Infant Feeding
Breast feeding
Human milk is the most appropriate milk for human
infant, it could be exclusive, predominant, partial breast feeding.
Exclusive: breast milk only without
any other substance .
Predominant: breast milk with non
calorie containing substance e.g. water or drug .
partial breast milk with
calorie containing substance like other milk and tea.
Anatomy of the breast
Breast is the largest
exocrine gland, it consists of 18 segments which impeded in connective
tissues and fat, each segment consists of thousands of secretory units (alveoli).
The alveoli are surrounded by myoepithelial cells that have the ability of contraction, by
which they push milk to ductules then to larger ducts and to the lactiferous
sinus that opens into the nipple.
Physiology of breast feeding
The infant sucking reflex
result in afferent impulse to the mother hypothalamus and then to both anterior
and posterior pituitary gland, from anterior pituitary the prolactin
is secreted which stimulate milk secretion in the acini of the alveoli
of the breast, from the post pituitary the secretion of oxytocin
lead to contraction of myoepithelial cells which surrounded the alveoli
which squeeze milk into the larger duct, this called milk ejection reflex.
Advantages of breast feeding
First for the mother:
1- enhance the involution of uterus
2- decrease the incidence of
breast cancer
3- emotional satisfaction
4- inhibit ovulation so as a method
of contraception
Second for the baby:
1- mother milk is not
allergic. Allergy to cow’s milk creates significant disturbances of
feeding, symptoms of cow’s milk allergy include: diarrhea, intestinal bleeding,
occult Melina, spitting up, colic and atopic eczema. Breast milk doesn't cause
this because it differs from cow's milk; in addition to contain secretory IgA.
2- decrease the liability for rickets because:
It contains double amount
of vit. D, It contains the optimum
calcium/ phosphate ratio (2:1) this enable good absorption of calcium from gut.
N.B. as growth progresses,
there will be an increased demand for vit. D,
calcium and phosphate, so we must supply the baby with extra vit.
D starting for 3-4 months of age
onwards, along with exposure to sun light that adds the conversion of
vit. D to active form.
3- Irons deficiency anemia is
less frequent because;
Breast milk contains 1.5 times more iron than cow's milk.
And better absorption
4- it has anti infectivity
properties because :-
a. bacterial and viral
antibodies including secretary IgA
which prevent microorganism from adhering to the intestinal mucosa, also it
contains IgG, IgM and IgD.
b. lysosymes against
bacteria and foreign bodies.
c. lactoferrin
(iron-binding protein), it has an inhibitory effect on the growth of bacteria
especially E.coli by it's link to iron i.e. deprive bacteria from its iron source leading to
bacterial stasis.
d. lactoperoxide (bactericidal).
e. interferon
(antiviral).
f. bifidus factor which enhances the
growth of lactobacillus bifidus (normal flora of the intestine that
produce vit. K).
g. bile salt which
stimulate the lipase enzyme that kills Giardia lamblia and Entameba
histolytica.
h. macrophage, lymphocyte
(T and B cells) and epithelial cell, all of which act against recurrent
infection, G.E, and ARI.
i. low ph of the
breast.
j. always breast milk is clean,
not need heating, not need sterilization, and not need
preparation which may contaminate milk.
5- psychological
satisfaction for the baby and mother.
6- Economical
advantage.
-- CONDITIONS FOR WHICH HUMAN MILK HAS BEEN SUGGESTED TO HAVE A
PROTECTIVE EFFECT
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Technique of breast feeding
1- Proper position:
The mother should be relaxed and sit
comfortably supporting her back, the infant should be warm and dry, held by his
mother in horizontal position facing her mother (not facing the ceiling) that
his abdomen in contact with mother's abdomen, his head is supported by mother
elbow and the buttock is supported by the hand of same side, so that the hand
of the other side is free, so can support the breast by C shaped way and avoid
scissoring way.
2- Proper attachment of baby
to the breast (proper latch on);
Signs of proper attachment: all of
upper areola and most of lower areola engaged in the mouth of baby, the baby's
upper lip and lower lip are averted, the baby's cheeks are fuelled, baby's chin
is in contact with the mother breast, there is no pain during sucking and the
sound of swallowing is heard by the mother.
To start feeding, the mother should
stimulate rooting reflex of the baby by touching the corner of the baby's
mother by her nipple, so by this reflex the baby will turn his face and open
the mouth toward the stimuli, then the mother should engage her nipple and areola
in the baby's mouth. To finish feeding, the mother finger is introduce into the
baby's mouth between the gums or onto the internal aspect of the check to
unlatch the nipple and stop feeding, rather than pulling the nipple from the
mouth.
After each feeding, the infant mouth
corner should be cleaned, baby is held in erect position for few minutes with
several taps over back to eructate him, then put to sleep on the cot on his
right side.
Establishing and maintaining
breast feeding
1- initiate breast-feeding within 1 hr of birth and four hrs. after s.c.
2- Rooming in: that is to put
the baby beside his mother Place the
newborn and mother skin-to-skin to satisfied her and decrease the worry of the
mother.
3- No need extra water unless the weather is hot. Do not give sterile water, glucose, or formula unless indicated
4- The baby must be exclusively breast fed in the first 4 and 6
months of life
5- 85% of the milk will be finish in the first 5 min. of feeding
and in the 2nd five min. the baby finish all milk, slow feeder
infant take about 15-20 min.
6- Feeding at night will lead
to prolactin secretion and milk supply.
7- Psychological factor: no
factor important than happy and relax state of the mother, and the mother
should be fully alert when breast feed her baby.
8- The infant should be fed
on demand, but infant who cannot be fed on demand he/she should be fed every 3
hrs. on day and every 4 hrs. at night.
9- Bottle feeding will stop
breast feeding because it lead to confusion of the baby between the nipple and
the teat of the bottle.
10- Mother's diet should be
balanced.
Criteria of adequacy of
breast feeding
1- The baby is calm, happy and sleep well after feeding.
2-
Normal bowel motion, no constipation.
3-
Normal urine output.
4-
Normal weight gain: 20-25 gm/day.
Criteria of inadequate breast feeding
1- the baby is crying most of
the time.
2-
Long meal time (grasp the breast for a long period).
3-
Very short sleep.
4-
Loss of weight or failure to gain weight.
5-
Constipation.
6- oliguria.
factors influencing milk Productions
and secretions
1- Endocrine factor: prolactin,
oxytocin, etc.
2-
Anatomical factor: under developed breast, retracted nipple.
3-
Mechanical factor: the Breast should be fully evacuated to enhance the process
of milk production and secretion so need good sucker.
4- Psychological
factor, such as fear and stress of the mother.
5-
Nutritional status of the mother.
6-drugs
like chloropromozin (largectil), metachlopromid ( plasil) increase milk
production, diuretic and contraception ( hormonal) decrease milk production.
Mothers should be encouraged to nurse at each breast at each feeding
starting with the breast offered 2nd at the last feeding. The mature milk when
secreted from the breast compose of two parts, the first part called fore milk
and second part called hind milk,
if the baby take both breast by one fed he will take only the fore milk
which contain more lactose than water, so the baby develop diarrhea (fore milk
diarrhea). To treat this
condition it is preferable to empty the 1st breast before offering the 2nd in
order to allow complete emptying.
Some
conditions make difficult breast feeding:
A- on
mother side:
1-
Flat or inverted nipple.
Treatment:
a-
antenatal treatment: probably not helpful, e.g. stretching the nipple, most
nipples improved around time of delivery.
b-
soon after delivery:
1-build
mother confidence explain that her breast will improve but need patience.
2-
help her to position her baby.
3-
help her to try different positions (other positions that easier for her), e.g.
under arm position.
4-
use pump or syringe method to make nipple stand out.
5- for
1st w. express breast milk and feed baby with cup, or express the
milk into the baby's mouth.
2-
Breast engorgement:
Painful,
edematous, shinny overlying skin, milk not flow.
Causes:
plenty of milk, delayed starting to breast feed, infrequent removal of the milk
(infrequent suckling).
D.D: full
breast; heavy breast, milk flow easily, no fever and not
shiny.
Prevention:
start feeding soon after delivery, encourage unrestricted breast feeding.
Treatment: do
not rest the breast.
*if baby able to suck: feed frequently
*if baby not able to suck:
express the milk by hand or with pump
Before
feed warm compress or warm shower, massage to neck and back of the mother to
stimulate oxytocin reflex and light massage to the breast toward the chest of
the mother.
After
feed: cold compress on breast to reduce edema.
3- Mastitis
Mastitis may follow breast engorgement or a condition called a blocked
duct. it occurs in 2-3% of lactating women and is usually unilateral,
manifesting with localized warmth, tenderness, edema, and erythema after the
2nd postdelivery week. Sudden onset of breast pain, myalgia, and fever with
fatigue, nausea, vomiting, and headache can also occur. Organisms implicated in
mastitis include Staphylococcus aureus, Escherichia coli, group A
streptococcus, Haemophilus influenzae, Klebsiella pneumoniae, and
Bacteroides spp. Diagnosis is confirmed by physical examination. Oral
antibiotics and analgesics, while promoting breast-feeding or emptying of the
affected breast, usually resolve the infection. A breast abscess is a
less-common complication of mastitis, but it is a more serious infection that
requires intravenous antibiotics as well as incision and drainage, along with
temporary cessation of feeding from that breast.
Causes
of blocked duct and mastitis:
1-
infrequent or short breast feeding
2- poor draining of part or all
the breast due to pressure from clothes, pressure from finger during feeds
3-
damaged breast tissue (due to trauma)
4-
bacteria allowed entry (due to nipple fissure)
Treatment:
Improve
draining of breast by treat the cause like remove the narrow clothes, advise frequent feeding,
start feeding on un affected side then on affected side, gentle massage toward nipple, warm compress, if no
improve use antibiotics like fluxacillin, erythromycin, complete rest.
4-Nipple Pain
Nipple pain is one of the most common complaints of breast-feeding
mothers in the immediate postpartum period. Poor infant positioning and
improper latch are the most common reasons for nipple pain beyond the mild
discomfort felt early in breast-feeding. If the problem persists and the infant
refuses to feed, consideration needs to be given to nipple candidiasis, and
both mother and baby should be treated if candidiasis is found. In some cases,
especially if accompanied by engorgement, it may be necessary to express milk
manually until healing has occurred
5-Nipple
fissure and sore nipple:
Causes:
improper position or attachment (latch on), or due to Candida infection.
Treatment: treat the cause like correct position and
attachment, treat Candidiasis for baby and mother, wash breast once and avoid
use soap, avoid medicated lotion or
ointment, rub hind milk on areola after feed.
B- on
baby side:
1-
Catarrhal and blocked nose: due to upper ARI.
Rx:
normal saline nasal drop or warm water nasal drop.
2- oral thrush; as mentioned.
3-
tongue tie: short frenulum.
4-
hare lip.
5-
poor suck as in prematurity.
6-Milk Leakage
Milk leakage is a common event in which milk is involuntarily lost from
the breast either in response to breast-feeding on the opposite side or as a
reflex in response to other stimuli, such as an infant's cry. Milk leakage
usually resolves spontaneously as lactation proceeds
Contraindication of breast feeding
A-on
mother side:
1-
mental and neurological disease of the mother.
2-
infections like malaria, septicemia, typhoid fever, T.B., viral hepatitis and
CMV infection.
3-secretion of toxic drug: like
anticoagulant, antithyroid drugs, cytotoxic drugs.
4-chronic
debilitatory disease, like H.F., renal failure, un controlled D.M.
B-on
baby side:
1-
inborn error of metabolism, like galactosemia, phanylketonurea.
2- cleft
lip and palate.
Colostrum
It is
the 1st milk produced after delivery continue for 3 days. At 3rd-10th
day of infant life it transform into the transitional milk and finally to
mature milk, the amount of colostrum is 15-50 ml/day it is bright lemon in
color, more alkaline than mature milk and has more specific gravity, also have
anti-infective and laxative effect which is benefit to get rid from meconium.
Content
of colostrums: more protein, more mineral, less CHO and fat.
Protein
2.7 gm/100ml, fat: 2.9 gm/100ml, lactose 5.3gm/100ml, mineral 0.5 gm/100ml
Comparison
between human milk and cow's milk
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Cow's milk
|
Human milk
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Material
|
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3.3 (80% casein, 20% whey)
|
1 (30% casein, 70 % whey)
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Protein gm/100ml
|
|
4 (40% unsaturated, 60%
saturated)
|
4 (6o % unsaturated, 40%
saturated)
|
Fat
|
|
4.5
|
7
|
Carbohydrate (lactose)
|
|
67 Kcl/100ml
|
67 Kcl/100ml
|
callori
|
|
0.8%
|
0.2%
|
Mineral
|
|
The same
|
Water
|
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Vitamins:
cow's milk is low in vit. C and D, breast milk contain adequate vit. C and D
provided that the mother in good diet and exposed to some light, cow's milk
contain more vit. K than human milk, both types contain adequate vit. A and B
complex.
Bacterial
content: although human milk is essentially uncontaminated by bacteria,
pathogenic organisms in significant number may enter the milk from mastitis.
Tubercle, typhoid bacilli, herpes, hepatitis B, rubella, mumps, HIV and CMV may
be found at times in the milk of women infected by these organisms.
Cow's
milk however is good culture for pathogenic bacteria, and many infections are
milk borne including streptococcal disease, diphtheria, typhoid fever,
salmonellosis and brucellosis, in addition to bacteria that cause G.E and diarrhea.
Digestibility:
The
stomach empties more rapidly after human milk than after whole cow's milk. The
curd of cow's milk is reduced in size by boiling and makes less tough and much
smaller by evaporation or by add acid and alkali.
drugs
and breast feeding
Contraindicated:
Antineoplastic,
amphetamine, bromocriptine, cimetidine, chloramphenicol, ergots, heroin,
immunosuppressant, iodide, meprobamate, nicotin, Tetracycline, methimazol
(antithyriod).
Avoid
or give with great caution:
Aspirin
(salicylats), atropine, birth contracaptive pill, cascare, calcifirol,
metoclopramide, metronidazole, Phenobarbital, primidine.
Probably
save but give with caution:
Anesthetic,
Acetaminophen, Aldomet, Chloropromazine, Codine, Digoxin, Hydralazin,
Prednisollon, Theophyllin.
Formula
feeding
Technique
of artificial feeding
The
mother and baby should be comfortable, unhurried and free from distraction, the
infant should be hungry, warm and fully a wake and should be held as if he is
breast feeding. The bottle should be held so that milk not air go through the
nipple of the teat, the bottle is warmed to body temperature, the temperature
is tested by dropping milk on to the wrist. The nipple hole should be of size
so that milk drops slowly, the eructation of air swallowed during feeding is
important to avoid regurgitation and abdominal discomfort (this technique is
the same in breast feeding).
Indications
of formula feeding
1- all contraindications of
breast feeding insufficient breast milk (this is compose only 2% of breast
feeding mother), employment of the mother outside, twins and metabolic disease:
Types:
1-
substitutive (no breast milk).
2-
complementary breast and formula:in each feed, and supplementary one feed from breast
and the second feed from formula.
Types
of milk formula
1-
liquid milk
a-
raw milk: this is not advised for infant feeding, it forms large curds in the
stomach is slowly digested and is easily contaminated.
b-pasteurized
milk: pasteurization destroys pathogenic bacteria and modified casein, raw milk
is heated at 37cº for 15 sec. then rapidly cooled, pasteurized milk should be
boiled when used for infant feeding, it is allowed to stand in the refrigerator
for as long as 48h.
c-
homogenized milk: in this milk the fat globules are broken into minute
particles so smaller and less tough curd produced in stomach
d-
evaporated milk: the advantages are can keep for months without refrigerator,
casein and fat and softer so less curd in stomach , this milk can be feed in
higher concentration (one ounce → 44 KCL)
e- condensed
milk: about 45% cane sugar has been added, more sweetened milk →↑ CHO content
to 60%. Although readily digested, it has no use in infant feeding for more
than short periods when a high calorie diet is desired.
2- dried milk: prepared by evaporating
water from milk to dry for each 100cc of liquid milk is transformed into 12.5gm
powder (1:8).
a-
dried whale milk: fat content is 3.5%.
b-
dried skim milk: non fat skim milk, fat content o.5%, in half skim milk fat
content is 1.5% are available for infant with fat intolerance, should not be
used in 1st 2 y. of life, it's high protein and mineral content may
cause sever dehydration.
Advantages
of dried milk:
1-
sterile and highly saluted.
2-
composition is constant.
3-
can be stored for along period.
4-
effect of heat on protein make it easily digested (casein is destroyed).
5-
can be modified to different children.
6-
less expensive.
Modified
formula;
1-
low lactose milk
2-
lactose free milk e.g. isomol for galactosemia
3- hypo
allergic milk (isomol) contain no milk protein, replaced by Soya protein
completely 4- phenylalanine free milk (lofenalac)
for phenylketonuria
6-Low
Na milk for congested heart failure
3-
acidified milk: these milk require less hydrochloric acid for gastric digestion
done by
a-
chemically : adding lactose, citrus or acetic acid to milk
b- biologically
: adding lactobacillus
How
much to feed?
80-120
kcal/kg/24 h. (110 kcal/kg/24h.), each
30 ml = 1oz = 20 kcal
Techniques
and preparation:
Bottle
is rounded not angled, teat is suitable in size, material and flow
Sterilization:
boiling 5-10 min., or with Na hypochlorid tablet. How to reconstitue.? Ratio 1:8 ; one scoop
4gm reconstitute in 30 ml of water. American scoop is 8gm.
Weaning
Aims:
1-
the child can not tolerate more than 1 liter/day, so with increasing needs for
energy, more solid food should be added.
2- with growth, babies requires
more food items, such as mineral and vitamins that can not be supplied by milk.
3- to
train G.I.T. digest starch and other solid food.
4- to
induce child dependence using spoon and cup by himself.
Basis
and technique of weaning:
1- should start at the age of 4-6m.
2-
weaning should be gradual to prevent G.I.T upset, also sudden weaning cause
psychological upset.
3- do
not start at summer.
4- should
not be start at convalescent period of any disease.
5-
replacing on meal for milk feed: any new food should be initially offered once
a day with small amount (1-2 teaspoonful) new food are generally best accepted
if fairly thin or dilute.
6- it is usually wise to offer
the same food daily until the baby become accustomed to it, and not introduce
new food more after than every 1-2w. e.g. of food item:
a- fruit:
washed banana is readily digested and enjoyed by most infants
b-
vegetables: should be freshly cooked, vegetables are usually added to infant's
food by 7m. of age
c-
eggs: the yolk of the eggs is used initially, egg white should be introduced
with caution from allergy. Potato start at the 2- 6m. of life, rice, bread
added of 6-8m. of life, meat can use by about 6m. of age. Citrus food after
1y., fish after 1y., tomato after 1y.
food
additives: artificial flavors and colors have been associated with respiratory
allergies, urticaria and angioderma.
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