Chapter 11 Newborn Feeding Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1.

Chapter 11

Newborn Feeding

Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1

Breastfeeding


Objectives

Define key terms listed. Discuss the cultural influences related to the

choice of breastfeeding or bottle-feeding the newborn.

Explain the physiologic characteristics of lactation.

Discuss the dietary needs of the lactating mother.

Compare the nutrients of human milk with those in cow’s milk.


Objectives (cont.)

Discuss breastfeeding in relation to advantages, care of the breasts, diet and fluids, newborn responses, and secretion of drugs in breast milk.

Compare various maternal and newborn positions used during breastfeeding.

Identify principles of breast pumping and milk storage.


Overview

The nurse assists the mother in learning the correct techniques on how to feed her infant, whether by breast or bottle

Education, including common concerns, will help parents assume their new role


Cultural Influences

Attitudes and beliefs vary Modesty or embarrassment Some see colostrum as unclean Recent immigrants see formula as a symbol

of a new way of life


Cultural Influences (cont.)

Hot-cold theory Postpartum seen as “cold”; therefore only “hot”

foods are eaten (e.g., chicken, honey, rice) Galactogogues (breast milk stimulators) such

as sesame tea, brewer’s yeast, and beer


Feeding Choices

Nurse’s role Educate parents concerning their choices Promote feelings of confidence and competence in

feeding techniques Accept feeding choice of the parents

Mother needs to be comfortable with her choice and to feel she is doing what is right for her and her baby


Breastfeeding and Federal Legislation

Many states have laws that allow women to breastfeed in public settings

It is not indecent exposure, lewd conduct, or sexual misconduct

There have been several attempts at the federal level to make breast pumps a deductible medical expense


Maternal Nutrition During Lactation

Mother needs 500 additional calories than her nonpregnant diet in order to maintain a healthy nutritional status

Protein intake: 65 mg/day Increased calcium intake Vitamin supplements also recommended 8 to 10 glasses of

noncaffeinated/nonalcoholic beverages each day


Physiology of Lactation

Lactation: secretion of milk Result of many interacting physiologic factors

Development of breast tissue and a duct system Under the influence of hormones, such as

estrogen, progesterone, and human placental lactogen (hPL)

hPL stimulates alveolar cells to begin lactogenesis


Physiology of Lactation (cont.)

Later part of pregnancy, breasts secrete colostrum

After delivery of the baby and the placenta, the hormones rapidly decrease

Lead to an increased production of prolactin (stimulates milk production)

Suckling of the breast stimulates oxytocin, which produces the let-down, or milk-ejection, reflex


Physiology of Lactation (cont.) Mother will usually feel

a tingling in her breasts when let-down occurs

Abdominal cramping may also be felt because oxytocin stimulates uterine contractions

Aids with involution of the uterus in the postpartum period


Breast Milk

Three types produced during the establishment of lactation Colostrum Transition milk Mature milk


Colostrum

Produced for first 3 or 4 days postpartum Contains high levels of antibodies, protein,

minerals, and fat-soluble vitamins Low in sugar and fat Easy to digest Rich in immunoglobulin Helps establish normal intestinal flora Laxative effect speeds passage of meconium


Transitional Milk

Lasts between the 5th day and 2 weeks postpartum

Composition of milk changes Lactose, fat, and calories increase


Mature Milk

Looks similar to skim milk (somewhat bluish) Causes some mothers to question whether

their milk is rich enough to support their baby Mature milk contains approximately 22.5

kcal/oz and is just right to meet the needs of the infant


Composition of Breast Milk

Protein is lower than in formulas Greater proportion of calories from

carbohydrates in form of lactose More fat present in the hindmilk Contains enzymes that aid in digestion Fluoride is present if mother drinks fluoridated

water


Immune Protection in Breast Milk

Protects against several bacterial and viral diseases Lactoferrin plays a part in controlling bacterial

growth in the GI tract Immunoglobulin A protects against

development of many allergies Contains long-chain polyunsaturated fatty

acids and amino acids that promote eye and neurologic development


Breastfeeding: Preparing the Breasts

Can begin during pregnancy Flat nipples: roll between fingers just before

feeding to help them become more erect Hoffman’s exercise: place fingers on areola

and gently pull to stretch tissue Releases adhesions that may cause nipple to be

inverted


Preparing for Breastfeeding

Void (empty bladder) Wash hands

Primary cause of the spread of infection Assuming comfortable position May want to change baby’s diaper


Frequency and Length of Feedings

Breast milk is digested more rapidly than formula

Feedings occur every 2 to 3 hours, around the clock If fed frequently during the day, infant may have

longer sleep periods during the night Until meconium passed, may consume 15 to

30 mL per feeding By 1 week of age, around 60 to 90 mL per

feeding


Readiness for Feeding

Observe infant’s behavior Rooting, sucking, hand-to-mouth activity,

clenched fist, kicking of legs, crying, and alertness are all cues

Mother often experiences “let-down” reflex (tingling, fullness, or stinging) or milk leakage when preparing to breastfeed her infant.


Length of Time for Feeding

About 15 to 20 minutes per breast If too short, infant only receives the fore-milk,

which will cause the infant to become hungry sooner than if he or she received the hindmilk

Burp the infant after feeding Alternate breasts used to start feedings


Cues Infant Is Receiving Adequate Feedings

Slowing of the sucking pattern Falls asleep at the breast Breasts feel soft and empty Has at least 6 wet diapers and several stools

per 24-hour period Infant gains weight


Teaching Feeding Techniques


Positioning


Hand Positions


Correct Positioning For the feeding to occur,

consider The alignment of both

mother and infant Position in which mother

holds newborn Hand position for

supporting breasts Newborn’s mouth, lip, and

tongue position


Sucking Patterns

Some infants will suck several times before swallowing; others will swallow with each one

Soft sound indicates infant is swallowing Noisy sucking, clicking sound, dimpling of

cheeks may indicate improper mouth position Repositioning is required


Initiating Breastfeeding

Ideal time to start is within 1 hour of birth Assist mother in positioning infant to the

breast Stimulate the rooting reflex of infant Latch-on technique


Removal from the Breast

Insert finger into corner of infant’s mouth to break suction

Remove breast before infant starts to suck

Place downward pressure on infant’s chin


Burping

Done to remove swallowed air

Perform at middle and end of feeding


The Sleepy Infant

Unwrap infant Change diaper Hold infant in upright position Talk softly to infant Gently massage back, palms, or soles of feet


The Fussy Infant

Stiffening or crying after feeding starts May indicate

Sore mouth from thrush Gas or cramps Some illness requiring further investigation


Evaluating Feeding Techniques

Infant position Maternal focus Technique Satiety


Special Breastfeeding Situations


Multiple Births

Twins can be breastfed simultaneously Mother may need help in positioning both

infants


Premature Birth

Infant needs the immunologic advantages breast milk can provide

Mother can pump breast milk so it can be given to infant, usually through gavage feeding technique

If infant can be fed at the breast, the same preparations need to be followed (e.g., hand hygiene, diaper change)


Delayed Feedings

Mother can pump breasts and store milk in refrigerator or freezer for specific amounts of time

Can be used by the mother who works outside the home


Supplemental Feedingsand Nipple Confusion

Supplemental feedings should not be offered while in process of establishing breastfeeding Infant may find it easier to obtain fluid from the

bottle nipple May become fretful or irritable

Once lactation is firmly established, a pacifier can be provided for nonnutritive sucking


Storing and Freezing Breast Milk

Can store at room temperature up to 4 hours Safe to store in glass or hard plastic

Leukocytes may stick to glass but are not destroyed

Use clear hard plastic bottles, not dull or cloudy in color


Storing Breast Milk

Polystyrene not designed for frozen milk storage

Polymers unstable when heating after freezing

Polypropylene bottles alters lysozyme, lactoferrin, and vitamin C content of breast milk

Plastic bottles/cups with the number 3, 6, or 7 embedded in a triangle on the bottom of the container are not safe to reuse


Temperatures for Storing

Refrigerator: 4° C (39.2° F) up to 24 hours Freezer: −6.7° C (−20° F) for up to 3 months Freezing can destroy some antimicrobial

factors in the milk


Thawing Breast Milk

In refrigerator for up to 24 hours Holding container under running lukewarm

water Placing milk container in lukewarm water,

rotating (not shaking) bottle often Microwaving not advised, because it destroys

some immune factors and lysozymes


Safe Storage of Breast Milk in the Hospital

Maintain secure mother-infant identification Label on bottle used to store breast milk must

match the identification on the mother’s wrist band and the infant’s ankle band

Label must include date and time milk was expressed from mother’s breast

ID band of mother and infant must be verified BEFORE the infant is given the breast milk


Nipple Soreness

Common, especially in early weeks of breastfeeding

Lanolin ointment maintains internal moisture and can help relieve pain

Breast milk can also help Hydrogel dressings Proper positioning and removal from breast

are key factors in prevention


Breast Engorgement

Prevent through early, regular, and frequent feedings Pumping of breasts to get milk flow started Cold applications to breasts between feedings Heat applications to breasts after feedings

Manual massage of all segments of breasts helps soften and express milk downward toward ducts


CAM Therapy During Breastfeeding

Alfalfa, dandelion, fennel, caraway, and anise increase milk production Caraway tea also good for colic

Black walnut, parsley, and yarrow decrease milk supply

Calendula cream for cracked nipples Oil of peppermint compresses help with

engorgement


Weaning

Gradual is better Abruptly stopping can cause breast engorgement,

increasing risk of mastitis Eliminate one feeding per day, then a few

days later eliminate another, and so on Eliminate the infant’s favorite time last (such

as the first of day or bedtime feeding)


Contraindications for Breastfeeding

HIV-positive status in the mother is an absolute contraindication to breastfeeding

History of IV drug abuse, past or current, should trigger HIV test

Woman with pulmonary TB Certain medications that can pass through

breast milk


Drugs That Decrease Milk Production

Levodopa Barbiturates Antihistamines Pyridoxine Estrogens Androgens Bromocriptine


Infectious Diseasesand Breastfeeding

The only absolute contraindications to breastfeeding is infection with HIV and human T-lymphotrophic virus (HTLV 1 and 2)

Both can be transmitted via breast milk If mother has hepatitis C with active liver

failure, breastfeeding also is contraindicated


Infectious Diseasesand Breastfeeding (cont.)

If mother is infected with herpes simplex virus or varicella zoster virus, breastfeeding is contraindicated until the lesions on her breasts have all healed

Mothers with pulmonary tuberculosis must be isolated from the newborn infant, but can pump breasts so the infant can still receive the benefits from breast milk


Breastfeeding and Immunizations

No contraindication to any vaccine with the exception of the smallpox vaccine

Most live virus vaccines have not shown evidence of being excreted in breast milk (CDC, 2006)


Audience Response SystemQuestion 1

What does the lactoferrin found in breast milk do for the infant?

A.Controls bacterial growth in GI tract

B.Helps digest fat

C.Protects from allergies

D.Promotes neurologic development


Formula Feeding


Objectives

Illustrate techniques of formula-feeding. Discuss the various types of formula and their

preparation. Explain nipple confusion. Identify contraindications to breastfeeding.


Formula-Feeding

Commercially prepared formula provides adequate nutrition to infant

Speak to health care provider to see what type of formula would be best for infant

Advantage is both parents can share in feeding the infant

Closeness and warmth are also a part of bottle-feeding


Types of Formula

Available in Powder form: add water Concentrated liquid: dilute with water Ready-to-feed: just pour in bottle

Powder inexpensive and easy to prepare Ready-to-feed most expensive but does not

require refrigeration (until container is opened) or preparation


Commercially Prepared Formulas

Three types Cow’s milk

• Average newborn

Soy milk• Lactose intolerance or galactosemia

Protein hydrolysate• Protein allergies and fat malabsorption


Milk- and Soy-Based Formulas

Designed to be similar to breast milk in terms of protein, carbohydrate, fats, and mineral content

Formulas contain, on average, 20 kcal/oz when prepared according to manufacturer’s directions


Formula Preparation

Mix according to manufacturer’s recommendation

Too little formula with water can prevent the infant from receiving enough nutrients and calories Can lead to growth restriction

Too much formula can cause diarrhea, electrolyte imbalance, or both


Teaching Bottle-Feeding Techniques


Bottle Feedings

Under no circumstances should a bottle be propped in the infant’s mouth Increases risk of aspiration Does not support parent-infant bonding

Bottles and nipples should be washed in warm soapy water

Prepared formula should stand at room temperature for no more than 2 hours Any remaining formula in the bottle after feeding is

completed should be discarded, not reused


Positioning

Semi-upright cradle position Hold bottle so that nipple is always full of milk

Helps prevent infant from swallowing too much air


Burping

Also called bubbling Should be done when bottle is half-full and at

end of feeding Once feeding is completed, infant should be

placed on side and propped with a rolled blanket Lessens risk of aspiration if infant should “spit up”


Frequency

Newborns should not be kept on a rigid schedule

Formula feedings occur every 3 to 4 hours Do not prop bottle

Increases risk of aspiration, dental caries, and ear infections (otitis media)

Do not overfeed infant Watch the cues the infant is giving


Avoiding Nursing Caries

Do not give an infant a bottle with milk or juice to suck on at will

Liquid can pool in mouth which promotes bacterial growth, leading to dental caries (cavities)


Discharge Planning

Begins on admission or even earlier (childbirth classes)

Clinical pathways or care plans help guide teaching

Provide written materials and website addresses where parents can go to review or learn additional infant care techniques


Feeding Tips

Breast milk or formula feedings are the only nourishment needed for the first 6 months of life

Newborns should not be given bottles of water, since it can lead to hyponatremia

Honey should not be given to infants younger than 12 months

If infant is constipated, give sorbitol-containing juices such as apple, prune, or pear


Audience Response SystemQuestion 2

What is an absolute contraindication to the mother breastfeeding her infant?

A.Hepatitis C with liver failure

B.HIV

C.HTLV1 and 2

D.Varicella with lesions on breast

E.Hepatitis A


Review Key Points


Chapter 11 Newborn Feeding Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1.

Documents

imprint of elsevier

choice of breastfeeding

milk storage

cows milk

principles of breast

newborn responses

newborn positions

newborn feedingcopyright