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