. It can also occur the first time the baby sleeps through the night. The breasts may feel heavy and swollen, with a flat nipple. • Breastfeed every 21/2 hours when the baby is awake. • Soften the breasts with a warm cloth or in the shower and express enough milk by hand to soften the breast to allow correct latch-on by the infant. • Latch-on the infant correctly and the feeding will take care of the engorgement.

PROLACTIN

-After childbirth and the delivery of the placenta, estrogen and progesterone levels drop quickly. -Nipple stimulation occurs from latching-on the infant to the breast, which stimulates the pituitary gland to trigger a rise in the hormone prolactin. -*Prolactin* causes the alveoli to take proteins, sugars, and fat from the blood supply and make breast milk -The first substance produced by the breasts is colostrum. It is produced in very small amounts during the second and third trimesters.

COLOSTRUM IMUNOGLOBULIN

-Colostrum is the perfect first food for the newborn. It is easy to digest and highly concentrated with carbohydrates and fat. -It also contains secretory *immunoglobulin* A (IgA), which is a new substance to the newborn. -IgA is a protein that functions as an antibody to protect the baby from infections in the mucous membranes in the throat, lungs, and intestines. -Leukocytes are also present in colostrum, which protects the newborn from infections. -Colostrum also has a laxative effect, which aids in the passage of the first meconium stool after birth

FLAT OR INVERTED NIPPLES

-Flat or *inverted nipples* may make it difficult to latch-on the baby. Flat nipples do not stand out from the areola and inverted nipples tend to retract or pull inward. Women with these types of nipples may require more assistance with breastfeeding. • Breast pumping may be used to pull out the nipple. • Before delivery, the lactation specialist may recommend that the pregnant woman wear a special device called a breast shield or a supple cup to encourage the nipple to protrude from the breast.

LET-DOWN REFLEX

-Frequent breastfeeding at least 8 to 12 times a day stimulates the pituitary to increase levels of prolactin, which causes an increase in the volume of breast milk. -Mature milk is produced around the 3rd and 4th postpartum day. -For the baby to receive the milk from the breast, the let-down reflex must occur. -The baby sucking the nipple stimulates the pituitary gland to release prolactin to produce the milk and oxytocin, another hormone, to release the milk. -Oxytocin causes the cells around the alveoli to squeeze the glands to push the milk into the ductules and into the ducts

LACTOGENESIS

-MILK PRODUCTION -The basic unit of the mammary gland is the alveolus that connects to a ductule. -Each ductule drains to a duct, which then empties into the lactiferous sinuses. -Milk is stored in the lactiferous sinus. -At the end of each ductule is a cluster of small, grapelike sacs called alveoli. -A cluster of alveoli is called a lobule; a cluster of lobules is called a lobe. -Each breast contains between 15 and 20 lobes, with one milk duct for every lobe. -The 15 to 20 milk ducts merge, with eight or nine ending at the tip of the nipple to deliver milk to the baby

TYPES OF FORMULA

-Most infant formulas have 20 calories in each ounce. -Prepared formula should be in a covered container in the refrigerator, and unused formula should be thrown out after 24 hours. -Hypoallergenic formula should be given if an allergy to milk-based formula is suspected. -Soy-based formula should be given to infants who cannot take dairy-based products for health, cultural, religious, or personal reasons, such as a vegan lifestyle • Ready-to-feed formula is available in a can or carton and should not be diluted. • Liquid concentrated formula is formulated to be diluted with equal amounts of water. • Powder formula should be dissolved in water.

RECOMMENDED INFANT NUTRITION

-The American Academy of Pediatrics (2012) recommends exclusive breastfeeding for the first 6 months of age, with the addition of solid foods along with breastfeeding for another 6 months. -The World Health Organization (2015) recommends exclusive breastfeeding for 6 months, and then the addition of appropriate food along with breastfeeding for 2 years or more.

THE FORMULA-FEEDING PARENTS AND INFANT

-The American Academy of Pediatrics (2012) states that cow's milk is not suitable for infants under 1 year of age. -It is not appropriate for infants because it contains a higher level of protein than the infant requires; the fat is difficult for the infant to digest; it is a poor source of iron; it contains only a small amount of vitamins C, E, and copper; and the sodium level is too high for an infant.

DRUG FACTS

Most drugs pass from the mother through the breast milk to the baby. If the mother requires medication while breastfeeding, the health-care provider should check for risks to the baby before prescribing the medication and fully inform the mother of the risk

PATIENT TEACHING GUIDELINES

As the new breastfeeding mother's milk flow increases, the contraction of the milk-filled alveoli may create a tingling, stinging, burning, or prickling sensation in her breasts. The milk may drip or even spray during letdown. Sometimes, just the sound of any baby crying will cause milk let-down. If this happens at an inconvenient time, she can try crossing her arms in front of her breasts and apply gentle pressure to stop the flow

POSITIONING

First, the mother should wash her hands to avoid transferring bacteria to her breast. -Next, she should be in a comfortable sitting position or side-lying in bed. -Pillows should be placed around the mother to support the baby and prevent the mother from hunching her back -The infant should be placed in the mother's arm with his or her stomach flat against the mother's abdomen -Another position is the football hold, in which the infant is cradled in the mother's arm with the infant's head in her palm and the toward the mother's elbow. -This position puts less stress on the abdomen if the mother is recuperating from a Cesarean birth.

SAFETY STAT!

If the parents are concerned about the safety of tap water, the water should be sterilized before making formula. Water can also be checked for lead, nitrates, and bacteria. The steps to sterilize the water are: • Let the cold water run until it is a cold as it gets. It may take 2 min. This process reduces the amount of lead and other contaminants in the water. • Bring the cold water to a boil and let it boil for 1-2 min. • Let the water cool before preparing the bottles Well water in rural agricultural areas can be contaminated with nitrates, which can be dangerous for babies under 6 months of age. The nitrates can cause a problem with the infant's blood oxygen level. Families relying on well water should be cautioned to have the water evaluated for safety before using it for formula preparation.

WARMING A BOTTLE

Never warm a bottle of formula or breast milk in the microwave. Microwaves heat unevenly and a baby could be burned. PROPPING A BOTTLE Bottle-fed babies should never have the bottle propped for feedings. There are two major problems with this practice. First, the baby could choke and aspirate without adult observation. Second, the baby who falls asleep with a propped bottle has residual milk left in the mouth that pools around the teeth. The milk sugar can cause breakdown of the teeth and cause nursing-bottle syndrome.

VIT D

The American Academy of Pediatrics (2012) recommends vitamin D supplementation (400 IU/d) starting after delivery. There is widespread vitamin D deficiency in the United States, and breastfeeding mothers deficient in vitamin D are unable to pass vitamin D in the breast milk to the infant.

ACHIEVING LATCH-ON

The mother should position her hand around the breast, cupping it with her fingers close to the chest wall. -Her hands are usually in a "C" position as she supports her breast: The thumb is on top and her fingers are underneath the breast. -She should avoid covering the *areola*, the dark area around the nipple. -This part of the breast goes into the infant's mouth. -After positioning her hand, the mother should lightly brush her nipple across the lips of her infant to elicit the rooting reflex. -The infant will instinctively open his or her mouth and extend the tongue. -The mother should bring her baby to her breast and maneuver the nipple and areola into the infant's mouth

INVERTED OR FLAT NIPPLES

Women who are screened for flat or inverted nipples early in the pregnancy can benefit from consulting a lactation specialist regarding options for preparing the nipples for breast- feeding. Women with flat or inverted nipples can breastfeed, but it does cause some degree of difficulty. The La Leche League recommends early detection and using nipple shields, breast pumps, and techniques to encourage the nipple to protrude more from the breast to aid in latch-on.

COMPONENTS OF BREAST MILK

• *Proteins*: The balance of the proteins, approximately 60% whey and 40% casein, allows the infant to digest breast milk easily. Other specific proteins in breast milk are: • *Lactoferrin*, which has bactericidal and iron-binding properties • Secretory IgA, which protects the infant from viruses and bacteria • Lysozyme, an enzyme that promotes the growth of healthy intestinal flora and has anti-inflammatory functions • *Bifidus factor*= supports the growth of lactobacillus, which creates an acidic environment in the intestines

NUTRITIONAL NEEDS OF AN INFANT

• 105 to 108 kcal/kg/day (Term infant) • 110 to 120 kcal/kg/day (Preterm infant) -The estimated fluid requirements for a newborn are: • 140 to 160 mL/kg/day (Term infant) • 60 to 80 mL/kg/day (Preterm infant) -Infant stomach capacity is the following: • Day 1: 5 to 7 mL • Day 3: 22 to 27 mL • Day 10: 45 to 60 mL

CONTRAINDICATIONS FOR BREASTFEEDING

• An infant diagnosed with *galactosemia*, a rare genetic metabolic disorder that makes it difficult for the infant to metabolize milk sugar; breastfeeding an infant with galactosemia can damage the liver, kidneys, and brain • The infant whose mother: • Has been infected with HIV • Is taking antiretroviral medications • Has untreated, active tuberculosis • Is infected with human T-cell lymphotropic virus type I or type II, which is the virus that causes some leukemias and lymphomas • Is using or is dependent upon an illicit drug • Is taking prescribed cancer chemotherapy agents, such as antimetabolites that interfere with DNA replication and cell division • Is undergoing radiation therapies; however, such nuclear medicine therapies require only a temporary interruption in breastfeeding

BOTTLE FEEDING THE INFANT

• Before purchasing, check the expiration date on the formula container. • After purchasing, sterilize the bottles and nipples. After initial sterilization, bottles do not need to be sterilized unless the family water supply is not safe. Washing bottle • Make sure to follow the package directions to dilute the formula or to mix the bottles correctly. • If the water supply is not proven to be safe, the water for mixing the formula should be boiled first. • Wash the formula container with soap and water before opening it. • Some babies will drink a bottle straight from the refrigerator. Others prefer a bottle warmed in a bowl of warm water. Parents should always check the temperature of warmed formula to avoid burning the infant. • Make sure the nipple is not too large to cause gagging or too small to cause frustration for the infant.

ADVANTAGES OF BREASTFEEDING

• Breast milk provides the exact nutrients required for an infant's growth and development. • Breast milk provides immunological protection. A mother will pass on some of her immunities to the baby. • Breast milk is convenient and economical for the mother. She does not need to prepare bottles. It is always ready and available for the infant. • Breastfeeding promotes close physical contact between a mother and child to enhance bonding and attachment

LOW MILK SUPPLY

• Breastfeed more often and allow the baby to decide when to end the feeding. Feeding the baby in this method is sometimes called "cluster feeding." The baby is allowed and encouraged to breastfed as often and as long as he or she wants. This method of feeding will increase milk supply for the growing baby. • Offer both breasts at each feeding. Have the baby stay on the first breast as long as he or she is still suckling and swallowing. Offer the second breast when the baby slows down

DISADVANTAGES OF FORMULA

• Formula costs can be expensive for parents on a budget. • Bottles, nipples, and formula must be purchased. • Bottles and formula must be carried along with the infant

WARNING SIGNS OF BOTTLE FEEDING PROBLEMS

• Infant cereal fed through a bottle • Water or fruit juice given before 6 months of age • Overdiluting the formula to reduce expense • Formula mixed with private well water that has not been tested for safety • Allowing a baby to sleep with a bottle in the crib

ADVANTAGES OF FORMULA

• It may be the appropriate choice for a mother with a chronic illness who requires medications harmful to the infant. • It provides adequate and acceptable nutrition for the infant. • Anyone can feed the infant. • It may be more comfortable for the mother to feed in public. • The mother does not need to worry that her food or alcohol intake may affect the baby. • It may be easier to leave the infant with a sitter or family member to give the parents a break.

WARNING SIGNS OF BREASTFEEDING PROBLEMS

• Losing more than 7% of birth weight • Not gaining back birth weight by 10 days of age • Not having at least two to three bowel movements per day after day 2 • Not having four or five wet diapers per day by day 4 with clear or pale yellow urine, which indicates adequate hydration of the newborn

SORE NIPPLES

• Make sure the infant has correct latch-on every time the baby is placed on the breast. • Try changing positions from sitting to side-lying or football hold to move the infant's mouth to a different position on the breast. • Change nursing pads often to avoid trapping moisture on the nipple areas. • Expose the nipple to air to promote healing. • Avoid harsh soaps on the breast. • Apply modified anhydrous lanolin after nursing to keep the skin soft. • Gentle massaging of colostrum or breast milk into the nipple can soothe an irritated nipple.

CHECKPOINTS FOR CORRECT LATCH-ON

• Observe the position of the mother. Is she comfortable, with pillows in appropriate locations? Reposition if needed. • Observe the position of the baby. Is he or she lying "tummy to tummy" with the mother? If not, reposition. • Observe the position of the baby on the areola. Usually the lips need to be 1 to 2 in. beyond the base of the nipple. • Observe the infant's lower lip. It should not be folded in. • Observe the motion of the masseter muscle and listen for sounds of swallowing. A clicking sound indicates improper positioning. Observe the comfort level of the mother. If she is experiencing any nipple pain, she should take the infant off the breast and latch-on again.

STAGES OF HUMAN MILK

• Stage 1: Colostrum • Yellowish fluid that is present for 2 to 3 days • Contains high levels of protein, and lower levels of carbohydrates, fats, and calories than mature milk • High in immunoglobulins G and A, which protect the infant from infections • Has a laxative effect to promote passage of the meconium stool • Stage 2: Transitional Milk • This stage is from day 3 to day 10. • Contains increasing levels of carbohydrates and fat with decreasing levels of protein • Stage 3: Mature Milk • Fore milk is the milk produced and stored between feedings. It has higher water content than hind milk. • Hind milk is produced after several minutes of feeding and has a higher fat content and contributes to the feeling of fullness and satisfaction for the infant

DISADVANTAGES OF BREASTFEEDING

• The mother must be available for feeding or provide pumped milk if she is absent. • Feeding in public may cause embarrassment. • Certain medications can interrupt breastfeeding. • Early breastfeeding may be uncomfortable. • Leaking of breast milk may occur and require nursing pads to be worn in the bra.

SIGNS OF EFFECTIVE BREASTFEEDING

• The mother's breasts soften during and after a feeding. • The mother can hear the infant swallowing during the feeding. • The number of wet diapers increases to at least six to eight by the time the infant is 6 days old. • The infant has two to three yellow stools by the 5th day after birth.