Feeding Infants



Feeding Infants


Susan A. Friedman

Brenda Waber



NUTRITIONAL NEEDS OF HEALTHY FULL-TERM INFANTS

Table 6-1 summarizes the nutritional needs of a healthy full-term infant.



image HINT: Contraindications to both breast- and bottle-feeding:



  • Respiratory rate >80 breaths/min


  • Infant with poor suck/swallow


  • Absent gag reflex


  • Symptoms of sepsis or asphyxia


BREAST-FEEDING

Breast-feeding is the optimal choice for feeding almost all infants, and breast milk is the gold standard on which most routine infant formulas are based.


RISKS OF FORMULA FEEDING



  • Increased incidence and severity of infectious diseases, including diarrhea, respiratory tract infections, bacterial meningitis, otitis media, urinary tract infections, necrotizing enterocolitis, and bacteremia


  • Increased incidence of sudden infant death syndrome


  • Increased incidence of childhood obesity


  • Increased incidence of type 1 and type 2 diabetes mellitus


  • Increased incidence of leukemia, lymphoma, and Hodgkin disease


  • Possible increased incidence of hypercholesterolemia


  • Possible reduced cognitive development


  • Maternal outcomes, including increased postpartum bleeding, slower return to pre-pregnancy weight, increased risk of breast cancer and ovarian cancer, increased risk of postmenopausal osteoporosis, and increased risk of postpartum depression.


CONTRAINDICATIONS TO BREAST-FEEDING



  • Some inborn errors of metabolism (e.g., classic galactosemia)


  • Maternal HIV-positive status


  • Active (untreated) tuberculosis



  • Maternal alcohol abuse and certain maternal illicit drug use. Significant cigarette smoking (more than four cigarettes per day) should be evaluated on a case-by-case basis


  • Herpes simplex lesions on a breast


  • Breast cancer (currently under treatment)


  • Maternal prolactinoma (in most cases)


  • History of breast reduction surgery involving ligation of many/most of the milk ducts (may breast-feed if supplements are provided as needed)


  • Maternal use of medications and/or radioactive materials that are contraindicated with breast-feeding, as per the findings of the American Academy of Pediatrics Committee on Drugs, 2001








TABLE 6-1 Nutritional Needs of Healthy, Full-Term Infants























Nutritional Element

Daily Requirement


Calories

˜110 kcal/kg/da


Fluids

˜160 mL/kg/db


Carbohydrates

37-44% of cal


Protein

10-12% of cal


Fat

40-50% of cal; 3% from linoleic acid


a Calories decrease over first year as follows: EER kcal/d 0-3 mo 89 × wt (kg) – 100 + 175 4-6 mo 89 × wt (kg) – 100 + 56 7-12 mo 89 × wt (kg) – 100 + 22

b Of formula or breast milk, to provide adequate calories.




image HINT: Maternal hepatitis B infection is not a contraindication to breastfeeding, provided the infant receives hepatitis vaccination and hepatitis immunoglobulin shortly after birth. Maternal hepatitis C infection is not a contraindication to breast-feeding.


PATIENT COUNSELING


Drug Use During Lactation

The nursing mother should be counseled to avoid all drugs, including over-thecounter and herbal medications, until she has consulted her physician. The reference by Hale (see Suggested Readings) is an excellent resource for evaluating maternal medication use. Alcohol intake should be limited. If the mother does have an occasional small drink (up to 6 oz beer or 4 oz wine), she should wait at least 2 to 3 hours before breast-feeding. Cigarette smoking should be discouraged but is no longer considered an absolute contraindication to breast-feeding because its benefits outweigh the risks for light smoking. The mother should be counseled regarding the dangers of decreased milk supply and the effects of nicotine on the infant if smoking exceeds four cigarettes per day.



Nutrition and Rest

Nursing mothers need greater amounts of most vitamins, protein, zinc, and fluid. Calcium needs, along with most other minerals, are not increased during lactation. Iron requirements are reduced due to lack of menses. It is recommended that mothers eat a well-balanced diet with a variety of foods including high-quality protein foods, fruits, vegetables, dairy products, and whole grains. A multivitamin is recommended. Mothers who have lost all their pregnancy weight gain may need to consume additional calories. Adequate rest is also important (it is ideal if the mother can nap when the infant naps).


Breast-Feeding Technique

It is neither necessary nor desirable to wash the nipples, but clean hands are important. The mother should be comfortable—it may be helpful to place extra pillows under her elbows and on her lap. The baby should be positioned on his side in the mother’s arms, facing the mother, with his nose lined up across from the nipple so the head is in the “neutral” position (i.e., the infant should not have to turn the head to latch on) and tipped back with the chin up.

The mother should support the breast, taking care to keep her fingers away from the areola. Stroking the lips downward from the nose toward the chin will induce him to open his mouth wide, at which point he should be drawn close to the mother’s body, encouraging latching on to as much of the alveolar tissue as possible. Both breasts should be offered at each feeding and the infant allowed to remain on each breast as long as suckling continues. One breast may be sufficient, especially during the first few days of life. The starting breast should be alternated. Nipples should be allowed to air-dry or be patted dry before covering them at the end of the feeding.


Feeding Frequency and Intake

The healthy infant should be encouraged to latch on within the first hour after birth. Continuous rooming-in facilitates breast-feeding. Feedings for the first few weeks should take place on demand at least every 2 to 3 hours, ideally 8 to 12 times per 24 hours. No supplemental water or formula should be given to the baby during the first 2 weeks, unless medically indicated. Table 6-2 summarizes nutrition supplementation for full-term breast-fed infants. An adequate latch-on and suckling should be assured and documented prior to hospital discharge.








TABLE 6-2 Nutrition Supplementation for Full-Term, Breast-Fed Infants















Formula

Not recommended during the first 2 wk unless medically indicated


Fluoride

0.25 mg/d, after 6 mo (if water is not fluoridated). Avoid fluoridated toothpaste until after 2 yr of age


Vitamin D

400 IU/d, starting ASAP after birth


Iron

Elemental iron (1 mg/kg/d starting @ 4 mo) Starting at 6 mo pureed meat as first food




MANAGEMENT OF PROBLEMS


Engorgement

Engorgement may occur on the third or fourth postpartum day and can cause significant discomfort for the mother. It is important to reassure the mother that a high level of engorgement typically lasts only 24 to 48 hours. Management strategies include the following:



  • Continuing to nurse frequently


  • Application of hot compresses or taking a hot shower before nursing to alleviate discomfort


  • Application of ice packs to the breasts after nursing. Chilled cabbage leaves are also effective


  • Administration of acetaminophen or ibuprofen


  • Pumping only a small amount of milk to avoid increased milk production (if a breast pump is being used)


Sore, Cracked, or Hemorrhagic Nipples



  • The infant’s position on the nipple should be reevaluated by a medical professional or lactation consultant; an infant that latches on to an inadequate amount of the nipple is the most common cause of sore nipples. The mother should be sure the infant’s lower lip is furled outward.


  • Exposure of the nipples to air is important. In addition, applying expressed breast milk to cracked nipples and allowing them to air-dry has resulted in dramatic healing in some patients. Lansinoh cream and ComfortGel pads may also be helpful.


  • Mothers should be advised to nurse the baby on the least affected side first. Prefeeding with milk that has been manually expressed may appease the overly vigorous nurser. In severe cases, breast-feeding on the affected side should be temporarily discontinued and a breast pump used.


  • Administration of acetaminophen 20 minutes before nursing (not to exceed recommended dosing) may alleviate discomfort.


Plugged Milk Ducts

A plugged milk duct or galactocele presents as a persistent hard, round, or linear lump, usually in the lateral and inferior quadrants of the breast. Warm moist heat should be applied to the breast for 20 minutes before each nursing, and the breast should be massaged from the body toward the nipple, concentrating on the involved area. Mothers should be advised to nurse the baby frequently (i.e., every 1 to 2 hours) for at least 10 minutes on each side. The affected side should be offered first, and the infant should be positioned with his chin toward the affected area, which will facilitate emptying of the affected quadrant. It may take several nursing sessions to empty the plugged duct. Complete emptying of the breast is advised; this may require the use of a breast pump after nursing. Rarely, a galactocele will become large enough to require surgical aspiration.



Mastitis

Lactating mothers with mastitis present with fever, shaking chills, and malaise, followed by localized breast erythema and pain. Mothers should be advised to continue to nurse frequently. Treatment is with oral ampicillin, the application of warm compresses, rest, and pain medication (if necessary).


Poor Early Weight Gain

Breast-fed full-term infants may lose as much as 10% of their birth weight during the first several days of life, but they should regain it by 7 to 10 days of age. Weight loss of >10% of birth weight should prompt a reevaluation of the infant and breast-feeding technique, with improvement documented prior to discharge.


Follow-Up of the Breast-Fed Infant

An evaluation by a pediatrician or health professional at 3 to 5 days of age is important to catch any problems early. This visit should include an infant weight and physical examination, with emphasis on hydration status and jaundice. The mother should be questioned regarding:



  • The frequency and duration of nursing sessions.


  • Signs of established lactation (i.e., diminished breast fullness after nursing, leaking, cessation of nipple discomfort after latching on, and uterine cramps during nursing).


  • Normal infant voiding (minimum of four to six times per day, pale urine). Note: The baby may void twice between diaper changes, so the number of voidings may vary.


  • Normal infant defecation (3 to 4 loose stools/day on days 3 to 4, 4 to 6 loose stools/day on days 4 to 6, 8 to 10 loose stools/day during weeks 2 to 4). Note: continued meconium stooling after day 5 may indicate low milk supply.


  • Infant response to feeding (e.g., sleepy and satisfied).

According to Lawrence (6th ed., 2005), these are the most common factors associated with poor early weight gain:



  • Ineffective breast-feeding technique


  • Infrequent or inappropriately short feedings (e.g., excessive nighttime intervals)


  • Water supplementation


  • Maternal problems that inhibit milk letdown


BOTTLE-FEEDING


Patient Counseling


Bottle-Feeding Technique

The bottle should be held so that no air enters the nipple, and the bottle should never be propped. Prop feeding is associated with a significantly higher risk of otitis media.



Feeding Frequency and Intake

Formula can be given every 3 to 4 hours. A small-for-gestational-age infant may require small frequent feedings until his gastric capacity increases, whereas a largeforgestational-age infant of a mother with diabetes should be given early and frequent feedings, and his blood sugar should be monitored carefully to reduce the risk of hypoglycemia.

The typical full-term neonate drinks only 15 to 30 mL (0.5 to 1 oz) per feeding during the first few days of life. The mother should be assured that this is sufficient because of stores acquired in utero. She should be told to expect an intake of 2 to 4 oz per feeding (approximately every 3 to 4 hours) by the end of the first week.


Formula Types

Tables 6-3 and 6-4 list the specific compositions for and indications for many commonly available infant formulas. Cow’s milk should not be introduced until 1 year of age. Manufacturers frequently change formula names and composition. Check websites (listed at end of this chapter) for most current accurate information.


Cow’s Milk-Based Formulas

Full-term (standard) formulas, which provide 20 kcal/oz, are generally suitable for infants with birth weights >2,000 g, and most full-term small-for-gestationalage infants.


Soy-Based (Lactose-Free) Formulas

Soy-based formulas are indicated for infants with temporary or chronic lactose intolerance and for infants with galactosemia. They are also often used when intolerance to cow’s milk protein is suspected. However, the use of soy-based formula in this situation is not generally recommended because of a significant antigenic crossover between cow’s milk protein and soy protein. Soy-based formulas are not recommended for prolonged use in preterm infants because the phytate content may lead to hypophosphatemia and rickets.


Preterm Formulas

The advantages of breast milk are even more significant for preterm infants because of the anti-infectious properties and easy digestibility of breast milk. If breast milk is not available, preterm formulas should be used. These formulas, available as 20, 24, or 30 kcal/oz, are specially designed to meet the needs of preterm infants. These can be mixed in different caloric concentrations to meet the nutritional needs of individual infants. They should be used until the infant reaches 40 weeks post-conception (or longer, if the infant’s birth weight is >1,000 g). Transitional formulas providing 22 kcal/oz are available and should be used for preterm infants until 9 to 12 months of adjusted age.


Dietary Calorie Supplementation

Caloric supplements are often required for infants with higher-than-usual caloric needs, decreased oral intake, decreased fluid tolerance, or a combination of these factors (e.g., preterm infants, infants with bronchopulmonary dysplasia, and






infants with congestive heart failure). Care should be taken to maintain the correct balance of nutrients. In general, the first step to increase calories should be to increase the concentration of the formula by adding less water to the powder or liquid concentrate. Careful instructions must be given to the parents to ensure the correct amount of water is added.








TABLE 6-3 Composition of Select Infant Formulas (Note: Names and Composition Frequently Change. Please Check Company Website for Latest Information)















































































































































































































































































































































































A: Breast Milk/Term Formulas


Product (Manufacturer)

kcal/oz

Carbohydrate (g/100 mL)

Protein (g/100 mL)

Fat (g/100 mL)

Fe mg/100 mL

mOsm kg Water


Mature human milk

20

Lactose (7.2)

Mature human milk (whey, casein) (1.1)

Mature human milk (3.9)

0.3

290


Enfamil Premium (Mead Johnson)

20

Lactose (7.5)

Whey Nonfat milk (1.4)

Palmolein, coconut, soy, higholeic sunflower oils DHA/ARA (3.6)

1.2

300


Similac Advance (Abbott)

20

Lactose Galactooligosaccharides (7.3)

Nonfat milk Whey concentrate (1.4)

High-oleic safflower, soy and coconut oils DHA/ARA (3.7)

1.2

310


Similac Advance Organic (Abbott)

20

Organic corn maltodextrin, organic Lactose, organic sugar (7.1)

Organic Nonfat milk (1.4)

Organic high-oleic sunflower, organic soy and organic coconut oils DHA/ARA (3.7)

1.2

225


Good Start Gentle Plus (Gerber/Nestle)

20

Lactose 70% Maltodextrin 30% (7.8)

Whey protein concentrate hydrolysate (1.5)

Palmolein, coconut, soy, higholeic sunflower oils, DHA/ARA (3.4)

1.0

250


Good Start Protect Plus probiotics (Gerber/Nestle)

20

Lactose 70% Maltodextrin 30% (7.5)

Whey protein concentrate hydrolysate (1.5)

Palmolein, coconut, soy, higholeic sunflower oils DHA/ARA (3.4)

1.0

250


Bright Beginnings Premium (Bright Beginnings)

20

Lactose (7.4)

Whey concentrate and nonfat milk (1.4)

High-oleic sunflower, safflower, palmolein, and coconut oils (3.6)

1.2

300


Bright Beginnings Organic (Bright Beginnings)

20

Lactose (7.1)

Whey concentrate and nonfat milk (1.5)

High-oleic sunflower, safflower, palmolein, and coconut oils (3.6)

1.2

274


B: Soy Formulas


Product (Manufacturer)

kcal/oz

Carbohydrate (g/100 mL)

Protein (g/100 mL)

Fat (g/100 mL)

Fe mg/100 mL

mOsm kg Water


Similac Sensitive Isomil Soy (Abbott)

20

Corn syrup and sucrose (7.0)

Soy protein isolate, L-methionine (1.7)

High-oleic safflower, coconut, and soy oils DHA/ARA (3.7)

1.22

200


Enfamil ProSobee (Mead Johnson)

20

Corn syrup solids (7.1)

Soy protein isolate, L-methionine (1.7)

Palmolein, coconut, soy, and high-oleic sunflower oils DHA/ARA (3.6)

1.2

170


Bright Beginnings Soy (Bright Beginnings)

20

Corn syrup (7.1)

Soy protein isolate, L-methionine (1.7)

Palmolein, coconut, soy, and high-oleic safflower/sunflower oils DHA/ARA (3.6)

1.2

162


Good Start Soy Plus (Gerber/Nestle)

20

Corn Maltodextrin (7.5)

Enzymatically hydrolyzed Soy protein isolate (1.7)

Palmolein, coconut, soy, higholeic sunflower oils DHA/ARA (3.4)

1.2

180


C: Additives


Product (Manufacturer)

kcal/oz

Carbohydrate (g/100 mL)

Protein (g/100 mL)

Fat (g/100 mL)

Fe mg/100 mL

mOsm kg Water


Similac Human Milk Fortifier (Abbott)

4 kcal/oz fortifier (per 4 pkts)

Corn syrup solids (1.8)

Nonfat milk and whey protein concentrate (1.0)

MCT oil and lecithin (0.36)

0.35

Adds 90


Prolact + H2MF + 4 (20:80 to maternal BM) (Prolacta)

4 kcal/oz fortifier (per 20 mL)

Human milk concentrate (2.0)

Human milk (1.2)

Human milk (1.8)

0.2

Adds 76


MCT oil (Nestle)

7.6 kcal/mL

None

None

MCT oil



Microlipid (Nestle)

4.5 kcal/mL

None

None

Safflower oil emulsion



Beneprotein (Nestle)

25 kcal per scoop = 1.5 Tbsp

None

Whey protein isolate lecithin (6.0)

None



Polycose (Abbott)

23 kcal per 6 g powder = 1 Tbsp

Glucose polymers (5.6)

None

None



Duocal (Nutricia)

42 kcal/Tbsp

Hydrolyzed cornstarch (6.2)

None

Corn, coconut, MCT oil (1.9)



Rice cereal (per Tbsp)

9 kcal/Tbsp

Rice starch (1.9)

None

None



D: Preterm Breast Milk/Premature Formulas


Product (Manufacturer)

kcal/oz

Carbohydrate (g/100 mL)

Protein (g/100 mL)

Fat (g/100 mL)

Fe mg/100 mL

mOsm kg Water


Preterm Human Milk

20

Human milk (6.6)

Human milk (whey and casein) (1.4)

Human milk (3.9)

0.12

290


Enfamil Premature 20 (Mead Johnson)

20

Corn syrup solids and lactose (7.4)

Whey and nonfat milk (2.0)

MCT, soy, hi oleic sunflower/safflower oils DHA/ARA (3.4)

1.2

240


Enfamil Premature 24 (Mead Johnson)

24

Corn syrup solids and lactose (8.7)

Whey and nonfat milk (2.4)

MCT, soy, hi oleic sunflower/safflower DHA/ARA (4.1)

1.4

300


Good Start Premature 24 (Gerber/Nestle)

24

Corn maltodextrin. lactose (8.4)

Hydrolyzed whey (2.4)

MCT, soy oil, hi oleic safflower oil DHA/ARA (4.2)

1.44

275


Similac Special Care 20 (Abbott)

20

Corn syrup solids and lactose (7.0)

Nonfat milk and whey protein concentrate (2.0)

MCT, soy, and coconut oils DHA/ARA (3.7)

1.22

235


Similac Special Care 24 (Abbott)

24

Corn syrup solids and lactose (8.4)

Nonfat milk and whey protein concentrate (2.4)

MCT, soy, and coconut oils DHA/ARA (4.4)

1.46

280


Similac Special Care 30 (Abbott)

30

Corn syrup solids and lactose (7.8)

Nonfat milk and whey protein concentrate (3.0)

MCT, soy, and coconut oils DHA/ARA (6.7)

1.83

325


Enfamil Enfacare (Mead Johnson)

22

Corn syrup solids and lactose (7.7)

Whey concentrate and nonfat milk (2.1)

Soy, high-oleic sunflower, MCT, and coconut oils DHA/ARA (3.9)

1.33

250


Similac Expert Care Neosure (Abbott)

22

Corn syrup solids and lactose (7.5)

Whey concentrate and nonfat milk (2.1)

Soy, coconut and MCT oils DHA/ARA (4.1)

1.34

250


E: Formulas with Protein Alterations


Product (Manufacturer)

kcal/oz

Carbohydrate (g/100 mL)

Protein (g/100 mL)

Fat (g/100 mL)

Fe mg/100 mL

mOsm kg Water


Similac Expert Care Alimentum (Abbott)

20

Sucrose, modified tapioca starch (6.9)

Casein hydrolysate, L-Cysteine, L-Tyrosine, L-Tryptophan, L-Methionine (1.9)

Safflower, MCT, and soy oils DHA/ARA (3.7)

1.2

370


Nutramigen with Enflora LGG (Mead Johnson)

20

Corn syrup solids, modi fied cornstarch (6.9)

Casein hydrolysate, L-Cysteine, L-Tyrosine, L-Tryptophan (1.9)

Palmolein, soy, coconut, and high-oleic sunflower oils DHA/ARA (3.6)

1.22

300


Pregestimil (Mead Johnson)

20

Corn syrup solids, modified cornstarch (6.8)

Casein hydrolysate, L- Cysteine, L-Tyrosine, L-Tryptophan (1.9)

MCT, soy, and high-oleic safflower/sunflower oil, corn oil DHA/ARA (3.8)

1.28

290


EleCare (Abbott)

20

Corn syrup solids (7.2)

L-Amino acids (2.1)

High-oleic safflower oil, MCT, soy oil DHA/ARA (3.3)

1.0

350


Nutramigen AA (Mead Johnson)

20

Corn syrup solids (6.9)

L- Amino acids (1.9)

Palmolein, soy coconut and high-oleic sunflower oil, DHA/ARA (3.6)

1.2

350


Neocate Infant with DHA/ARA (Nutricia)

20

Corn syrup solids (7.8)

L-Amino acids (2.1)

Palm and or coconut, hi oleic safflower, soy oil DHA/ARA (3.0)

1.24

375


F: “Gentle” Formulas


Product (Manufacturer)

kcal/oz

Carbohydrate (g/100 mL)

Protein (g/100 mL)

Fat (g/100 mL)

Fe mg/100 mL

mOsm kg Water


Enfamil Gentlease (Mead Johnson)

20

Corn syrup solids, lactose 25% (7.2)

Partially hydrolyzed nonfat milk, whey protein concentrate solids (1.5)

Palmolein, coconut, soy, and high-oleic sunflower oils DHA/ARA (3.6)

1.2

220


Enfamil AR Also known as Enfamil Restful (Mead Johnson)

20

Rice starch, lactose, and maltodextrin (7.4)

Nonfat milk (1.7)

Palmolein, coconut, soy, and high-oleic sunflower oils source DHA/ARA (3.4)

1.2

240


Similac Sensitive for Spit up (Abbott)

20

Corn syrup, rice starch, sugar (7.2)

Milk-protein isolate (1.5)

High-oleic safflower, soy and coconut oil, DHA/ARA (3.7)

1.22

180

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Sep 14, 2016 | Posted by in PEDIATRICS | Comments Off on Feeding Infants

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