Chapter 19

interferon

(a protein that protects against viruses), help interfere with virus growth. The bifidus factor is a specific growth-promoting factor for the beneficial bacteria Lactobacillus bifidus. The presence of L. bifidus in breast milk interferes with the colonization of pathogenic bacteria in the gastrointestinal tract, thus reducing the incidence of diarrhea

Common reasons women give for not exclusively breastfeeding or discontinuing breastfeeding include

(a) insufficient milk supply, (b) feeling very tired, (c) having trouble with the infant latching to breast, and (d) wanting to allow their partner to feed the infant also latch difficulty, soreness, low milk supply, wants others to feed the baby, work/school related issues

Commercial formulas are supplied in four separate forms:

-Powder that is prepared by adding water as directed (least expensive) -Condensed liquid that is diluted with an equal amount of water -Ready-to-feed, which requires no dilution -Individually prepackaged and prepared bottles of formula

To calculate the adequacy of a formula, the following may be used:

1. The total fluid ingested for 24 hours must be sufficient to meet the infant's fluid needs: 75 to 90 ml (2.5 to 3 oz) of fluid per pound of body weight (150 to 200 ml/kg) per day. 2. The number of calories required per day is 50 to 55 per pound of body weight (100 to 120 kcal/kg).

When is "true" breast milk produced?

10th day

average quantity a mother may produce and guidelines for breast milk storage include

37 ml (7 to 123 ml) within the first 24 hours, 500 ml by day 5, 750 ml/day by month 3, and 800 ml/day by month 6. For mothers of twins, it can vary at approximately 2,100 ml/day.

An easy way to recall breast milk storage is

4 hours at room temperature, 4 days in the refrigerator, and 4 months in the freezer.

iron

A newborn (37 or more weeks gestation age) whose mother had adequate iron intake during pregnancy will be born with iron stores that, theoretically, will last for the first 3 months of life, until the newborn begins to produce adult hemoglobin the AAP recommends infants who are formula fed ingest an iron-enriched formula for the entire first year of life) . Some women who breastfeed are also advised to supplement iron to ensure their infant does not develop iron-deficiency anemia

vitamins

Although both breast milk and commercial formulas contain sufficient vitamins for growth, the AAP now recommends that breastfed newborns be given a supplement of 400 international units per day of vitamin D, beginning in the first few days of life. Newborns who are fully or partially formula fed also benefit from a daily 400 international units vitamin D supplement

contraindications of breast milk

An infant with galactosemia (such infants cannot digest the lactose in milk) Herpes lesions on a mother's nipples Maternal exposure to radioactive compounds (such as occurs with thyroid testing) Mothers receiving antimetabolites or chemotherapeutic agents Mothers receiving prescribed medications that would be harmful to an infant, such as lithium or methotrexate Women with maternal active, untreated tuberculosis, who need to be evaluated individually depending on the stage of their disease Women who are positive for HIV, who are advised not to breastfeed in the United States until further studies confirm the risk of not breastfeeding outweighs the risk of breast milk transmission of the virus. In developing countries, women who are HIV positive may be advised to breastfeed because commercial formula is not available. Women whose toxicology screens for substance abuse are positive, who need to be evaluated on an individual basis regarding recommendations to breastfeed

oxytocin and the let down reflex

As the infant sucks at the breast, oxytocin, released from the posterior pituitary, causes the collecting sinuses of the mammary glands to contract, forcing milk forward through the nipples, making it available for the baby. This action is called a let-down reflex. A let-down reflex may also be triggered by the sound of a baby crying or by thinking about the baby. New milk, called hind milk, is formed after the let-down reflex.

fluid

Because of all these factors, a newborn needs 150 to 200 ml/kg (2.5 to 3.0 oz/lb) of water intake every 24 hours (adults require 2,400 ml per day or less than 1 oz/lb). This requirement can be supplied completely by breastfeeding or formula feeding. Fruit juice is not recommended for infants younger than 6 months because it supplies no protein and, if not pasteurized, can carry infectious organisms

breastfeeding multiple infants

Because of in vitro fertilization, an increasing number of women are giving birth to multiple newborns. Reassure women they can provide breast milk to more than one newborn. Nurses can recommend pillow supports designed to allow twins to feed simultaneously. These pillows are similar to the pillows used to support one baby but are wider on the sides to support two babies for simultaneous feedings

where is breast milk formed

Breast milk is formed in the acinar or alveolar cells of the mammary glands With the delivery of the placenta following birth, the level of progesterone in a woman's body falls dramatically, stimulating the production of prolactin

weight loss breast vs bottle

Breastfed newborns may lose up to 3% of birthweight on day 1, 5% of birth weight on day 2, and 7% of birthweight on day 3. A formula-fed newborn's weight loss is not as much as a breastfed newborn. A formula-fed newborn regains birth weight at about 10 days; a breastfed infant does so at about 14 days.

Antibodies

Breastfeeding has major physiologic advantages for infants as well as it does for women. Breast milk contains secretory immunoglobulin A (IgA), which binds large molecules of foreign proteins, including viruses and bacteria, thus keeping them from being absorbed from the gastrointestinal tract.

calcium

Calcium is important to the newborn because a newborn's skeleton grows so rapidly. Because milk is high in calcium, tetany resulting from a low calcium level seldom occurs in infants who suck well, regardless of whether they are fed human milk or commercial formula

cigarette smoking and breast feeding

Cigarette smoking is not a contraindication to breastfeeding, but women should be aware some nicotine is carried in breast milk. Nicotine has the potential to decrease a mother's milk supply (Reece-Stremtan & Marinelli, 2015). If the infant is exposed to secondhand smoke, it could lead to an increase in respiratory illnesses. The nurse needs to be aware of a number of other situations that call for individual planning in consultation with a lactation consultant.

calories

For example, an infant up to 2 months of age requires 110 to 120 calories per kilogram of body weight (50 to 55 kcal/lb) every 24 hours to provide an adequate amount for maintenance and growth. After 2 months of age, this amount gradually declines until the requirement at 1 year is 100 kcal/kg (45 kcal/lb) per day. In contrast, the adult caloric requirement is 42 kcal/kg (20 kcal/lb) per day (U.S. Department of Agriculture, 2016). During growth spurts, more calories are needed to supply additional energy. Commercial infant formulas are designed to provide approximately the same number of calories as breast milk, 20 calories per ounce. They contain about 9% to 12% of their calories as protein and 45% to 55% of calories as lactose carbohydrate. The balance (34% to 46%) is fat, of which linoleic acid accounts for about 4%.

Hind milk

Hind milk, which is higher in fat than fore milk, is the milk that makes a breastfed infant grow most rapidly. The release of oxytocin has a second advantage in that, by causing smooth muscle contraction, it helps contract the uterus. As a result, a woman may feel a small tugging or cramping in her lower pelvis during the first few days of breastfeeding

common concerns of formal feeding

Infant sucks for a few minutes and then stops and cries. Infant does not burp well after feeding. Parent reports constipation in infant.

electrolyte and mineral composition

It is high in lactose, an easily digested sugar that provides ready glucose for rapid brain growth. The protein in breast milk is easily digested, and the ratio of cysteine to methionine (two amino acids) in breast milk favors rapid brain growth in the early months. It contains nitrogen in compounds other than protein, so an infant can receive cell-building materials from sources other than just protein.

jaundice in breastfed infants

Jaundice occurs in as many as 15% of breastfed infants because pregnanediol (a breakdown product of progesterone) in breast milk depresses the action of glucuronyl transferase, the enzyme that converts indirect bilirubin (which cannot be excreted) to the direct form, which is then readily excreted in bile

carbohydrates

Lactose, the disaccharide found in human milk and added to commercial formulas, appears to be the most easily digested of the carbohydrates. Lactose also improves calcium absorption and aids in nitrogen retention. It produces stools consisting predominantly of gram-positive rather than gram-negative bacteria and therefore decreases the possibility of gastrointestinal illness (which usually results from gram-negative organisms). Adequate lactose also allows protein to be used for building new cells rather than for calories, encouraging normal water balance and preventing abnormal metabolism of fat

inverted nipples

Less than 1% of woman have inverted nipples. A nipple shield (a plastic shell) may be suggested to help her nipples become more everted

fat

Linoleic acid, an essential fatty acid, is necessary for brain growth and skin integrity in infants. When the amount of linoleic acid is sufficient, the infant can then manufacture docosahexaenoic acid (DHA), an omega-3 fatty acid, and arachidonic acid (ARA), an omega-6 fatty acid, both of which are important for brain growth. Breast milk contains a generous supply of all three of these fatty acids. Commercial formulas contain varying amounts depending on the brand and type of fats included in the formula. Because fat is so important for brain and nerve growth, use of fat-free milk for long periods in newborns and infants (when other sources of food are not being offered) can result in linoleic acid deficiency. Therefore, parents should not feed fat-free milk as a means of preventing obesity in newborns or young infants. In addition, fat-free milk does not contain sufficient calories for a newborn; it only has about half as many calories as commercial formulas or breast milk.

NUTRITIONAL AND HEALTH BENEFITS OF BREASTFEEDING

Lower respiratory tract infections 72 Gastrointestinal infections 64 Otitis media (exclusive vs. formula fed) 50 Atopic dermatitis 42 Diabetes types 1 and 2 19-27/39 Obesity 7-27 Sudden infant death syndrome 36 Childhood leukemias 15-19 Maternal breast cancer 28 Ovarian cancer 21

flow of breast milk

Milk flows from the alveolar cells, where it is produced, through small tubules to reservoirs for milk, the lactiferous sinuses, located behind the nipple. This constantly forming milk is called fore milk. Its availability depends very little on the infant's sucking at the breast

Engorgement

On the third or fourth day after birth, when breast milk volume increases, women often notice breast distention, accompanied by hardness, and tenderness, and the skin may appear red, tense, and shiny. this is caused by vascular and lymphatic congestion arising from an increase in the blood and lymph supply to the breasts. Newborns have difficulty latching when breasts are engorged because the areola can be too hard to grasp (Fig. 19.7). A woman also may have difficulty breastfeeding her newborn because her breasts are uncomfortable

time-honored positio

Placing the baby over one shoulder and gently patting or stroking the back However, this position is not always satisfactory for a newborn who has poor head control because a parent may have difficulty supporting the baby and patting the back at the same time.

Risk factors for hypoglycemia in newborns include:

Preterm (less than 37 weeks gestation) Intrauterine growth restriction Low birth weight (less than 2.5 kg) SGA (less than 10%) Maternal diabetes LGA (greater than 90%) Hypothermia Infection/other illness in the newborn Severe intrapartum asphyxia Maternal use of β-blockers, such as labetalol (Trandate)

skin to skin

Skin-to-skin contact should be initiated within the first hour of delivery, while the infant is in the first reactivity period (U.S. Department of Agriculture, 2016). Skin-to-skin contact is defined as placing the undressed infant on the mother's chest against her skin. When placed in this position, the infant will root toward the nipple and initiate a latch. This may be more successful in an unmedicated birth of a full-term infant. A mother breastfeeding for the first time may require additional support (Box 19.3). Pumping with a hospital grade pump or manual expression is an alternative method to provide breast milk to a newborn who is unable to latch or if mother and baby are separated.

Nipple trauma may be evaluated using the following scale:

Stage 1: superficial intact Stage 2: superficial with tissue breakdown Stage 3: partial erosion Stage 4: full thickness erosion

protein

The newborn has a high requirement of protein, which is necessary for the formation of new cells, during this period to provide for a rapid growth of new cells as well as maintenance of existing cells. The nutritional allowance of protein for the first 2 months of life is 2.2 g per kilogram of body weight. Both human milk and commercial formulas provide all the essential amino acids necessary to form protein. Histidine, an amino acid that appears to be essential for infant growth but is not necessary for adult growth, is found in both milk forms.

nipple care

The nurse can also recommend applying a few drops of breast milk to the nipples after feeding and gently massaging it into the areola. The components of breast milk have healing properties. Sore nipples are not a contraindication to breastfeeding as long as a proper latch is obtained. If the latch is too painful, the mother can pump to provide expressed breast milk to her newborn and ensure her milk supply is protected. A nipple shield, worn while breastfeeding, can protect the nipple while the reasons for poor latch are determined (Figure 19.9A). A nipple shell is worn over the nipple in between feedings to promote healing and protect the nipple from irritatio

advantages of breast feeding

The release of oxytocin from the posterior pituitary gland aids in uterine involution. Breastfeeding may serve a protective function in preventing breast cancer and possibly ovarian cancer. A woman may return to her prepregnant weight sooner, and if menstruation is delayed, this may serve as a temporary family planning method. Successful breastfeeding can have an empowering effect because it is a skill only a woman can master. Breastfeeding reduces the cost of feeding and preparation time for infant feeding. A long-term effect may include a decreased risk of hip fractures and osteoporosis in the postmenopausal period for the woman (U.S. Department of Agriculture, 2016). Breastfeeding provides an excellent opportunity to enhance a true symbiotic bond between mother and child. Although this does readily occur with breastfeeding, a woman who holds her baby to formula feed can form this bond as well.

preventing and relieve engoregment

There are few evidence-based methods for relieving engorgement; a common suggestion is to empty the breasts of milk by having the infant feed more often. Unfortunately, a woman's breasts are sometimes so painful it is difficult for her to continue to breastfeed unless she is given something such as a mild analgesic for pain relief. Good breast support from a firm-fitting bra also helps prevent a pulling, heavy feeling.

reasons for formula feeding

These may include partner unsupportive, prefer someone else feed the infant possibly due to maternal fatigue, nipple soreness, newborn fussy or difficult and question whether they are receiving adequate nutrition, returning to work or school, and real or perceived inadequate milk supply.

prevent excess buildup of bilirubin

To prevent this excess buildup of bilirubin (i.e., hyperbilirubinemia) in their newborn, women should feed frequently in the immediate postpartum period because colostrum is a natural laxative and helps promote passage of both meconium and bile. Newborns who are discharged early from their birth setting or born at home need to be observed carefully for jaundice. Breastfeeding rarely results in a serum bilirubin level high enough to warrant therapy or to require discontinuation of breastfeeding, however, because pregnanediol remains in breast milk for only 24 to 48 hours

cows milk

Unaltered cow's milk is not recommended for newborns because it contains about 16% of its calories as protein, whereas human milk contains about 8%. Cow's milk products, such as yogurt and cottage cheese, should not be introduced until 9 to 12 months of age because of this same reason.

football

Using a football hold with the newborn supported on a pillow also may be helpful, especially if a mother had a cesarean birth (Fig. 19.4B). This position is also helpful if the baby is having difficulty latching due to large breasts that obstruct the mother's view or less prominent nipples that provide little palate stimulation.

When using presterilized formula, the parent need only do the following to prepare a bottle of formula:

Wash off the top of the can with warm, soapy water and rinse. Open the can and pour the desired amount of formula and water into a previously cleaned bottle. Put on the nipple, taking care not to handle the nipple projection. Place the bottle cap over the nipple and refrigerate or use to feed immediately. If using powdered formula, the parent simply combines tap water and the measured amount of powder into a previously cleaned bottle, caps the bottle, and shakes it to mix the ingredients.

lysozyme

actively destroys bacteria by lysing (dissolving) their cell membranes, possibly increasing the effectiveness of antibodies. Leukocytes in breast milk provide protection against common respiratory infectious invaders.

A quick rule of thumb to estimate how much an infant will drink at a feeding is to

add two or three to the infant's age in months. After initially taking 0.5 to 1 oz for the first 2 days, a newborn (0 age) will take 2 to 3 oz each feeding; a 3-month-old child, 5 to 6 oz; and a 6-month-old child, 8 oz. As infants change from six to five feedings a day (at about 4 months of age, when they begin to sleep through the night), they begin to take more at each feeding, keeping their total intake the same.

linoleic acid

an essential fatty acid for skin integrity, and less sodium, potassium, calcium, and phosphorus than do many formulas. Breast milk also has a better balance of trace elements, such as zinc. These levels of nutrients are enough to supply the infant's needs, yet they spare the infant's kidneys from having to process a high renal solute load of unused nutrients. Exclusively breastfeeding for at least 3 to 4 months or longer was found to reduce the incidence of certain allergies in 42% of infants where there was a family history of allergies

Lactoferrin

an iron-binding protein in breast milk that interferes with the growth of pathogenic bacteria.

prolactin

anterior pituitary hormone. Prolactin acts on the acinar cells of the mammary glands to stimulate the production of milk. In addition, when an infant sucks at a breast, nerve impulses travel from the nipple to the hypothalamus to stimulate the production of prolactin-releasing factor. This factor stimulates further active production of prolactin.

Modified milk-based formulas

are used for the majority of newborns; lactose-free formulas are used for newborns with lactose intolerance or galactosemia (inability to use sugar)

he effects of breastfeeding on the formation of the dental arch

because babies suck differently from a breast than from a bottle (Fig. 19.2). Babies pull their tongue backward as they suck from a breast. They thrust their tongue forward to suck from a rubber nipple. That may make breastfeeding the best preparation for forming common speech sounds

Manual expression of breast milk

consists of supporting the breast firmly, then placing the thumb and forefinger on the opposite sides of the breast just behind the areolar margin, and first pushing backward toward the chest wall and then downward until secretions begins to flow (Box 19.4). Women should avoid soap on the nipples as it may lead to dryness and skin breakdown. The release of oxytocin by breastfeeding, pumping, or manual expression initiates let-down of milk and also stimulates uterine contraction.

soy formulas

devised for infants who are allergic to cow's milk protein, although such infants may be given casein hydrolysate formulas, which have protein particles too small to be recognized by the immune system

Caution parents to keep opened cans of liquid formula covered and refrigerated,

discarding any unused formula within 24 hours

mom before breastfeeding

efore breastfeeding, recommend a woman wash her hands to be certain they are free of pathogens picked up from handling perineal pads or other sources. Washing her breasts is not necessary unless she notices caked colostrum on the nipples.

fluoride

essential for building sound teeth and for preventing tooth decay. Because teeth are already set in their primary form during pregnancy, it is important for women to drink fluoridated water during pregnancy. A lactating mother should continue drinking fluoridated water (although only a small amount of fluoride passes into breast milk), and formulas should be prepared with fluoridated water.

Signs of hunger in a newborn

estlessness, tense body posture, and mouth movements as signs of hunger in their infant. Otherwise, they may wait for their infant to cry, and this is actually a late sign of newborn hunger.

how long to bottle feed

first year of life

colostrum

hin, watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies, is secreted by the acinar breast cells starting in the fourth month of pregnancy. For the first 3 or 4 days after birth, colostrum production continues. Because it is high in protein and fairly low in sugar and fat, colostrum is easy to digest and capable of providing adequate nutrition for a newborn until it is replaced by transitional breast milk on the second to fourth day.

Holding the baby in a sitting position on the lap and then leaning the child forward against one hand, with the index finger and thumb supporting the head,

is often the best position to use. This position provides head support and leaves the other hand free to pat the baby's back (Fig. 19.5). Parents usually need to be shown this method because it does not seem as natural as placing a baby against the shoulder. Laying the baby prone across the lap is yet another alternative position.

side lying position

may permit the mother to rest while feeding. This may be difficult as the initial feeding position as it requires the newborn to latch more independently.

If an infant cannot grasp a nipple to latch properly because of engorgement,

moist heat applied to both breasts or standing under a warm shower for a few minutes before feeding, combined with massage to begin milk flow, often promotes breast softness so a newborn can suck. Manual expression or the use of a breast pump to completely empty the breasts after the baby has breastfed can help maintain or promote a good milk supply during a period of engorgement

weaning breast milk

recommends infants be exclusively breastfed for the first 6 months and breastfed with complementary foods for the first year of life; the World Health Organization recommends exclusive breastfeeding for 6 months and continuation for 2 years

adequate nutrition

sleeps between feedings looses no more than 10% of birth weight good skin turgor voids six to eight times/day two to three bowel movements

Mature breast milk may appear

thin and blue-tinged in appearance. Some women may need assurance that this color and consistency are normal; otherwise, they may think their milk is not nutritious enough.

elemental formulas

used for infants with protein allergies or fat malnutrition.