Breast-feeding

Breast-feeding is the best means of feeding babies, and all efforts should be made to promote, encourage and maintain it. Exclusive breast-feeding is recommended for the first 6 months of life. Breast-feeding can be continued for as long as mother and baby prefer (see Table 6.1).

Normal variations of breast-feeding

Frequency of feeds

Breast-fed infants usually feed every 2–5 h from both breasts each feed. Young babies feed frequently but demand feeding (i.e. feeding when hungry) will usually have the baby settle into a fairly predictable pattern of feeds. The frequency of feeds is determined by the baby’s appetite and gastric capacity, as well as the amount of mother’s milk available.

Length of feeds

The duration of the feed is determined by the rate of transfer of milk from the breast to the baby, which, in turn, depends on the baby’s suck and the mother’s ‘let down’. This may vary from 5 to 30 min. Young infants tend to feed for longer. It is the cessation of strong drawing sucks and the appearance of shorter-duration bursts of sucking that indicate the ‘end’ of the feed – not the time.

If the mother feels the baby is on the breast ‘all the time’, rather than focusing on the sucking alone, it is more important to look for longer duration of pauses between bursts of sucking. At this point, either take the baby off the breast or swap to the other side.

Appetite spurts

Babies seem to experience appetite spurts at 2 weeks, 6 weeks and 3 months. It is crucial that parents are aware of this or the baby’s natural increase in feed frequency may be mistaken for diminution of milk supply. This is especially true at 6 weeks when breasts are no longer carrying extra fluid and the supply is settling to the demands of the baby. Unfortunately, many women wean at this time through poor advice. Let the baby feed on demand, even 2 hourly, and this should settle in 48 h.

Table 6.1 How to assess good breast-feeding

Source: Murray S., Breast Feeding Information and Guidelines for Paediatric Units, Royal Children’s Hospital, Melbourne, Australia 1992.

Qualities of breast milk

Breast milk is naturally thinner in consistency than an artificial formula and may have a bluish tinge – this is normal, healthy and nutritious. The composition of breast milk varies during the feed. The fat content of milk varies diurnally: it is lowest at about 6 am and gradually increases to its peak at about 2 pm. At any one feed, the highest concentration of fat is at the end of the feed in the ‘hind milk’. The change in concentration is a gradual merging over the feed and is part of the feeding process. Hind milk is not ‘better’ than the early ‘fore milk’; fore milk is higher in water and lactose and provides liquid to quench the baby’s thirst and a quick surge of energy.

The presence of blood in the milk may cause a red or pinkish-brown discoloration. If this is present when the mother first starts expressing colostrum it may be due to duct hyperplasia. This gradually disappears and is of no significance. The most common cause of blood-stained milk (usually first noticed when the baby possets) is trauma to the nipple.

Bowel actions

The motions of breast-fed infants are normally bright yellow and soft to loose. The baby may have a bowel action with every feed (strong gastrocolic refl ex) or once every 5–8 days.

Mastitis is a common reason for early weaning. Any reports of pain by the mother should be actively addressed (see chapter 32, Neonatal conditions, p. 450).

Temporary cessation of breast-feeding

If the feeding pattern is interrupted because of illness, a planned fast for a procedure or the mother’s absence, the mother will need to express to maintain milk supply.

• Milk can be expressed by hand or by pump.
  
• Express as often as the baby would normally feed (i.e. 6–8 times a day). Several volumes of expressed milk can be added to the same bottle or storage bag (available from commercial pharmacies), but a new container should be used every 24 h.
  
• Milk may be kept in the freezer section of the refrigerator for 2 weeks or in the deep freeze for 3 months.
  
• To thaw frozen milk, place a bag/bottle in a container of cool water and run in hot water until the bag/bottle is standing in hot water. When the milk is thawed, it will be cold; continue to heat in hot water or place in the fridge until required for a feed.
  
• Thawed milk should be used within 24 h.

How much milk to express?

If the mother wants to express to give a feed by bottle or to substitute a feed as she is weaning, how much will the baby need?

Daily requirements of milk are:

• From 0–6 months: 150 mL/kg.
  
• >6 months: 120 mL/kg.

Growth in breast-fed infants

Growth patterns differ between breast-fed and artificially fed infants. Average weights of breast-fed babies are similar to or higher than formula-fed babies until 4–6 months, after which breast-fed babies slow significantly in their weight gain. Length and head circumference remain similar.

Growth charts are now available for fully breast-fed infants, although these are not in standard use. The naturally slower weight gain of breast-fed infants should not be taken in isolation as abnormal.

Maternal illness

When the mother is unwell, breast-feeding should continue. In the case of maternal infection, antibodies will pass through the breast milk to protect the baby.

Maternal drugs

If the mother has to take medication, the risk–benefit ratio should be weighed carefully by the prescriber. The mother should continue to breast-feed unless use of the drug is absolutely contraindicated during lactation and there is no safe alternative. There are very few such drugs and almost all have a safe alternative. If the mother is concerned about continuing breast-feeding, even if the drug is safe, suggest taking the drug after a feed to minimise the concentration or dividing the dose if possible.

Vitamin D

Vitamin D deficiency is increasingly recognised in Australia. Women who wear coverings (hejab), are dark-skinned or have limited sunlight exposure are at highest risk. They should be prescribed oral supplementation with vitamin D at 1000 IU/day during pregnancy. Their infants are at risk of vitamin D deficiency due to low hepatic stores and the paucity of vitamin D in breast milk. Exclusively breast-fed infants of vitamin D-deficient mothers should be screened or treated empirically e.g. with Penta-Vite 0.45 mL/day.

Formula feeding

If breast milk is not available, either from the breast or as expressed milk, a commercially prepared formula should be chosen. These are based on cow’s milk, modified to lower the protein, calcium and electrolytes to levels better suited to the human infant and contain added amino acids, vitamins and trace minerals. See tables of formula composition at www.rchhandbook.org, Nutrition, chapter 6. A ‘from-birth’ formula should be selected for infants from birth to 6 months. For infants >6 months, follow-on formulas may be used. They have a higher protein and renal solute load and are not suitable for infants <6 months of age.

The introduction of some formula (e.g. when returning to work, low milk supply) need not mean the end of breast-feeding. A combination of breast and formula may be quite suitable for the infant.

Cow’s milk-based formulas

• The range of formula options has increased in recent years, with options now including specifically modified proteins, long-chain polyunsaturated fatty acids (LCPUFA) and probiotics. All formulas meet the Australian Food Standards code and are suitable, although some are more expensive.
  
• Changes between types of formula are made for a variety of reasons, including irritability, poor sleep and possetting. In the normal thriving infant there is little indication to change the type of formula.
  
• Care should be taken when changing between formulas to use the correct scoop and dilution (as these vary between brands). A history for a formula-fed infant with possible feeding problems should include a review of formula preparation.

Soy formulas

If a soy-based feed is required, an infant formula should be chosen. These are nutritionally adequate for infants, but are suggested for specific indications (such as lactose intolerance) rather than as a regular feed option. Follow-on soy formulas are available.

Antiregurgitation formulas

Thickened formulas are aimed at reducing regurgitation. Their use should be limited to the stepwise treatment of gastro-oesophageal reflux (see chapter 27, Gastrointestinal conditions page 345). They are not recommended in healthy infants without regurgitation.

Low-lactose formulas

Infant formulas with low-lactose content are recommended only in cases of proven lactose intolerance (see chapter 27, Gastrointestinal conditions page 340).

Hypoallergenic formulas

Based on partially hydrolysed protein in place of whole cow’s milk protein, this formula group is intended as part of a preventive programme for infants who are not being breast-fed and are at high risk of developing allergy. Breast-feeding continues to be the feed of choice in infants at high risk of developing allergy. Hypoallergenic formula is not to be used as a treatment formula for an infant with diagnosed cow’s milk allergy.

Number of feeds

Introduction of whole cow’s milk

Introduction of solids

Weaning

Toddlers who will not eat

Daily food needs of preschoolers

Feeding the sick infant and child

Recommended energy and protein requirements for healthy infants and children are based on nutrient reference values (NRVs) for use in Australia and New Zealand. A full statement of the NRVs can be found at www.nhmrc.gov.au/publications/subjects/nutrition.htm

Energy requirements are increased in the following conditions:

• Very low birthweight (VLBW) infants.
  
• Chronic lung disease.
  
• Cardiac defects.
  
• Cystic fibrosis.
  
• Diseases causing malabsorption i.e. liver, SBS, allergic enteropathy.
  
• Burns.
  
• Tumours.

Energy requirements are decreased in:

• Critically ill patients who are ventilated.

Protein

Increased protein intake is recommended in:

• Protein-losing states i.e. enteropathy and nephrotic syndrome.
  
• Chronic malnutrition.
  
• Burns.
  
• Renal dialysis.
  
• HIV.
  
• Haemofiltration (∼2 g/kg per day).

Reduced protein intake is recommended in:

• Hepatic encephalopathy (0.3 g/kg per day).
  
• Severe renal dysfunction (not dialysed).

Fat

• Concentrated source of energy and essential for transport of fat-soluble vitamins and hormones.
  
• Deficiency can occur rapidly in neonates and is evidenced by reduced growth rate, poor hair growth, thrombocytopenia, susceptibility to infection and poor wound healing.

Micronutrients

Special consideration is needed when estimating the micronutrient requirements of sick children (see Table 6.2).

Feeds for infants

See Table 6.3.

• Breast milk, including expressed breast milk (EBM).
  
• Infant formulas, including ‘low birthweight’ formulas.
  
• Specialised feeds for specific disease states, e.g. inborn errors of metabolism, renal, complex malabsorption and liver conditions.

Breast milk

Breast-milk feeding should be the primary aim for very sick babies. When babies are too ill or too premature to suckle at the breast, most mothers can establish lactation by expression. EBM can be fed via a tube until the baby is well enough to be placed on the breast. In this way breast-milk feeding can be achieved in extremely premature babies and those with major malformations, birth defects and other serious illnesses. The only situations in which breast-milk feeding is not possible are:

• When an informed mother chooses not to express.
  
• Specific inborn errors of metabolism, which require exclusion formulas.
  
• Some complex malabsorption syndromes.

Table 6.2 Diseases that increase micronutrient requirements

Breast-milk fortifiers

Breast-milk fortifiers are available to add to EBM to increase its content of protein, energy and other nutrients. The addition of fortifier should be delayed until feeds are fully established (i.e. 150–200 mL/kg), unless babies have a condition requiring fluid restriction, e.g. congestive cardiac failure or chronic lung disease.

Babies who may benefit from fortifiers are those with increased nutritional requirements (e.g. VLBW babies) and those requiring fluid restriction (as listed above).

In addition, VLBW babies may require folate, iron, sodium and vitamins C, D and E. Iron should not be started until 12 weeks of age. VLBW babies who receive multiple blood transfusions may not need supplemental iron.

Infant formulas

When breast milk is not available an infant formula is required. Low birthweight (LBW) formulas are designed for very premature (<32 weeks) babies. In general, these contain more energy, protein, calcium, phosphorus, trace elements and certain vitamins than standard formula. They include LCPUFA as part of their fat content, based on evidence that this improves the developmental outcomes in premature infants. Generally LBW formulas are used until a weight of 2.5 kg is achieved. Babies are then fed with a standard infant formula which can be fortified if necessary.

Fortification of standard infant formulas

Standard formulas provide approximately 280 kJ/100 mL (20 kcal/30 mL) and 1.5 g protein/ 100 mL. Fortification should only be implemented under the supervision of a paediatrician or dietician.

• To increase energy to 350 kJ/100 mL (25 kcal/30 mL):

– Use additional formula powder, i.e. for formulas where the standard dilution is 1 scoop/30 mL of water, use 1 scoop/25 mL of water, or for formulas where the standard dilution is 1 scoop/60 mL of water use 1 scoop/50 mL of water.

– This will also increase protein and other nutrient intakes.

– Care should be taken in infants with renal or liver impairment.

• To increase energy to 420 kJ/100 mL (30 kcal/30 mL):

– Use additional formula powder as above with the addition of either glucose polymer or fat emulsion.

– Concentrate the formula further with additional powder (e.g. 1 scoop/30 mL to 1 scoop/20 mL). This provides an improved energy/protein ratio and additional nutrients which can be beneficial in fluid restricted infants and those with high catch up growth requirements. Use of this formula needs to be monitored carefully due to its higher renal solute load (RSL) and osmolality.

Specialised feeds can also be fortified in similar ways to the above.

• Infants and young children who develop an intercurrent gastroenteritis must have all fortification ceased until vomiting and diarrhoea resolve, to avoid the potential complication of hypernatraemic dehydration.
  
• VLBW babies require 180–200 mL/kg per day of EBM or standard formula, or 150– 180 mL/kg per day of fortified EBM or LBW formula, starting at 20–30 mL/kg per day at birth and increasing by 30 mL/kg per day as tolerated. Regimes should be modified according to condition and stability in VLBW infants. Initial feed frequency should be 1–2 hourly. Hourly feeds may be necessary in babies <1000 g.
  
• Orogastric tubes should be used in babies <1250 g, as nasogastric tubes cause significant airways obstruction. Continuous intragastric infusion of feed rather than intermittent boluses may help if reflux, gastric distension or apnoea is persistent.
  
• Term infants require 150 mL/kg per day. This is usually reached over 5–7 days, starting at 30–40 mL/kg per day and increasing by 30 mL/kg per day as tolerated. Feed frequency should be 3–4 hourly, although with reflux or abdominal distension, smaller volume and more frequent feeds may help.

Table 6.3 Appropriate feeds for infants

Table 6.4 Oral or enteral feeds for children 1–6 years (8–20 kg)

Feeds for children

Young children often maintain oral intake when they are ill. In some cases additional energy needs to be added to oral feeds to maintain nutritional status.

These include:

• Energy supplements, e.g. glucose polymers or fat emulsions added to normal foods and fluids to increase energy intake
  
• Complete supplements, e.g. Pediasure, Fortisip or Sustagen drinks, which can be used in addition to usual foods to increase energy, protein and nutrient intake.

Enteral feeding

Enteral nutrition is the provision of nutrients to the alimentary tract through a feeding tube. It can be used to provide the total nutritional needs of a patient (either short or long term), or to provide additional nutrients when voluntary oral intake is inadequate. See nutritional support algorithm, fig. 6.1.

Enteral feeding has certain advantages over parenteral nutrition:

• Less risk of infection.
  
• Less risk of metabolic abnormalities.
  
• Nutrients provided to the alimentary tract enhance intestinal growth and function.
  
• Inexpensive.

Administration

The most commonly used route is nasogastric, its main benefit being ease of insertion. When long-term feeding is required, a gastrostomy tube may be indicated. It is generally placed endoscopically rather than surgically.

When gastric motility is poor or when gastric residues are persistently high, a nasojejunal tube may be of benefit.

Feeding method

When choosing a method consider the feeding route, the expected length of time the feed will be required and the type of feeding regime to be used (see Table 6.6). The introduction of hyperosmolar feeds should be gradual.

Selection of feed

A full nutritional assessment (current nutritional status, current intake, requirements and the consideration of medical condition/fluid restrictions) should be carried out by a paediatric dietician to establish which feed will be optimal. See Tables 6.4 and 6.5 for appropriate feeds to use with different age groups.

It is inappropriate to administer puréed foods down feeding tubes as the amount of fluid required to achieve a suitable consistency dilutes the energy and nutrient content, while increasing the risk of microbial contamination and tube blockage.

Monitoring enteral nutrition

When monitoring patients on enteral feeds, mechanical, metabolic, gastrointestinal, nutritional and growth parameters must be assessed routinely. In the early stages of feeding, the patient’s tolerance of the feeding regimen is critical to the success of feeding.

Once the feeding plan has been fully implemented, regular assessment of the patient’s nutrient requirements is needed to ensure that nutritional support has been adequately maintained and to indicate when enteral feeding can be possibly ceased.

From enteral to oral feeding

Once the patient is able and willing to eat by mouth, enteral feeds can be reduced in proportion to the amount consumed orally. Transition from continuous feeds to overnight feeds may help establish oral intake while ensuring the patient is not nutritionally compromised.

Table 6.5 Oral or enteral feeds for children 6 years+ (>20 kg)

Table 6.6 Types of enteral feeding regimens

Home enteral feeding

The decision to provide home enteral feeding should take into consideration the patient’s medical needs and the practical, social and psychological factors that influence the family’s ability to cope with a home feeding programme.

Children on home enteral feeding, especially those who have minimal or no voluntary oral intake, require close monitoring of their growth and need their feeding regimens altered appropriately.

Common problems

• Gastrointestinal disturbance. This is the most common problem (diarrhoea, cramping, nausea and vomiting). It can be minimised by correct formula selection and review of medications. High gastric residues should be treated by reducing the rate of feeds given, feeding smaller volumes, continuously reassessing the concentration of feed and assessing GI function. Directing feed into the jejunum alleviates the problems caused by slow gastric emptying.
  
• Food aversion. Young children who have been fed enterally during infancy or for long periods of time may miss important developmental steps in self-feeding. Non-nutritive sucking and mouth contact or taking small amounts of appropriate food/fluid orally will help establish or maintain eating and feeding skills. A speech pathologist may be of assistance.
  
• Malnutrition is associated with major changes in electrolyte balance. Enteral feeding should be initiated with caution in patients with significant and long-standing undernutrition. Serum phosphate, potassium, magnesium and glucose levels should be assessed regularly (see Refeeding syndrome, p. 99).

Parenteral nutrition

For ordering and monitoring parenteral nutrition, refer to www.rchhandbook.org, Nutrition, chapter 6.

Refeeding syndrome

Fig 6.1 Nutrition support algorithm

Stay updated, free articles. Join our Telegram channel

Join