Infant and Neonatal Nutrition

Dr Tom Leach

8 years ago

Introduction

Breastfeeding is generally considered to be superior to bottle feeding and should always be encouraged. The rates of breast feeding are surprisingly low:

In the UK, 17% of children are exclusively breastfed by 6 months
After 12 months, <1% of children in the UK receive any breastmilk. In other countries this is much higher – for example this is 25% in Germany and 56% in Brazil
In Australia – rates are also higher with about 70% of babies exclusively breast fed at 3 months and 35% at 6 months

Breastmilk is an ideal food for infants. It contains all the nutrients they need for the first 6 months of life, as well as antibodies from the mother to protect against infection. After 6 months of age, breastmilk can provide up to about 50% of the nutritional requirements for a child, and up to 1/3 in the second year of life. The WHO recommends that all children receive breast milk up to 2 years of age.

The benefits of breastfeeding compared to bottle feeding include:

Reduced risk of obesity and diabetes for the child later in life
Children who are breastfed score higher on intelligence tests
May reduce the risk of allergies in the child
Reduced risk of breast and ovarian cancer for the mother
Mothers who breast feed loose weight more quickly than those who bottle feed
Promotes bonding with baby and oxytocin release in both mother and baby which may help to reduce the risk of anxiety and post-natal depression

Breastfeeding can be difficult to learn, and is best taught by an experienced health care professional, in a supporting environment. Midwives will often provide some of this coaching in the first few weeks, and more difficult cases may need to see a lactation consultant.
It is best to start breastfeeding as soon as possible – ie within minutes of birth. However:

It is never too late to start as long as lactation is still occurring
A few difficult feeds in the first week should not put the mother off. Babies have a good reserve of nutrients and health of the infant will not be immediately impacted
Topping up feeds with formula milk is not typically recommended, and may negate some of the benefits

The mother should try to breastfeed within 2-3 days of birth; otherwise it is very difficult to start producing milk.
Breast fed babies will typically weigh slightly less than their bottle fed counterparts on the growth charts. However, as always, the importance of growth charts is to monitor if/when the plotted values cross the percentile lines, and not necessarily which percentile they are following.
Family pressures strongly influence breastfeeding:

10% of mother will bottle feed if the father disapproves
70% if he approves

Who breast feeds?

Rates vary across the country. The highest rates are in the most affluent areas. For the Manchester region the values are:

45% in the first week
21% by the 4^th week
7% by 3 months
1% by 6 months
This is increasing over past data

Practicalities

It is recommended that babies breast feed within the first hour of life.

Newborn babies can perform an instinctive manoeuvre called the “breast crawl” where they can quite literally crawl around on the mother’s chest to find the nipple.

Babies should be fed “on demand” – i.e. when they become unsettled. For the first 6-8 weeks this can be up to every 2 hours – all through the day and night. This can be exhausting for mothers! A newborn infant’s stomach is only about the size of a grape.

Solids can be introduced from 6 months of age to supplement breast milk

Correct breast feeding position involves:

Baby’s chin touching the breast, but nose not touching. The whole nipple and almost all of the areola will be in the infants mouth during good “latching”.
Slow, rhythmic jaw movements, and suckling noises / movements

The first few sucks may be short and not drawn any milk, but this is normal

The baby may take a big mouthful of breast and nipple – this is normal!

Expressing breast milk

Many mothers choose to express milk so that they are not tied down to feeding the baby alone (e.g. can give milk to father), and tied down to feeding at specific times. Other times when expressing is helpful is:
Relieving painful breast engorgement inbetween feeds
Air nutrition – if the baby is a poor suckler
Should be taught by a midwife, and usually involves watching a mother who is already skilled
Pumps are available from any chemist, but expressing can also be performed manually
Manual technique – stroke the breast gently towards the nipple, and use circular motions. There are about 15 ampullae below the areolar. Learning the find these, and applying gentle pressure also aids flow.
Make sure you wash your hands first!
Using warm towels, or expressing whilst in the bath can aid flow

Keeping the milk

Refrigerator – should be used within 48 hours
Freezer – should be used within 3 months. Thaw by leaving in a jug of warm water. Do not refreeze.
Refrigeration is better than freezing. Some test have sown that anti-oxidant levels or reduced by freezing, but it is not known if this causes any adverse effects
Be aware that the content of day-time and night-time milk can be different – for example melatonin is present in night-time milk – a hormone associated with the induction of sleep. It is advisable to label expressed milk as day or night time and give this milk at the appropriate time

Feeding on demand – is usually encouraged, as it reduces the risk of breast complications, and keeps baby happy. Feeding by routine is discouraged, but may help establish a diurnal pattern.

If you feed on demand, then you can reassure mothers that baby is getting enough – as long as growth charts are normal.

Breast feeding should be especially strongly encouraged in prematurity. Usually given with added vitamins D and K. Rarely Rickets may occur – even in term babies.

Health benefits for baby

Reduces the risk of development of allergies during the breastfeeding period but may or may not alter the long term risk. Evidence is controversial.
Breast milk contains mothers immune agents, including macrophages, lymphocytes, and IgA
To get the benefit from this you should:
Not begin weaning until 6 months old
Avoid cows milk until 1yr old
Avoid egg until 2yrs old
Avoid nuts and fish until 3yrs old

Contains LCP’s – involved with nervous development. Some studies suggest these increase IQ
Reduced risk of obesity, insulin resistnace and diabetes
Acid in breast milk promotes ‘friendly’ bacteria growth in the bowel
Reduces infant mortality, pneumonia and diarrhoea
The typical ‘baby smell’ is more apparent in breast fed babies!

Provides bonding between mother and baby
Cheap!
Health benefits for the mother

Mothers lose weight gained during pregnancy more quickly
Reduces risk of ovarian and breast cancers – at least in pre-menopausal years
Promotes uterine contractions – thus can reduce the risk of PPH if breast-feeding occurs within minutes of birth
Promotes oxytocin release – reduces anxiety in mother

Contra-indications

HIV +ve mother
Amiodarone
Antithyroid drugs
Opiates
Antimetabolites

Complications

Breast engorgement – painful, enlarged breast. Easily avoidable e.g. wth hourly expression, feeding
Breast abscess – do not let the baby drink the milk if it looks pus like! – just use the other breast. Treat with flucloxacillin – 250mg / 6h PO. Safe for baby
Sore nipples

Ensure correct attachment when feeding
Use some sort of moist gel – e.g. Jelonet
Do not encourage resting the affected nipple

Improving milk supply

Perceived low milk supply is the number one reason why breastfeeding mothers use formula. Truly low milk supply is rare and most mothers need only reassurance.

Breast-fed babies often lose a small amount of weight in the first 2 weeks of life
Consider inadequate milk supply in babies who are failing to gain weight appropriately

Provide reassurance to mothers who express these common concerns about perceived low milk supply:

Frequent feeding – babies nee dot feed 8-12x every 24hrs in the first few weeks
Baby is increasing the number of feeds per day – this is normal in periods of rapid growth. Increased on-demand feeding will physiologically cause an increase in supply from the mother
Baby is not feeding for long enough. Babies get more efficient as they get older
Baby is unsettled between feeds – babies can cry for a lot of reasons! “Colic” is a term used to described babies who are unsettled. This is also normal
Only small amounts can be expressed – the volume of expressed milk is not indicative of the underlying milk supply

Bottle Feeding

There aren’t many contraindications to breast feeding, but there are plenty of pressures not to.

Advertising for formula milk is now banned
It costs about £45/month to feed a baby on formula

Advantages of bottle feeding

Allows others (e..g the father) to take a more active role in feeding
Some mothers like the reassurance of knowing the exact volume of feeds

Choosing a teat

– A ‘cross cut’ teat allows the baby to determine the rate and volume of the feed. Studies suggests this encourages happier babies, who spend more of the day awake, and cry less.

Types of formula

From birth to 1yr

These milks are usually altered cows milk, which have had their solute concentration reduced, and protein, fat and vitamin content altered. They usually contain added LCPs for neuronal development, and Omega 3 & 6. As with breast milk, protein is usually in the form of whey. In some varieties (below) it is in the form of casein:
60% whey, 40% casein– the standard milks, most similar to breast milk.
80% casein, 20% whey – more similar to cow’s milk. Usually branded as being for hungrier babies. They extra casein delays gastric emptying, and thus increases the time between feeds.
Changing brands is unlikely to solve feeding problems, as they are very similar

Follow-on formula

Typically have a high casein content, and should only be used from 6 months onwards. Typical use is from 6-24 months

Soy milks

Should be strongly discouraged
Still sold in supermarkets
High levels of oestrogen like products. Can cause hormonal problems in boys, as well as thyroid problems, and reduced immunity.

Hydrolysed formula

Used in babies with allergy to cow’s milk (1%).
The protein in the cow’s milk is hydrolysed into short peptides.
Cow’s milk can be re-introduced after 1 year – but risk – try in hospital
Can reduce the risk of atopy

Feeding the formula

Wash hands
Use sterilised bottles
Used boiled water to make up the powder – gastroenteritis is a big cause of morbidity in the UK, and mortality in developing countires
Measure powder accurately!
- Underfed – reduced growth
- Overfed – hypernatraemia, constipation, obesity

How much to give

After the first few days, a rough guide is:

150ml / kg / 24hrs – usually given in the course of 4-6 feeds
Younger children will usually require more feeds (e.g. 7-8 feeds at <1 month, 4-6 between 2 and 6 months, and 4 at 6 months)
If small for dates – increase to 200ml / Kg
If large for dates – reduce to 100ml / Kg
Warming the milk has no proven beneficial effect
Try to ensure that air is not sucked in with the milk
The bottle should eject a constant stream. Check that the teat is not blocked before each feed. Teat can be enlarged with a hot needle.

Weaning

Why wean?

Iron stores low by 6 months
Encourages oral motor skills
Nutritional requirements can no longer be met by milk alone
Late weaning can cause:

Increased risk of future feeding difficulties / problems accepting new foods
Implementation of new food textures are important to prevent future fussy eating.
Risk of iron deficiency anaemia
Risk of rickets
Poor weight gain / growth

When

Current advice is to begin weaning at no sooner than 6 months old

Stages of weaning

Stage One – 6 – 8M

Solid foods of negligible nutritional value
Smooth, bland cereals, with no-wheat content E.g. pureed cooked vegitables and fruit
Should be offered to baby on a spoon
NO ADED SALT / SUGAR
Cows milk products, such as custard and yoghurts are ok in small quantities
PLUS 500-600ml of breast / formula milk

Stage two – 8 – 10M

Increase the variety and volume of other foods
Can introduce mashed foods and other soft sontituencies
Raw fruit and soft vegitables
Encourage eating with fingers
Iron rich foods – inc meat
Use feeding cup instead of bottle
Cows milk can be given in small amounts
PLUS 500-600 ml of breast / bottle milk

Stage Three – 12M +

Cows milk may be given as the main drink
Child should have 3 meals per day
Can have chapped / mashed family foods
Encourage self feeding
Still use 500-600ml of breast / formula milk as required, but cows milk can begin to take over this role

Normal expected weight gain

Age (months)	Weight Gain (per week)
0 – 3	200g
4 – 6	150g
7 – 9	100g
9 – 12	50 – 75g