ATI Ob Chapter 25 Newborn Nutrition

Feeding Readiness Cues

Provide the mother with education about feeding-readiness cues exhibited by newborns and encourage the mother to begin feeding her newborn upon cues rather than waiting until the newborn is crying. Cues include the following. ●Hand-to-mouth or hand-to-hand movements ●Sucking motions ●Rooting ●Mouthing

Risk factors for impaired newborn nutrition

Risk factors for failure to thrive (newborn) can be r/t ineffective feeding patterns of the newborn or inadequate breastfeeding by the mother. NEWBORN FACTORS ●Inadequate breastfeeding ●Illness/infection ●Malabsorption ●Other conditions that increase energy needs MATERNAL FACTORS ●Inadequate or slow milk production ●Inadequate emptying of the breast ●Inappropriate timing of feeding ●Inadequate breast tissue ●Pain with feeding ●Maternal hemorrhage ●Illness/infection

When are solid foods introduced? Why not sooner?

Solids are not introduced until 6 months of age. If introduced too early, food allergies can develop.

Can you thaw breast milk in microwave? Why or why not?

Thawing by microwave is C/I because it destroys some of the immune factors and lysozymes contained in the milk. Microwave thawing also leads to the development of hot spots in the milk because of uneven heating, which can burn the newborn.

How to thaw breast milk?

Thawing the milk in the refrigerator for 24 hr is the best way to preserve the immunoglobulins present in it. It also can be thawed by holding the container under running lukewarm water or placing it in a container of lukewarm water. The bottle should be rotated often, but not shaken when thawing in this manner. ◯Do not refreeze thawed milk.

Iron in milk/formula

The mineral content of commercial newborn formula and breast milk is adequate with the exception of iron and fluoride. ◯Iron is low in all forms of milk, but it is absorbed better from breast milk. Newborns who only breastfeed for the first 6 months maintain adequate hemoglobin levels and do not need additional iron supplementation. After 6 months of age, all newborns need to be fed iron-fortified cereal and other foods rich in iron. Newborns who are formula-fed should receive iron-fortified newborn formula until 12 months of age. Mothers who breastfeed their newborns are encouraged to do so for the newborn's first 12 months of life.

How often should newborn be bottle fed?

The newborn should be fed every 3 to 4 hr. Parents should awaken the newborn to feed at least every 3 hr during the day and at least every 4 hr during the night until the newborn is feeding well and gaining weight adequately. Then, a feed‑on‑demand schedule can be followed.

Adequate caloric intake

Adequate caloric intake is essential to provide energy for growth, digestion, metabolic needs, and activity. For the first 3 months, the newborn requires 110 kcal/kg/day. From 3 to 6 months, the requirement decreases to 100 kcal/kg/day. Both breast milk and formula provide 20 kcal/oz.

When does assessment of newborn nutrition occur?

Assessment of newborn nutrition begins during pregnancy and continues after birth by reviewing the parents' attitudes and choices about their newborn's feeding. Breastfeeding is the preferred method. However, if the mother chooses not to breastfeed, she must not be made to feel guilty.

Fat (triglycerides) %

At least 15% of calories must come from fat (triglycerides). The fat in breast milk is easier to digest than the fat in cow's milk.

What is colostrum?

Baby gets colostrum (early milk) for the first few days after birth.

How long can breast milk be stored?

Breast milk can be stored at room temperature under very clean conditions for up to 8 hr. It can be refrigerated in sterile bottles for use within 8 days, or can be frozen in sterile containers in the freezer compartment of a refrigerator for up to 6 months. Breast milk can be stored in a deep freezer for 12 months

Vitamins in milk

Breast milk contains the vitamins necessary to provide adequate newborn nutrition. According to the American Academy of Pediatrics, all infants who are breastfed or partially breastfed should receive 400 IU of vitamin D daily beginning in the first few days of life. Infant formula has vitamins added, but vitamin D supplements also are recommended. Mothers who are breastfeeding and are vegetarians who exclude meat, fish, and dairy products should provide vitamin B12 supplementation to their newborns

How many BM and wet diapers do breast fed and bottle fed babies have each day?

Breastfed infants usually have 3 or more bowel movements a day; formula-fed infants less frequent. Breastfed and formula-fed infants usually have 6 or more wet diapers a day.

How long is breast feeding recommended exclusively?

Breastfeeding is the optimal source of nutrition for newborns. Breastfeeding is recommended exclusively for the first 6 months of age by the American Academy of Pediatrics.

Carbohydrates %

Carbohydrates should make up 40% to 50% of the newborn's total caloric intake. The most abundant carbohydrate in breast milk or formula is lactose.

Breastfeeding benefits specific to families and society:

Convenient, Less expensive than formula, reduces annual health care costs, and reduces environmental burden related to disposal of formula packaging and equipment

Breastfeeding Benefits specific to the mother:

Decreased postpartum bleeding and more rapid uterine involution, decreased risk for ovarian and breast cancer, DM type 2, HTN, hypercholesterolemia, cardiovascular disease, and rheumatoid arthritis

Breastfeeding Benefits specific to the infant

Decreased risk for GI infections, celiac disease, asthma, lower respiratory tract infections, otitis media, sudden infant death syndrome (SIDS), obesity in adolescence and adulthood, DM types 1 and 2, and acute lymphocytic and myeloid leukemia

Newborn needs

Desirable growth and development of the newborn is enhanced by good nutrition. Feeding the newborn provides an opportunity for parents to meet the newborn's nutritional needs as well as an opportunity for them to bond with the newborn. Whether the mother chooses to breastfeed, use donor milk, or formula (bottle) feed, nurses should provide education and support.

When is colostrum secreted from mom's breast?

During postpartum days 1 to 3.

When is the optimal time to provide newborn nutritional information?

During pregnancy, so that the parents make a decision prior to hospital admission.

Failure to thrive

Failure to thrive is slow weight gain. A newborn usually falls below the 5th percentile on the growth chart.

Fluoride supplementation

Fluoride levels in breast milk and formulas are low. A fluoride supplement should be given to newborns not receiving fluoridated water after 6 months of age.

Protein intake

For adequate growth and development, a newborn must receive 2.25 to 4 g/kg/day of protein.

Formula (bottle) feeding

Formula feeding can be a successful and adequate source of nutrition if the mother chooses not to breastfeed.

Fluid intake

Healthy newborns need a fluid intake of 100 to 140mL/kg/24 hr. Newborns do not need to be given water because they receive sufficient water from breast milk or formula.

Human milk feeding/donor milk

If the mother is not able to provide the breast milk, the recommended alternative is pasteurized donor milk from a milk bank (obtain informed consent). However, in many cases, it's not readily accessible, and a commercial infant formula is used

What does colostrum contain and what does it provide?

It contains immunoglobulin A (IgA), which provides passive immunity to the newborn.

Assessment of newborn nutrition

NEWBORN ●Maturity level ●History of labor and delivery ●Birth trauma ●Maternal risk factors ●Congenital defects ●Physical stability ●State of alertness ●Presence of bowel sounds MOTHER ●Previous experience with breastfeeding ●Knowledge about breastfeeding ●Cultural factors ●Feelings about breastfeeding ●Physical features of breasts ●Physical/psychological readiness ●Support of family and significant others

How often should newborns be breastfed?

Newborns should be breastfed every 2 to 3 hr. Parents should awaken the newborn to feed at least every 3 hr during the day and at least every 4 hr during the night until the newborn is feeding well and gaining weight adequately. Breastfeeding should occur 8 to 12 times within a 24-hr window. Then, a feed-on-demand schedule can be followed

Nursing Interventions for breastfeeding

Nursing interventions can help a new mother be successful in breastfeeding. This includes the provision of adequate calories and fluids to support breastfeeding. The practice of rooming-in (allowing mothers and newborns to remain together) should be encouraged as part of baby-friendly initiatives. Lactation consultants can improve the mother's efforts and success in breastfeeding.

Failure to thrive: Interventions for bottle fed newborns

●Evaluate how much and how often the newborn is feeding. ●If the newborn is spitting up or vomiting, he can have an allergy or intolerance to cow's milk-based formula and can require a soy-based formula.

Failure to thrive: Interventions for breastfeeding newborns

●Evaluate positioning and latch-on during breastfeeding. ●Massage the breast during feeding. ●Determine feeding patterns and length of feedings. ●If the newborn is spitting up, the newborn can have an allergy to dairy products. Determine the maternal intake of dairy products. The mother can need to eliminate dairy from her diet. Instruct her to consume other food sources high in calcium or calcium supplements

Successful storage of breast milk obtained by a breast pump

●Inform the mother that breast milk can still be provided to the newborn during periods of separation by using a breast pump or hand expression. ◯Breast pumps can be manual, electric, or battery‑operated and pumped directly into a bottle or freezer bag. ◯One or both breasts can be pumped, and suction is adjustable for comfort. ●Teach the parents that breast milk must be stored according to guidelines for proper containers, labeling, refrigerating, and freezing.

Successful breastfeeding

●Place the newborn skin to skin on the mother's chest immediately after birth. Initiate breastfeeding ASAP or w/n first 30 min following birth. ●Explain breastfeeding techniques to the mother. Have the mother wash her hands, get comfortable, and have caffeine-free, nonalcoholic fluids to drink during breastfeeding. ●Explain the let-down reflex (stimulation of maternal nipple releases oxytocin that causes the let-down of milk). ●Reassure the mother that uterine cramps are normal during breastfeeding, resulting from oxytocin, which also promote uterine involution. ●Express a few drops of colostrum or milk and spread it over the nipple to lubricate the nipple and entice the newborn. ●Show the mother the proper latch-on position. Have her support the breast in one hand with the thumb on top and four fingers underneath. With the newborn's mouth in front of the nipple, the newborn can be stimulated to open his mouth by tickling his lower lip with the tip of the nipple. The mother pulls the newborn to the nipple with his mouth covering part of the areola as well as the nipple. ●Explain to the mother that when her newborn is latched on correctly, his nose, cheeks, and chin will be touching her breast. Hunger cues include hand to mouth or hand to hand movements, sucking motions, and rooting reflex. ●Demonstrate the four basic breastfeeding positions: football hold (under the arm), cradle (most common) or modified cradle (across the lap), and side-lying ●Encourage the mother to breastfeed at least 15 to 20 min per breast to ensure that her newborn receives adequate fat and protein, which is richest in the breast milk as it empties the breast. Newborns need to be breastfed at least 8 to 12 times in a 24 hr. period. ●Avoid educating mothers regarding the duration of newborn feedings. Mothers should be instructed to evaluate when the newborn has completed the feeding, including slowing of newborn suckling, a softened breast, or sleeping. Both breasts should be offered to ensure that each breast receives equal stimulation and emptying. ●Explain to the mother that newborns will nurse on demand after a pattern is established. ●Show the mother how to insert a finger in the side of the newborn's mouth to break the suction from the nipple prior to removing the newborn from the breast to prevent nipple trauma. ●Show the mother how to burp the newborn when she alternates breasts. The newborn should be burped either over the shoulder or in an upright position with his chin supported. The mother should gently pat the newborn on his back to elicit a burp. ●Tell the mother to begin the newborn's next feeding with the breast she stopped feeding him with in the previous feeding. ●Tell the mother how to tell if her newborn is receiving adequate feeding (gaining weight, voiding 6 to 8 diapers per day, and contentedness between feedings). ●Explain to the mother that the newborn can have loose, pale, and/or yellow stools during breastfeeding, and that this is normal. ●Tell the mother to avoid nipple confusion in the newborn by not offering supplemental formula, pacifier, or soothers until breastfeeding has been established typically 2 to 3 weeks. Supplementation can be provided using a small feeding or syringe feeding, if needed. When supplementation is deemed necessary, giving the baby expressed breast milk is best. ●Tell the mother to always place her newborn on his back after feedings. ●Promote rooming-in efforts. ●Offer referral to breastfeeding support groups. ●Contact a lactation consultant to offer additional recommendations and support, especially to mothers who have concerns about adequate breast milk or mothers who have been unsuccessful with breastfeeding in the past. ●Herbal products, such as fenugreek or blessed thistle, and prescription medications, such as metoclopramide, have been reported to increase breast milk production. There is insufficient data to confirm or deny their effect on lactation. Mothers should check with the provider before taking OTC or prescription medications.

Benefits of breastfeeding

●Reduces the risk of infection by providing IgA antibodies, lysozymes, leukocytes, macrophages, and lactoferrin that prevents infections. ●Promotes rapid brain growth due to large amounts of lactose. ●Provides protein and nitrogen for neurological cell building and improves the newborn's ability to regulate calcium and phosphorus levels. ●Contains electrolytes and minerals. ●Breast milk is easy for the newborn to digest. ●Breastfeeding is convenient and inexpensive. ●Reduces incidence of sudden infant death syndrome (SIDS), allergies, and childhood obesity. ●Promotes maternal-infant bonding and attachment

Nursing Interventions to assure adequate nutrition in fussy newborns

●Swaddle the newborn. ●Hold the newborn close, move, and rock him gently. ●Reduce the newborn's environmental stimuli. ●Place the newborn skin-to-skin.

What to do with unused milk?

Used portions of breast milk must be discarded.

Nursing Interventions for Bottle feeding

●Teach the parents how to prepare formula (mix according to instructions), bottles, and nipples. Review the importance of hand washing prior to formula preparation. ●Teach the parents about the different forms of formula (ready‑to‑feed, concentrated, and powder) and how to prepare each correctly. ●Instruct parents to use tap water to mix concentrated or powder formula. If the water source is questionable, tap water should be boiled first. ●Instruct parents that prepared formula can be refrigerated for up to 48 hr. ●Teach the parents to check the flow of formula from the bottle to ensure it is not coming out too slow or too fast. ●Advise parents not to use formula past the expiration date located on the container. ●Show the parents how to cradle the newborn in their arms in a semi-upright position. The newborn should not be placed in the supine position during bottle feeding because of the danger of aspiration. Newborns who bottle feed do best when held close and at a 45 ̊angle. ●Instruct the mother how to place the nipple on top of the newborn's tongue. ●Keep the nipple filled with formula to prevent the newborn from swallowing air. ●Always hold the bottle and never prop the bottle for feeding. ●Give newborn opportunities to burp several times during a feeding ●Place the newborn on his back after feedings. ●Tell the parents to discard any unused formula remaining in the bottle when the newborn is finished feeding due to the possibility of bacterial contamination. ●Teach the parents how to tell if their newborn is being adequately fed (gaining weight; bowel movements are yellow, soft and formed; and satisfaction between feedings).

Nursing Interventions to assure adequate nutrition in sleepy newborns

●Unwrap the newborn. ●Change the newborn's diaper. ●Hold the newborn upright, and turn him from side to side. ●Talk to the newborn. ●Massage the newborn's back, and rub his hands and feet. ●Apply a cool cloth to the newborn's face.

Normal newborn weight loss immediately after birth and subsequent weight gain

◯Loss of 5% to 10% after birth (regain 10 to 14 days after birth) ◯Gain of 110 to 200 g/week for first 3 months

Monitor the newborn for adequate growth and weight gain.

◯Weights are done daily in the newborn nursery. Every newborn should be seen and examined at the doctor's office within 72 hr (2 to 3 days) after discharge from the hospital. Growth is assessed by placing the newborn's weight on a growth chart. Adequate growth should be within the 10th to 90th percentile. Poor weight gain would be below 10%, and too much weight gain would be above 90%. ◯The newborn's length and head circumference are also routinely monitored. ●Assess the mother's ability to feed her newborn, whether by breast or bottle. ●Calculate the newborn's 24-hr I&O, if indicated, to ensure adequate nutrition.