Chapter 16

Newborn Nutrition
 Parents look to nurses to provide: education, guidance, & support when choosing feeding method
 Nutrition has effect on infant’s growth & brain development

RECOMMENDED INFANT NUTRITION

 American Academy of Family Physicians recommend exclusive breastfeeding for 1st 6 months
o w/ addition of solid foods along w/ breastfeeding for another 6 months into second year of life
 World Health Organization recommends exclusive breastfeeding for 6 months
o and then the addition of appropriate foods along with breastfeeding for 2 yrs. Or more
 Breastfeeding = Normal “gold” standard
 Woman w/ education & family support more likely to continue breastfeeding to 6 months or longer PP
 Nurse plays crucial role in facilitating success w/ lactation
o Mother makes decision to breastfeed before delivery in most cases
 Choices should be discussed in 2nd trimester & throughout pregnancy & PP
 Percentage of infants breastfed
o At birth 83.2%
o 6 months of age 57.6%
o 12 months 35.9%

NUTRITIONAL NEEDS OF THE INFANT

 Calorie needs based on age, size, & sex
o Calorie needs per/kilogram of weight are higher during 1 st yr of life
 HCP measures by length and weight on growth chart to determine adequacy of infant’s caloric intake
 Calories are provided from protein, fat, & carbohydrates in diet
o Of the protein requirement
 50% used for growth in first 2 months of life
 Declines to 11% by 2-3 yrs. of age
o Fat provides
 40-50% of calories supplied during infancy and is source of essential fatty acids
o Carbohydrates, primarily lactose, principle source of dietary energy
 Water requirements for 1st 6 months are met when adequate amts. Of breast milk or formula
consumed
 Newborn eats small amounts first few days
o Infants have small stomach and caution parents to avoid overeating
 Over feeding will lead to regurgitation after feedings
o Infant stomach capacity:
 Day 1 = 5-7 mL
 Day 3 = 22-27 mL
 Day 10 = 45-60 mL
 Calorie & fluid requirements of the newborn
o Estimated calorie requirements
 Term infant: 105-108 kcal/kg/day
 Preterm infant: 110-120 kcal/kg/day
o Estimated fluid requirements
 Term infant: 140-160 mL/kg/day
  Preterm infant: 60-80 mL/kg/day

THE BREASTFEEDING MOTHER & INFANT

 CDC & WHO encourage exclusive breastfeeding to promote infant health & reduce mortality
 Academy of Breastfeeding Medicine recommends all health care professionals promote breastfeeding
early in prenatal care & recognize that it is superior to bottle feeding.
 Policies to promote breastfeeding
o Place newborn in direct skin-to-skin contact w/ mother after delivery
 Mother & baby should not be separated & encourage to sleep in close proximity
 Water or formula should not be given unless medically indicated
o Assist w/ latching on during the 1st hour after birth
LACTOGENESIS
 “milk production” includes processes needed to transform the mammary gland from its nonproducing
state to milk production
 At puberty, estrogen stimulates breast tissue to enlarge through growth of mammary ducts into
mammary fat pad
o Effects of estrogen & progesterone enable formation of the structure of the adult female breast, but full
alveolar development & maturation of the epithelium require hormones of pregnancy
 Mammary glands basic unit is alveolus that connects to a ductule.
o Each ductule drains to a duct, then empties into the lactiferous sinuses (where milk is stored)
o At end of each ductule is a cluster of small, grapelike sacs called alveoli
 Cluster of alveoli is called a lobule
 Cluster of lobules is called a lobe
o Each breast contains between 15-20 lobes w/ one milk duct for every lobe
 The 15-20 milk ducts merge w/ 8 or 9 ending at the tip of the nipple to deliver milk to baby
 After birth & delivery of placenta, estrogen & progesterone levels drop quickly
 Nipple stimulation occurs from latching the infant onto the breast
o Signals pituitary gland to trigger to increase prolactin
 Prolactin causes alveoli to take proteins, sugars, & fat from the blood supply & make breast milk
 Colostrum- 1st substance produced by breast
o Very small amts during the 2nd & 3rd trimesters
 Pregnant woman may notice small amt of sticky substance on bra/nightgown
o Perfect 1st food for newborn
 Easy to digest
 Highly concentrated w/ carbohydrates & fat
 Contains secretory immunoglobulin A (IgA)
 IgA protects baby from infections in MM in the throat, lungs, & intestines
 Contains leukocytes to protect baby from infections
 Contains laxative that aids in passage of the first meconium stool after birth
 For baby to get milk from breast, the let-down reflex must occur
o Suction on nipples stimulates pituitary gland to release prolactin to produce milk & oxytocin
o Oxytocin causes cells around alveoli to squeeze glands to push the milk into the ductules and into the
ducts.
 Mother may notice let-down reflex and a tingly/warm sensation in breast
o Let-down reflex can be triggered by mother hearing baby cry or thinking about her baby
o As baby suckles, the let-down reflex, compression of areola, & negative pressure created by suction
allows milk to be delivered to baby
COMPONENTS OF BREAST MILK
  Proteins: balance of the proteins approx.. 60% whey and 40% casein, allows infant to digest breast milk
easily. Other specific proteins in breast milk are:
o Lactoferrin: has bactericidal & iron-binding properties
o Secretory IgA: protects infant from viruses & bacteria
o Lysozyme: enzyme that promotes growth of healthy intestinal flora & had anti-inflammatory functions
 Bifidus factor: support the growth of lactobacillus, which creates acidic environment in intestines
 Cholesterol & Fats: essential for brain development & absorption of fat-soluble vitamins & is a
primary calorie source
 Vitamin: amts. & types in milk are directly related to mother diet intake
 Carbohydrates (lactose): Lactose is primary carbohydrate found in human milk
o Accounting for 40% of total calories provided in milk
 Antibodies: from mother reduce the risk of neonatal infections

STAGES OF HUMAN MILK

 Stage 1 COLOSTRUM
o Yellowish fluid present for 2-3 days
o Contain high level of protein & lower levels of carbohydrates, fats, & calories than mature milk
o High in immunoglobulins G & A
 Protect infant from infections
o Laxative effect to promote passage of meconium stool
 Stage 2 TRANSITIONAL MILK
o This stage is from day 3 to day 10
o Contains increasing levels of carbohydrates & fat with decreasing levels of protein
 Stage 3 MATURE MILK
o Fore milk: milk produced & stored in breast between feedings.
 Higher water content than hind milk
o Hind milk: produced after several minutes of feeding
 Had higher fat and content contributes to the feeling of fullness & satisfaction for baby
ADVANTAGES OF BREASTFEEDING
 Provides exact nutrients required for an infant’s growth & development
 Provides immunologic protection
o Mother will pass on some of her immunities to the baby
 Convenient & economical for mother
 Promotes physical contact between mother and baby to enhance bonding & attachment
 Lower risk for developing premenopausal breast & ovarian cancer for mother
DISADVANTAGES OF BREASTFEEDING
 Mother needs to be available for feeding or provide pumped milk if absent
 Feeding in public may be embarrassing
 Certain medications can interrupt feeding
 Early breastfeeding may be uncomfortable
 Leaking of breast milk may occur & require nursing pads to be worn in bra
CONTRAINDICATIONS FOR BREASTFEEDING
 An infant diagnosed with galactosemia can damage liver, kidneys, & brain
 o Galactosemia: rare genetic metabolic disorder that makes it difficult for infant to metabolize milk
sugar
 Infant whose mother is:
o HIV +
o Taking antiretrovirals
o Untreated, active TB
o Infected with human T-cell lymphotropic virus type I or II
 Virus that cause some leukemias & lymphomas
o Using or dependent upon illicit drugs
o Has herpes lesion on breast
o Taking cancer chemotherapy agents,
 Such as antimetabolites that interfere with DNA replication & cell division
o Undergoing radiation therapies
 Nuclear medicine therapies require only temporary interruption in feedings
BREASTFEEDING TECHNIQUES
 Mother benefits from a relaxed & supportive environment
o Assist w/ positioning, education, & positive feedback during process
o Minimize interruptions & visitors will facilitate process
o Partners should be educated & involved in feeding sessions
 Woman w/ partners who support & encourage are more likely to choose this method of feeding
 NEWBORN CUES
o Mother needs to be taught signs that baby is interested in nursing.
 If baby does not show signs of hunger, still offer the breast every 2 ½ hours until breastfeeding
has been established
 Infant hunger cues include:
 Rooting
 Making hand to mouth movements
 Making mouth & tongue movements while awake/alert state
 POSITIONING
o Mother should wash hands first to avoid transferring bacteria to breast
o Mother should be in comfy sitting or side lying position in bed
 Pillows should be placed around mother to support baby and prevent mother from hunching back
 Pillows can be placed to support arm
 Baby should be placed in mothers arm w/ his/her stomach flat against the mothers abdomen
o Another position is football hold, infant is cradled in mothers arm w/ infants head in palm and buttocks
toward mothers elbow
 This position puts lets stress on abdomen if mother is recuperating from C/S
 ACHIEVING LATCH-ON
o Mother position her hand around the breast, cupping it with finger close to chest wall
 Hands usually in “C” position as she supports her breast
 Thumb on top, & her fingers underneath breast
 Avoid covering areola (dark area around nipple) which goes into infants mouth
o After positioning lightly brush nipple across lips of infant to elicit rooting reflex
 Baby will open mouth and extend tongue
 Mother should bring baby to her breast and maneuver the nipple and areola into infants mouth
that will initiate sucking reflex
o Put baby on breast every 2 ½ hours during 1st 4-5 days after birth to assist in creation of milk supply
 30-40 min of sucking for infant to have complete feeding
 If baby falls asleep on breast, mother should take him/her off breast and change to other breast,
and resume feeding
 Burp baby between breast
o Mother should alternate breast at which each feeding begins.
  Helps stimulate the production of milk
o Avoid offering supplemental formular or water b/c some babies will suck on bottle even if full of breast
o Reassure mother that even though it takes up much time in beginning, after feeding is established the
infant becomes stronger and feeding are much faster
o Instruct woman that baby should have several wet diapers & 2-3 dirty diapers per/day
 Stools are looser than formula fed babies
 CHECKPOINTS FOR CORRECT LATCH-ON
o Observe position of mother
 Is she comfortable w/ pillows in appropriate locations?
 Reposition if needed
o Observe position of baby.
 Is he/she lying “tummy to tummy” with the mother?
 If not, reposition
o Observe position of baby on the areola
 Usually lips need to be 1-2 inches beyond the base of the nipple
o Observe infants lower lip
 Should not be folded in
o Observe motion of the masseter muscle & listen for sounds of swallowing
 A clicking sound indicated improper positioning
o Observe the comfort level of mother.
 If she experiencing any nipple pain
 Take the infant off the breast & latch-on again
 SIGN OF EFFECTIVE BREASTFEEDING
o Mothers breast soften during and after feeding
o Mother can hear infant swallow during feeding
o Number of wet diapers increases to at least 6-8 by time infant is 6 days old
o Infant has 2-3 yellow stools per/day by the 5th day after birth

BREASTFEEDING CHALLENGES
 SORE NIPPLE INTERVENTIONS
o Make sure infant has correct latch-on every time baby placed on breast
o Change positions from sitting to side-lying or football hold to move infants mouth to different position
on breast
o Gently insert little finger between breast & infant’s mouth to break seal & prevent pulling baby off nipple
o Change nursing pads often to avoid trapping moisture
o Expose nipple to air to promote healing
o Avoid harsh soaps on breast
o Applied modified anhydrous lanolin after nursing to keep skin soft
o Massage colostrum or breast milk into nipple to soothe
 NIPPLE CONFUSION
o To avoid nipple confusion & be able to later give the baby a bottle, she should establish breastfeeding for
at least 2-3 wks. before introducing bottle
 Latex nipple fits into infants mouth differently than a breast nipple
 Infant learning to breastfeed can have difficulty learning how to place his/her jaws & tongue if a
latex nipple introduced to early
 LOW MILK SUPPLY
o During baby’s growth spurts at 3 weeks, 6 weeks, & 3 months, the supply may be a little low to please
baby
 o The “cluster feeding” method is when a mother breastfeeds more often and allows the baby decide when
to end the feeding to accommodate the baby’s increased hunger
 Baby feeds as often & as long as he/she wants
 This method of feeding will increase milk supply
o Mother can also try offering both breast at each feeding
 Have baby stay on first breast as long as he/she is still suckling & swallowing
 Offer other breast when baby slows down
 ENGORGMENT
o Can happen when body is adjusting to the amount of milk to make or 1 st time baby sleeps through the
night
o Breast may feel heavy & swollen with a flat nipple
 To prevent or minimize, the mother should breastfeed every 2 ½ hours when baby is awake
 can soften the breast with a warm cloth in the shower and then express enough milk by hand to
allow correct latch-on by baby
o latching-on correctly, & the feeding will take care of the engorgement
 FLAT OR INVERTED NIPPLES
o Make difficult to latch-on the baby
o Flat nipples do not stand out from areola; inverted nipples retract or pull inward
o Women w/ these nipples may require more assistance w/ feedings
 Breast pump may be used to evert or “pull out” the nipple
 Before delivery, the lactation specialist may recommend pregnant women wear breast shield or a
supple cup to encourage the nipple to protrude from breast
 PROS: Nipple shields have been shown to aid in the establishment of a breastfeeding
relationship, & research shown that they are helpful for premature infants who have weak
suction, allowing the infant to stay attached at the breast, & obtain milk with minimum
suction
 CONS: The use of nipple shields have been also associated with poor weight gain in the
baby, prevention of proper positioning of the nipple in baby’s mouth, decreased milk
supply, & worsening of sore nipples. May also be difficult to wean baby from the shield
 Lactation specialist should offer individualized breastfeeding care, including advantages
& disadvantages of nipple shields
o Involving the mother in process will empower her to make decision that is
beneficial for her & baby
 WARNING SIGNS OF BREASTFEEDING PROBLEMS
o Losing more than 5-7% of birth weight
o Not gaining back birth weight by 10 days of age
o Not having at least 2-3 bowel movements per day after day 2
o Not having 4-5 wet diapers per/day by day 4 w/ clear or pale-yellow urine
 Indicates inadequate hydration

THE FORUMLA-FEEDING PARENTS & INFANT

 Formular industry acknowledges importance of human milk & recognizes breastfeeding as preferred
method for feeding baby’s
o Industry is committed to producing formulas modelled on breast milk
o Commercially prepared formulas meet the nutritional requirements based on recommendations of the
committee on Nutrition of the American Academy of Pediatrics to provide infant with the right
combination of protein, fat, carbohydrates, vitamins, & minerals
 Cow’s milk is not suitable for infants under 1 yr. of age
o Contains higher level of protein than infant requires
o Fat is difficult for infant to digest
o Poor source of iron
o Contain small amts of vitamin C, E, & Copper
 o Sodium level is too high for baby
ADVANTAGES OF FORMULA
 May be appropriate choice for a mother w/ chronic illness who requires medications harmful to infant
 Provides adequate & acceptable nutrition for the infant
 Anyone can feed baby
 Mother does not need to worry food or alcohol intake can affect baby
 May be easier to leave the infant w/ sitter or family member to give parents a break
DISADVANTAGES OF FORMULA
 Woman breastmilk may come in anyways, causing breast engorgement and pain
 Formula can be expensive for parents on budget
o Low-income parents can apply to special nutrition program for woman, infants, & children (WIC)
 WIC targets low-income nutritionally at-risk woman who are pregnant through 6 weeks PP,
breastfeeding woman, nonbreastfeeding woman, infants, & children up to 5 years of age
 Government funded program provides nutritious food such as infant cereal, baby food,
eggs, milk, cheese, yogurt, whole grain foods, vegetables, & fruits
 Also provides screening & referral to other health & welfare services
 Bottles, nipples, & formula must be purchased
 Bottles & formular must be carried along with the infant
 Increased risk for serious illness d/t improper dilution or home additives
 Increased risk for GI illness
TYPES OF FORMULA
 Most have 20 calories in each ounce
 Prepared formular should be in covered container in fridge, & unused formula should be thrown out
after 24 hrs.
 Hypoallergenic formula should be given if an allergy to milk-based formula is suspected
 Soy based formula should be given to infant who cannot take dairy-based products for health, cultural,
religious, or personal reasons
o Such as vegan family lifestyles
 Parents should be taught the following about formula:
o Read-to-feed formula: available in a can or carton & should NOT be diluted
o Liquid concentrated formula: is formulated to be diluted with equal amts of water
o Powder formula: should be dissolved in formula
 Parents concerned about safety of tap water
o Water should be sterilized before making formula
 Can buy sterilized water or make your own
 Water can also be checked for lead, nitrates, & bacteria. The steps to sterilize water are these:
 Let cold water get as cold as possible.
o May take 2 min.
o This process reduces the amount of lead and other contaminates in water
 Bring the cold water to a boil & let it boil for 1-2 min
 Let water cool before preparing bottles
 Well water in rural agricultural areas can be contaminated w/ nitrates, which is dangerous for baby
under 6 months old
o Can cause a problem with blood oxygen level
BOTTLE FEEDING THE INFANT
 Educating parents about bottle feeding, include the following:
 o Prior to purchasing formula, check expiration date
o After purchase, sterilize bottles and nipples.
 After initial sterilization, bottles do not need to be sterilized unless water supply is not safe
 If water supply not safe, water for mixing formula should be boiled first
 Washing bottle & nipples w/ soap & water or in dishwasher kills bacteria
o Follow directions exactly to dilute formula or to mix bottles correctly
o Wash outside of formula container prior to opening
o Some babies drink formula out of fridge, others prefer bottle warmed
o Warm in bowl, warm water, or bottle-warming device
 NEVER warm formula in microwave. Microwaves heat unevenly and baby can be burned
o Check temp of warmed formula on inner wrist to avoid burning baby
o Make sure the nipple is not too large to cause gagging or too small to cause frustration for infant
o Parents & caregivers should wash hands prior feedings
o Before feeding, find comfy seating & have burp cloth near
o Cradle baby in one arm, with head slightly elevated, and hold the bottle with the opposite arm
 Angle bottle so baby is not sucking in air
o Keep nipple filled with formula
o Stop & take burping breaks
o Try different nipple shapes to see what baby prefers
o Discard contents of any bottle that has been out of fridge for more than 2 hours
o Continue to feet until newborn gives indications of being full
 Such as decrease in sucking, spitting out the nipple, turning away, or pushing bottle away
 Never force baby to finish a bottle
o When baby begin to cut teeth, do not let baby fall asleep with bottle in mouth b/c this can lead to tooth
decay from milk sugar
BOTTLE-FEEDING PROBLEMS
 Warm parents about following practices that are not healthy or safe for infant:
o Infant cereal fed through a bottle increases the risk of choking
o Water or fruit given before 6 months of age does not meet calorie and nutritional needs
o Overdiluting formula to reduce expenses decreases calorie content and reduce the nutritional value of
formula
o Formula mixed w/ private well water that has not been teste for safety
o Allowing baby to sleep with bottle in crib
 Propping a bottle should never occur
o The baby could choke and aspirate without adult observation
o The baby who falls asleep with a propped bottle has residual milk left in mouth that pools around the
teeth
 Milk sugar can cause breakdown of the teeth causing nursing-bottle syndrome