lifespan ch. 6-9

What to Feed Preterm Infants

Breastmilk Human-milk fortifier Preterm infant formulas— Vary in caloric content MCT oil Whey protein

Preterm infant

CNS does not signal hunger unstable feeding position oral hypersensitivity

Prevention of Baby Bottle Caries and Ear Infections

Feeding techniques to reduce caries and ear infections Limit use of bedtime bottle Offer juice in cup Only give water bottles at bedtime Examine and clean emerging teeth

Fluid cow milk consumption can lead to:

GI bleeding Iron deficiency: competes with iron absorption in the intestines Displacement of nutrients High renal solute load Type 1 diabetes Higher risk of developing milk allergy

Physiological Differences: Vitamin D

Human milk only contains <25 IU/L The vitamin D content of human milk is related to the mother's vitamin D status, so mothers who supplement with high doses of vitamin D may have correspondingly higher levels in their milk

Oxytocin

letdown: ejection of milk from myoepithelial cells

Preterm infants fed by nutrition support: enteral

nutrients delivered directly to GI tract

Preterm infants fed by nutrition support: parenteral

nutrients delivered directly to the bloodstream

Linolenic:

omega 3 fatty acid

Linoleic acid:

omega 6 fatty acid

Secretory cells

responsible for secreting milk components into collecting ducts

Diarrhea:

result of viral and bacterial infections, food intolerance, or changes in fluid intake

Myoepithelial cells

surround secretory cells; contract and cause milk ejection

Constipation:

typically seen more in formula fed than in breast fed infants; assure infant is getting adequate fluids and avoid medications unless prescribed

Lactogenesis II

"when milk comes in" (2-5 days postpartum) Supply and demand based on supply and demand...extremely important to keep up demand either by having baby on breast if healthy enough or by using a breast pump

Protein Requirements

3.0-3.5 g/kg required for preterm or recovery from illness 4 g/kg may be needed for ELBW

Functional Units of Mammary Gland

Alveoli Secretory cells Myoepithelial cells

Exclusive Breastfeeding

An infant receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medications

Allowing for Infant Controls

Attentive to infant behavior - allows quantity to vary Holds bottle still at an appropriate angle Poises nipple over lips and allows baby to open up Problem solving - using trial and error Allows pauses - gives time to finish feeding Soothes fussiness - finds reasons for discomfort

Lactogenesis I

Begins during third trimester of pregnancy Can be disrupted by premature delivery, method of delivery, and other factors Suckling not needed

Anticipatory Guidance for Newborns

Expected volume of breast milk or formula: 150-200ml/kg/day 8-12 feedings over 24 hr period = every 2-3 hours If not breastfed, will need iron fortified formula Teaching: satiety cues, no solids, vitamin D supplementation, not all crying represents hunger

Milk Carbohydrates

Lactose: Easily digested Enhances calcium absorption Oligosaccharides: Low osmolality (easier on GI tract/do not cause diarrhea) Stimulate growth of bifidus bacteria

Physiological Differences: Protein

Larger percentage of essential amino acids Tryosine, cystine, and taurine essential for premature infants 2.2 g/kg/day from birth to 6 months 1.6 g/kg/day from 6 to 12 months

Moms benefits to breastfeeding

Lowers risk of Premenopausal breast cancer Ovarian cancer Type 2 diabetes Improves bonding Lowers healthcare costs convenient

Vitamins and Minerals preterm

May need additional vitamins and minerals to support "catch-up" growth or during recovering from illness Human-milk fortifiers provide additional calories and nutrients

Lactogenesis III

Milk established (10 days after birth) 3-6 cups/day

Nutritional Needs For Lactation

Most substances ingested are secreted into mother's milk Energy Milk production requires ~750 kcal/day RDA for energy is 500 kcal/day The 250 kcal difference will contribute to slow gradual weight loss for mom

Feeding Infants Cow Milk

Not recommended during the first year. No skim milk (low fat) first two years Other dairy products at 8 months Yogurt and cheese

Four Benefits of WIC

Nutritional Assessment Nutritious food Nutrition Education Health Care Referrals

Breastfeeding reduces baby's risk of:

Obesity Ear infections Respiratory infections GI infections Skin conditions Diabetes Leukemia SIDS

Foremilk

Resembles skim milk ~17% fat, ~74% CHO, ~9% protein Makes up 60% of volume

Rooting Reflex

Results in infant turning to the side (or towards the nipple) when stimulated on the side of the upper or lower lip

Initiation of solid food

Rice cereal - least likely to have allergic response One food at a time (allows to identify intolerances) Strained fruits Strained vegetables No salt, sugar added

What is Vitamin D important in preventing???

Rickets

Lipids

Second largest component of breast milk by concentration Provide half the energy of human milk Fatty acid profile of human milk reflects maternal diet

Infant hunger signs

Sucking on fingers Moving head from side to side with mouth open (rooting reflex) Late sign of hunger is crying Infants feed 10 to 12 times/day Should be allowed to feed until satisfied

Developmental Characteristics

Sucks well on nipple Extrusion reflex causes tongue to protrude when solid food or spoon is put in mouth Feeds every 2-4 hours during the day by age 2 months Finishes each feeding within 45 minutes by 4 months

Colic

Sudden onset of irritability, fussiness or crying Disappear at 3rd or 4th month Cause unknown but associated with GI upset, infant feeding practices

Introducing Solid Foods

Supplement - NOT replacement for breast milk or formula. Introduce when developmentally ready sit up with support, hold head steady, draw in lower lip infants reach age 4 to 6 months Timing risks to early and late introduction order of food groups

Vitamin Supplements for Breastfeeding Infants

Vitamin K injection given at birth 400 IU vitamin D per day in the first 2 months of life to prevent rickets

Who are breastfed at 6 months of age

Western states; about 75% breastfeeding initiation rates Southern states not so much Longer duration of breastfeeding is associated with higher SES status and higher education level Women receiving Food Stamps or WIC assistance less likely to breastfeed; young mothers and single mothers also less likely to breast feed African American and American Indian women less likely to breastfeed

Mother's Diet While breastfeeding

adequate fluid intake sufficient caloric intake - caloric intake of at least 2000 calories per day with an optimal intake of ~500 calories Other diet considerations while breastfeeding: spicy or gassy foods vegetarian diets coffee, tea, or sodas Alcohol consumption and breastfeeding smoking/tobacco use

Sensorimotor Stage of Development

chart

Fat Soluble Vitamins Vitamin D:

dependent upon maternal diet and sun exposure

Alveoli

developed during pregnancy bunch into 7-10 clusters or lobes

Food Allergies can lead to

diarrhea, vomiting, wheezing, anaphylactic shock, abdominal pain, gas, hives, skin rashes

Trans Fatty Acids:

do appear in breast milk if consumed in maternal diet

Food Allergies caused by common foods

eggs, milk, peanut, soy, wheat, fish, tree nuts, shellfish

Challenges in feeding VLBW or ELBW infants include:

fatigue low tolerance of volume "disorganized feeding"

Plugged Ducts Treatment

gentle massage, warm compress, and complete emptying of the breast Changing nursing positions to help facilitate emptying of the breast Oral lecithin

Metabolic rate, calories, fats and protein—how do they all tie together?

low carbohydrate and/or energy intake results in protein catabolism impacting growth

Casein and whey proteins:

major class of proteins in mature milk Helps facilitate calcium and iron absorption (respectively)

Term infant

signals hunger has supportive newborn feeding reflexes readily accepts food by mouth

Mastitis symtoms

similar to those of a plugged duct Important for the mother to continue nursing through mastitis If symptoms do not go away after 24 hrs, antibiotics should be started

Examples of whereWIC Services may be provided

County health departments Mobile clinics (vans) Community centers Schools Hospitals

Cleft Lip and Cleft Palate

Facial and oral malformations that occur early in pregnancy Affects 1 in 700 babies annually Disrupts infants ability to feed properly

Mastitis

Inflammation of the breast, can become infected

Physiological Differences: Vitamin K

Initial injection at birth Breast milk much lower than infant formula Don't need to supplement after injection

Physiological Differences: Lipids

Minimum 30g fat/day

Prolactin

alveolar development and milk secretion

Cholesterol:

essential component of all cell membranes Breastfed infants have higher intake Studies show early consumption through breast milk is related to LOWER levels later in life

Development of muscle control

is top down: head control is the start, and last comes lower legs Reaching stage when they can sit without support and grasp objects; important for nutrition

The let down reflex

look at chart

The let-down reflex

look at chart

Plugged Ducts cause

obstructed duct result from milk stasis (milk remaining in the ducts) Results in painful knot in one breast

Water Soluble Vitamins

vitamin B12 and folic acid

Proper Feeding

old while feeding - head should be higher than rest of body Never prop bottle Proper mixing, storage, dilution

Physiological Differences: Water

1.5ml/kcal/day Under ordinary conditions, breast milk and infant formula adequately provide for fluid requirements

Food Allergies

About 6-8% of children < 4 yrs have allergies Absorption of intact proteins causes allergic reactions

Physiological Differences for Digestion: Carbohydrates

Carbohydrates: disaccharidases reach adult levels by 28-32 weeks gestation Lactase at adult level upon birth Pancreatic amylase at low levels until approx. 6 months 30-60% of total energy No honey or corn syrup due to potential contamination with botulism spores

How often to breast feed?

Keep it simple/rely on hunger cues from baby Good foundation helps build long-term production Breastfeeding frequently (8-12 times every 24 hours/feed every 2-4 hours) Avoid infant formula supplements in early days

Physiological Differences: Renal Function

Kidney concentrating ability may be low for some infants 6 weeks, most have kidney function of adult May be a problem in situations with potential dehydration (diarrhea) or formula that is too concentrated

Intervention for FTT

May be complex and involve a team approach including the registered dietitian

4-6 months developmental landmarks

Tongue laterally transfers food in mouth Shows voluntary and independent movements of the tongue and lips Sitting posture that can be sustained Shows beginning movements of the jaw

DHA:

important essential fatty acid for brain and CNS development it is a concentration of breast milk is improved with supplements

hormones act on the reproductive organs

prolactin inhibits ovulation oxytocin promotes uterine contractions

hormones act on the mammary glands

prolactin stimulates milk production oxytocin stimulates milk ejection

Physiological Differences for Digestion

Increasing stomach capacity from 20ml (1 oz) to 200ml (1 cup) by 1 year Takes up to 6 months for infant GI tract to mature

Energy Needs

108 kcal/kg/day from birth to 6 months (range from 80 to 120) 98 kcal/kg/day from 6 to 12 months

Why formula is introduced

52% of babies are being supplemented with infant formula in the hospital 61% of new mothers regularly give formula by 3 months Many mothers lack confidence/lack awareness of newborn feeding behaviors

Growth

Additional methods to use if underlining conditions exist include: Growth charts for specific conditions Biochemical indicators Body composition Head circumference Medications that impact growth

Mature Milk

Composition changed, is thin, watery Easy to digest proteins and protein binds to iron reducing bacteria growth High linoleic acid and cholesterol content for brain development Long chain omega-3 fatty acids-docosahexaenoic acid (DHA) for synthesis of brain tissues, CNS, eyes DHA not available in formula

Breast Milk: The Gold Standard

Breast milk has: Vitamins and minerals for proper nutrition Growth factors that help with infant growth and development Antibodies that help babies resist disease The ability to change constantly for babies unique needs

Factors that delay breastfeeding

Cesarean delivery Hypothyroidism Obesity (lowers prolactin response to suckling) Type 1 diabetes (insulin needed to make milk) Mothers in their 40s Retained placental fragments

Barriers to Breastfeeding

Confidence regarding milk production Time and social constraints Embarrassment Lack of support (Dad, grandmothers) Fears of pain

Colostrum in Human Milk

First fluid produced during late pregnancy and few days after birth (lactogenesis II) Thick, yellow fluid Contains antibodies, immune-system cells and Lactobacillus bifidus factor Provides protection to infant against infections Facilitates the passage of 1st stool, meconium

Newborn Health

Full term infants usually weight 2500-3800 grams (5.5-8.5lb) 47-54 centimeters (18.5-21.5 inches)

Conditions that require parenteral feeding

Gastrointestinal problems may interfere with oral feeding Damage or inflammation to GI tract from necrotizing enterocolitis (NEC)

Conditions that require enteral feeding

Gastrointestinal reflux, constipation, spitting up, vomiting,

Feeding Baby Safely

Guard against choking hazards hot dogs, soft bread, grapes, hard candies Beware these ingredients honey, salt, sugar home cooked beets, carrots, spinach, turnips, collards citrus Prevent food borne illnesses no unpasteurized fruit juices

Protein preterm

Human milk protein concentration low compared to cows milk Unique composition designed specifically for babies needs/changes based on stage of growth Contain special digestive enzymes that may protect against infection or inflammation

WIC Program

IS NOT an entitlement program IS a Federal grant program IS a Supplemental Nutrition Education Program

Parent Controlled

Ignores infant behavior - enforces externally determined quantity Rotates, tilts, jiggles bottle Imposes feeding routine Terminates feeding abruptly at pauses Interprets infant fussiness as a sign of satiety

Lactose Intolerance

Inability to digest the disaccharide lactose Characterized by cramps, nausea and pain and alternating diarrhea and constipation Treated with soybean-based or lactose-free cow's milk formulas Many infants "outgrow" lactose intolerance

Failure to thrive (FTT)

Inadequate wt or lt gain Organic—diagnosed medical illness Nonorganic—not based on medical diagnosis

Severe Preterm Birth and Nutrition

Incidence and prognosis About 60,000 VLBW born in U.S. each year Survival rate ~ 90% Nutrition support generally required High metabolic rates

Energy needs preterm

Increased calories required for infections, fever, difficulty breathing, temperature regulation, and recovery from surgery Preterm energy needs are 120 kcal/kg Decreased calories recommended for spina bifida or Down syndrome

Hospital Practices that Affect Exclusive Breastfeeding

Infant formula samples and discharge bags Unnecessary formula supplementation Pacifier use Insufficient breastfeeding support

Late-Preterm Infants

Infants born between 34-37 weeks Difficulty establishing breastfeeding, putting infant at risk for insufficient milk intake, hypoglycemia, jaundice, and poor weight gain

Breast Development from Puberty to Lactation

Initiated during puberty; orchestrated by estrogen and progesterone Remain "inactive" until pregnancy; growth and proliferation of milk alveoli and ductal branching

Hormones necessary for milk production

Insulin Cortisol Thyroid hormone Parathyroid hormone Human growth hormone

Weaning

Introduction of cup at 6-9 months Able to ingest adequate milk from cup 12-18 months of age no more bottle, drinking from cup

Physiological Differences: Fluoride

No supplementation before 6 months of age Will need additional supplementation after this age 0.5mg/day if water is nonfluoridated Dental caries in early childhood more frequent if DRI for fluoride is not met during infancy

Engorgement

Occurs when breasts are over filled with milk Common in first time mothers Most commonly caused by infrequent or ineffective removal of milk from breast Best way to prevent is nurse frequently Mothers who are stressed can have lack of oxytocin produced; can lead to

Types of enteral tube feeding

Oral-gastric (OG) Gastrostomy Jejunostomy

Population Served

Pregnant women Breastfeeding women Non-breastfeeding postpartum women Infants Children through the month of their 5th birthday

Milk Banking

Provide human milk to infants who cannot be breastfed by their mothers Premature and sick infants are most likely to receive Human milk donors are chosen by their health profile

Nutrition Education

Provide nutrition education to: Adult participants Parents or caretakers of child participants Participants learn about: Specific nutritional needs Nutrients necessary for their diet Foods rich in those nutrients

Fats preterm

Provide up to 55% calories from fat Low-fat diet rarely required Medium-chain triglycerides (MCT) beneficial to VLBW and ELBW infants because of low pancreatic and liver enzymes Essential fatty acids and DHA and AA important

6-12 months

Reaches for and grasps objects (palmar grasp) Brings hand to mouth Voluntarily releases (pincer grasp) Shows rotary chewing pattern

Physiological Differences: Iron

Recommend children 7-12 months of age 11mg/kg/day Iron important for brain development and immune defense; iron deficiency leads to improper brain development and decreases immune defense

Hindmilk

Resembles cream ~66% fat, ~28% CHO, ~6% protein Makes up the last 5% of the volume Released 10-20 minutes into the feeding

Oral Search Reflex

When infant opens his or her mouth wide in proximity to the breast while thrusting the tongue forward

Fat Soluble Vitamins Vitamin K:

infants given injections upon birth

when should a mother avoid breastfeeding

infected with HIV taking antiretroviral medication untreated active tuberculosis using drugs chemo radiation therapies t-cell lymphotropic virus