Infant Feeding Jillian Parekh, MD, FAAP July 8, 2010

Rates of breastfeeding:  In 2004 and 2003,70% of US women initiated breastfeeding Breastfeeding rates for Hispanic mothers are greater than total US population (79%)  At 3 mos, only 39% and 41% still exclusively breastfeeding  At 6 mos, only 36% of infants receiving any breast milk Only 14% were exclusively breastfeeding  In all ethnicities: married, older and highly educated women not working outside of the home were more likely to initiate and sustain breastfeeding for longer periods

Federal laws on breastfeeding:  President Obama signed the Patient Protection and Affordable Care Act, H.R. 3590, on March 23rd and the Reconciliation Act of 2010, H.R. 4872, on March 30,  Requires an employer to provide reasonable break time for an employee to express breast milk for her nursing child for one year after the child's birth each time such employee has need to express milk.  The employer is not required to compensate an employee receiving reasonable break time for any work time spent for such purpose.  The employer must also provide a place, other than a bathroom, for the employee to express breast milk.  If these requirements impose undue hardship, an employer that employs less than 50 employees is not subject to these requirements.  Furthermore, these requirements shall not preempt a state law that provides greater protections to employees.

NYC and breastfeeding:  N.Y. Civil Rights Law § 79-e (1994) permits a mother to breastfeed her child in any public or private location. (SB 3999) N.Y. Civil Rights Law § 79-e(SB 3999)  N.Y. Labor Law § 206-c (2007) states that employers must allow breastfeeding mothers reasonable, unpaid break times to express milk and make a reasonable attempt to provide a private location for her to do so. Prohibits discrimination against breastfeeding mothers. N.Y. Labor Law § 206-c  N.Y. Penal Law § et seq. excludes breastfeeding of infants from exposure offenses. N.Y. Penal Law § et seq.  N.Y. Public Health Law § 2505 provides that the Maternal and Child Health commissioner has the power to adopt regulations and guidelines including, but not limited to donor standards, methods of collection, and standards for storage and distribution of human breast milk. N.Y. Public Health Law § 2505  N.Y. Public Health Law § 2505-a creates the Breastfeeding Mothers Bill of Rights and requires it to be posted in a public place in each maternal health care facility. The commissioner must also make the Breastfeeding Mothers Bill of Rights available on the health department's website so that health care facilities and providers may include such rights in a maternity information leaflet. (2009 N.Y. Laws, Chap. 292; AB 789) N.Y. Public Health Law § 2505-a2009 N.Y. Laws, Chap. 292AB 789

Advantages of Breastfeeding - Mom:  Prevents postpartum hemorrhage (uterine contraction)  Facilitates postpartum weight loss  Reduces stress hormone levels  May provide contraceptive effect If used exclusively for 4-6 months – not reliable Amenorrhea also allows iron stores to be repleted Increased child spacing  Decreases risk of breast cancer Anovulation may also protect against ovarian cancer  Maternal-infant bonding

Advantages of Breast Feeding - Infant:  Prevents or reduces severity of illnesses GI, respiratory, OM  Reduces incidence of NEC in premature infants  Reduces frequency of UTI  Reduces death from botulism  Reduces risk of sepsis and meningitis  Reduces infant mortality  Decreases risk of chronic diseases Crohn’s, leukemia, lymphoma, DM, hypercholesterolemia,asthma, and atopic conditions  Increases long term cognitive and motor skills  Provides analgesia  Increases visual acuity  Reduces obesity in adolescents and young adulthood

Keys to successful Breastfeeding:  Informing all pregnant women about the benefits  Help mothers initiate breastfeeding within the first hour  Allow rooming-in  Encourage breastfeeding on demand  Teach positions, provide access to lactation consultant  Teach how to pump  Avoid pacifier use until breastfeeding successfully initiated  Resources for support groups…

Complications of Breast feeding:  Nipple pain  Engorgement  Plugged ducts  Mastitis

Possible contraindications:  Breast surgery  Primary insufficient milk syndrome  ID: HIV, HTLV, TB, VZV, HSV, Hep B, Hep C  Substance abuse  Alcohol  Cigarettes  Medications  Inborn errors of metabolism

Milk Supply:  Colostrum is made first Provides all nutrients neonate needs in first few days Higher in protein, lower in sugar, lower in fat  Transitional milk “milk came in” From day 2-5 up to days Supply is much greater – engorgement  Mature milk Appears near the end of second week Thinner and more watery/bluish than transitional milk

Latching:  Infant should be held so that the mouth is opposite the mother’s nipple and neck is slightly extended. Head, shoulders and hips are in alignment  While learning to latch, helps to support breast in the C-hold

Latch:  Elicit rooting reflex (nipple to lip) Wait for infant to open mouth and pull baby quickly to breast, aim nipple upperward toward hard palate  Infant should grasp entire nipple as much of aerola as comfortable  In correct latch, infants nose and chin are against breast Lips should be everted

Signs of incorrect latch:  Indentation of the infant’s cheeks during suckling  Clicking noises  Lips curled inwards  Frequent movement of infant’s head  Lack of swallowing  Maternal pain

Flow:  Suckling begins with rapid bursts and intermittent pauses – helps milk let down  Once milk flow established, approx 1 suckle or swallow per second  Peristaltic action from tongue

Breast feeding positions:  Cradle hold: Baby’s head supported by elbow May put too much pressure on abdomen if post C-Section

Cross-Cradle hold:  Works well for babies who need to be guided to latch  Hands support baby  Baby’s chest and abdomen face yours

Football or clutch hold:  This hold also allows you to guide mouth to nipple  Good for low BW or premature babies  Good for post C-Section as no pressure on abdomen

Reclining position:  Good for post C-section or feeding at night  Need to support self with pillows

Twin positioning:

Patterns:  Feeding one vs both breasts Draining one breast – hindmilk has more fat Both breasts drained – engorgement  Feedings should last minutes per breast  Allow infant to drain first breast before switching  Notice early hunger cues Increased alertness, flexion of extremities, mouth and tongue movements, cooing sounds, rooting, fist to mouth, sucking on hands  Crying is late sign of hunger – becomes more difficult to get good latch

Frequency:  In first 24 hours: infants feed 8-12 times  Frequent feeds help reduce weight loss and jaundice and establishes good milk supply  Average is every 1.5 – 3 hours  Breast milk empties from stomach faster than formula

Is my baby getting enough?  Monitoring weight 20-40g/day (after initial losses in first week)  6 or more wet diapers/day BF babies will pee less until full supply of milk arrives  Seem satisfied and happy for 1-3 hours after feed  BMs  Nurse at least 8-12 times in 24 hours  NO WATER

 Bottle Feeding: 1 month: 2-4 oz/feed 2 months: 5 oz/feed 3 months: 5-6 oz/feed 4 months: 6-7 oz/feed 5-12 months: 8 oz/feed  Breast Feeding: Birth -1 month: 6-8/day 2-6 months:4-5/day 7-10 months: 3-4/day months: 3/day

Growth:  Birth weight doubles by 5 months  Birth weight triples by 1 year

Pumping and Storage:  Establish good breastfeeding before start pumping – usually around 4 weeks old  Start with pumping in morning – supply is best  Storage of pumped breast milk: 4-6 hours at room temperature Up to 24 hours in a cooler with ice packs 5-8 days in a fridge (best in first 72 hours) 3-4 months in freezer 6-12 months in deep freezer Don’t re-freeze milk

Breast Milk Formula Fats -DHA and AA -Levels decline as baby gets older -best absorption -has lipase to digest fats -No DHA (now being added) -incomplete absorption -no lipase Protein -WHEY – easy to digest -better absorbed -lactoferrin and lysozyme – intestinal health -rich in growth factors and sleep-inducing proteins -CASEIN – harder to digest -incomplete absorption, harder on kidneys -No lactoferrin or lysozyme -Low in brain/body building proteins -Deficient in growth factors Carbs -Rich in lactose -rich in oligosaccharides -+/- lactose -deficient in oligosaccharides (promote intestinal health) Immunity -rich in WBC -rich in immunoglobulins -No live WBCs -few immunoglobulins Vitamins/Minerals -better absorbed (iron, zinc, calcium) -iron 50-75% absorbed -contains more selenium -not absorbed as well -Iron is 5-10% absorbed -less selenium Cost -$600/year in extra food for mom-$1,200/year -$2500/year for hypoallergenic -Cost of bottles and supplies Enzymes/Hormone s -rich in digestive enzymes (lipase, amylase) -Rich in hormones (prolactin, oxytocin, thyroid…) -Need to supplement Vitamin D -Processing kills digestive enzymes -processing kills hormones (not human to begin with) -Contains Vitamin D!

Types of formula:  Cow's milk-based formula - the type of formula that the average baby should be on if not being breastfed (examples: Enfamil Lipil, Nestle Good Start Gentle Plus, Similac Advance)  “Gentle" formula with less lactose than regular milk based formula - for babies with some gas or fussiness on milk-based formula (examples: Enfamil Gentlease Lipil and Nestle Good Start Gentle Plus)  Lactose-free formula - for babies with lactose intolerance (examples: Enfamil LactoFree Lipil and Similac Sensitive)  Added rice starch formula - for babies with acid reflux (examples: Enfamil A.R. Lipil and Similac Sensitive R.S.)  Soy formula - for babies with galactosemia, lactose intolerance, and milk protein allergies (examples: Enfamil Prosobee Lipil, Nestle Good Start Soy Plus, and Similac Isomil Advance)

Types of formula cont’d:  Formula for premature babies - have more calories and other nutrients for premature and low-birth weight babies (examples: Enfamil EnfaCare Lipil and Similac Neosure)  Next-step or toddler formula - for older infants and toddlers between the ages of 9 and 24 months of age (examples: Enfamil Next Step Lipil, Nestle Good Start Gentle Plus 2, and Similac Go & Grow)  Elemental formula - for babies with milk protein and soy allergies (examples: Nutramigen Lipil, Pregestamil Lipil, and Similac Alimentum)  Amino acid based formula - for babies with milk protein and soy allergies who don't tolerate an elemental formula (examples: Neocate and Nutramigen AA Lipil)

Correct Mixing of formula:  Ready-to-use : Most expensive, but no mixing is necessary.  Concentrated liquid : Less expensive, you mix the formula liquid with an equal part of water.  Powder : least expensive formula. Mix one level scoop of powdered formula with 2 ounces of water and stir well.  Not necessary to warm bottle – ok to be cool or room temperature  If baby prefers it warm: put the filled bottle in a container of warm water and let it stand for a few minutes.  Do not use a microwave (uneven heating)  Always check temperature of milk on skin before feeding to the infant.

Pediatricians’ role in breastfeeding:  MVI (Vitamin D) AAP recommends 200IU/day of Vitamin D Not needed if getting 16 oz/day of formula  Encouragement  Support  Allowing them to stop when needed

Ready for solids?  Loss of tongue-thrust reflex  Signs of self-regulation Able to tell you when you s/he is full  Ability to sit up and hold head unsupported  Interest in food  Usually around 4-6 months AAP recommends exclusive breast feeding for 6 months

Solid food introduction:  Start with rice cereal – and continue it (iron) Start with watery consistency 1 Tbsp cereal/4 Tbsp milk No evidence about which foods to start first Babies are born with sweet preference Single ingredient cereals only  Wait 3-5 days before starting a new food  Limit milk to 28 oz/day to ensure adequate nutritional intake

Stages of solids:  Stage I:  Stage II:  Stage III:

Home made solids:  Boil foods and puree  No added salts or spices  Can freeze in individual servings (ice cube trays)

Introduction of cow milk:  After age 1  Less easily digested  Contains increased minerals and proteins  Inadequate vitamins and iron

4-6 months  Cereals and grains – rice, barley, oat  Fruits: avocado, apples, bananas, pears  Vegetables: Acorn/butternut squash, sweet potatoes, green beans  Protein: None  Dairy: None  **Avocados and bananas never need to be cooked (cook all others for < 8 mos)

6-8 Months:  Cereals/Grains: rice, barley, oat  Fruits: avocados, apples, bananas, mangos, nectarines, peaches, pears, plums, prunes, pumpkin  Veggie: Sweet potatoes, squash, carrots, green bean, peas, zucchini, parsnips  Protein: chicken, turkey, tofu (estrogens)  Dairy: Plain whole milk yogurt

8-10 Months:  Cereals/Grains: Flax, graham crackers, quinoa, millet, cheerios, wheat, toast  Fruits: blueberries, melons, cherries, cranberries, dates, figs, kiwi, papayas  Veggies: asparagus, broccoli, cauliflower, eggplant, potatoes,onions, peppers, mushrooms, parsnips  Protein: egg yoks, beans/legumes, beef, pork, ham  Dairy: cream cheese, cottage cheese, cheeses (not soft)  Can start to add some spices, cook all proteins

10-12 Months:  Cereals/Grains: pastas, wheat cereals, bagels  Fruits: berries, cherries, citrus, dates, cut up grapes  Veggies: artichokes, beets, corn, cucumbers, spinach, tomatoes  Protein: Whole eggs (12 mos), fish  Dairy: whole milk after 12 mos, soft cheese after 12 months

Dangerous table foods:  Don’t introduce finger foods until age 8-9 months old  Avoid hard and smooth foods that need to be grinded Grapes – unless cut up Nuts Popcorn Hot dog – can cut up until small pieces

AAP Report in 2008:  "Although solid foods should not be introduced before 4 to 6 months of age, there is no current convincing evidence that delaying their introduction beyond this period has a significant protective effect on the development of atopic disease regardless of whether infants are fed cow milk protein formula or human milk. This includes delaying the introduction of foods that are considered to be highly allergic, such as fish, eggs, and foods containing peanut protein."

 Honey : >1 y/o  Peanut butter : age 1-2  Nuts– age 1-2  Citrus or acidic foods : >1 y/o  Raw strawberries,raspberries, blackberries : >1 y/o  Corn: > 1 y/o  Egg whites: > 1 y/o  Whole milk: > 1 y/o  Wheat: >8-10 months  Grapes: 10 mos-1 year  Shellfish: 1-2 years

Question:  A 2 month old exclusively breast-fed infant presents to your office b/c mom thinks he is irritable. Has been passing loose stools and cries with bowel movements. Generally, happy at other times. PE is normal. Anal inspection reveals no fissures. Stool specimen has redish flecks, guaiac is +.  Of the following the BEST next step is to: A. begin therapy with oral Amox B. institute trial of lansoprazole C. Obtain an upper GI series D. remove milk products from maternal diet E. send stool for C. Diff toxin testing

Answer: A. begin therapy with oral Amox B. institute trial of lansoprazole C. Obtain an upper GI series D. remove milk products from maternal diet E. send stool for C. Diff toxin testing

Explanation:  Infant is passing small amounts of blood in stool, but very well appearing.  Most likely allergic colitis – first line treatment is dietary restriction of milk protein from mother’s diet. Other common offending agents: soy, wheat, eggs, corn, fish, nuts  Usually rectal bleeding resolves within 3 weeks after dietary restriction. Condition usually resolves by 1 year of age.  C. Diff is present in stool of 25% of healthy term infants – but rarely cause of colitis

Question:  During your morning nursery rounds, you find you have a new patient who was born to a mother infected with HIV. The mother asks about any precautions she needs to take in the care of her newborn.  Of the following, you are MOST likely to tell the mother that she should: A. add a teaspoon of liquid bleach to the infant’s bath water B. avoid breastfeeding C. avoid sharing utensils D. take no specific action E. wear gloves while changing diapers

Answer: A. add a teaspoon of liquid bleach to the infant’s bath water B. avoid breastfeeding C. avoid sharing utensils D. take no specific action E. wear gloves while changing diapers

Explanation:  Risk of transmission of HIV from infected mother to infant without an intervention is ~15-25%.  Breastfeeding by an infected mother increases the risk by 5-20%.  In countries where safe alternatives to breastfeeding are readily available, feasible, affordable – avoidance of all breastfeeding is recommended.

Question:  You are evaluating an 8 week old infant whose BW was 1,000g and was delivered at 30 weeks gestation. Initially he had early resp distress and sepsis, but now these problems are resolved and he has moved from parenteral nutrition to full enteral feeds.  Of the following the feeding that will provide the BEST mineral content to ensure healthy bone development for this infant is: A. cow milk based formula B. human milk C. premature formula D. protein hydrosolate formula E. soy protein based formula

Answer: A. cow milk based formula B. human milk C. premature formula D. protein hydrosolate formula E. soy protein based formula

Explanation:  VLBW preterm infants are at risk for delayed bone mineralization due to constraints in delivering optimal nutrition to them while in NICU.  Need to optimize Ca and Phosphorus balance (hard to do with TPN). Demineralization of bone often happens after 4 weeks of TPN (increased alk phos).  Term infant cow milk formula has insufficient calories, protein, Ca, P, and other trace minerals and vistamins (same as human milk).  Preterm formulas contain higher calorie density, more readily absorbed lipids, greater protein content, encriched Ca and Phos, minerals and vitamins  Healthy bone development usually ensured by 44 weeks (post conception)

Question:  You are addressing a group of new mothers regarding infant feeding. One mom asks you when an infant can be switched from formula to whole cow milk.  Of the following, you are MOST likely to respond that whole cow milk: A. Can be introduced at 6 mos of age if an infant has significant GER. B. can be given at 9 mos if the infant is also taking a wide variety of supplemental foods. C. may be given as supplement at any age as long as infant also receives human milk. D. should be avoided until 12 mos of age because its iron content is poorly absorbed. E. should be avoided until 2 years of age because its caloric content is inadequate for optimal growth.

Answer: A. Can be introduced at 6 mos of age if an infant has significant GER. B. can be given at 9 mos if the infant is also taking a wide variety of supplemental foods. C. may be given as supplement at any age as long as infant also receives human milk. D. should be avoided until 12 mos of age because its iron content is poorly absorbed. E. should be avoided until 2 years of age because its caloric content is inadequate for optimal growth.

Explanation:  Iron content of cow milk is 0.5mg/L – up to 10% is absorbed – inadequate to prevent iron deficiency even when iron rich foods added.  Iron fortified formulas contain 10-12mg/L of iron and ~4% is absorbed. This is sufficient up to 6 months, then iron rich foods should be added (as iron stores become depleted).  Cow milk also has a higher content of protein and electrolytes (Na, K) – renal solute load is too high for infant kidneys