Swanson – Infant Feeding

Swanson’s Family Medicine Review 2017
Ch. 98 Infant Feeding 498
Lani K. Ackerman

1. The minimal acceptable weight gain in the neonatal period and infancy is 30 g/day (1 ounce) through 3 months of age, 20 g/day 3-6 months, and 10 g/day 6-12 months. If weight gain equals or exceeds this, you can be reasonably confident that the infant is thriving. Breast-fed infants should not lose more than 8% of their body weight; however, some mothers have a difficult time starting to breast-feed. If the birth weight is attained by 2 weeks or the infant is gaining 30 g/day, the mother can be reassured. Electronic scales should be used, and care should be taken to weigh the baby wearing a fresh diaper. Other measures of hydration, such as five or six diapers a day and two or three stools a day, may be helpful. Reminding the mother that the best way to increase her milk production is the latch-on and suck of the infant, coupled with adequate rest and nutrition for her, is important as well.
2. Often, women who are breast-feeding need reassurance that they are providing adequate nutrition to their infant; fear that milk is insufficient is a common cause of early termination of breastfeeding. Weight gain and confirmation from the physician encourage women to continue to breast-feed. During the first few weeks and months of life, the ideal feeding schedule is feeding on demand. This will vary from infant to infant but eventually will settle into a reasonable schedule averaging 8 to 12 feedings per day. Because it is important to establish lactation early on, it is better that the mother not bottle-feed at all to avoid nipple confusion and decreased milk production. In the case of this mother, the infant is likely to be sucking often for comfort, and encouraging her that this is not due to lack of nutrition will help prevent bottle-feeding and overfeeding. Nipple confusion is less common after the first 6 weeks, when the feeding patterns are established. This mother appears to have adequate milk, and does not need more milk production (a lactagogue.)
3. Infants cry for a variety of reasons, and crying may not always be a sign of hunger. Some infants are placid, some are unusually active, and some are irritable. Sick infants are often uninterested in food. Health care providers should encourage mothers to breast-feed for comfort and nurture as well as for nutrition. In contrast to bottle-fed babies, breast-fed babies can regulate their intake of milk at the breast by altering their suckling patterns. The mother should check for feeding cues; if crying stops when the infant is picked up or rocked, the infant may only need closeness and security.
4. Maternal anxiety, fatigue, postpartum depression, and stress from other causes are causal candidates for decreased milk production and let-down. The main determinant of a good milk supply is frequent, effective milk removal.
5. Colostrum provides macrophages that synthesize complement, lysozyme, and lactoferrin and antibodies against bacteria and viruses that protect the infant against infection through the GI tract.
6. Human colostrum contains antibodies of the IgA class that protect the infant from bacterial species such as Escherichia coli and certain viruses. In addition, human colostrum contains macrophages that are able to synthesize complement, lysozyme, lactoferrin, and the iron-binding whey protein that is normally approximately one-third saturated with iron.
7. Parents often want to introduce cereal and solid foods earlier than recommended. Exclusive breastfeeding for 3-4 months shows a protective effect in reducing incidence of clinical asthma, atopic dermatitis, and eczema. However, there are conflicting studies that look at the timing of adding complementary foods after 4 months and the risk of allergy in either allergy-prone or nonatopic individuals. There is no convincing data that delaying introduction of potentially allergenic foods after 6 months has any protective effect, and new evidence suggests that, rather than decrease incidence of food allergies, avoidance of solid foods including avoidance of highly allergenic foods like eggs, peanuts or fish, may actually increase the incidence of food allergies. New foods should not be introduced more often than one every 1 or 2 weeks. The order of food introduction appears relatively unimportant. The introduction of one food at a time will help determine if there is an allergic or atopic reaction to any particular newly introduced food. Iron-containing foods are desirable. Signs of readiness for solid foods include loss of the tongue protrusion reflex, the ability to sit unsupported, and the ability to grasp food and bring it to the mouth.
8. The American Academy of Pediatrics recommends 400 IU of vitamin D daily for infants older than 2 months. Maternal deficiency is associated with low levels of vitamin D in the milk. Evidence is still lacking, and the recommendation is based on consensus opinion. Dark-skinned infants not exposed to adequate sunlight are at higher risk. Although there is less iron in breast milk, it is better absorbed, and iron can cause constipation and GI upset. Whereas term infants do not routinely need iron supplementation before 6 months of age, preterm infants do. If the community water supply has 1 ppm of fluoride, the infant does not need supplementation, and excessive fluoride may cause staining of the teeth.
9. Unless exceptional circumstances dictate otherwise, the recommended course of action with maternal mastitis is to continue breastfeeding and to use symptomatic treatments, such as hot compresses, and antibiotics effective against Staphylococcus aureus (including coagulase-positive staphylococcus). The antibiotic of choice in this case is dicloxacillin or cephalexin. If MRSA is suspected, clindamycin may be used.
10. Causes of recurrent mastitis are multiple. Check the latch-on and make sure the baby’s nose is pointing toward the nipple and the mouth has most of the areola encircled. The mother should change positions so the infant’s mouth massages different ducts. Teaching a woman to watch for clogged milk ducts before the development of mastitis, to use massage with a motion toward the nipple, and to use warm, moist packs can often resolve the plugged duct before development of mastitis. Advice to “go to bed with baby” is important so the mother can relax, allow time for feeding, and prevent milk duct stasis. Frequent emptying of the breast—often difficult with some of the less expensive, less effective pumps—is especially important for the working mother. The electric double-pumping system (Medela and Hollister are commonly used brands) is generally more effective than hand or battery-operated pumps. An undiagnosed fungal infection of the nipple that may be due to infant thrush (or vice versa) should be treated to prevent fissuring and cracks. If a nipple has a sore or crack, the infant should begin feeding on the least sore side. Breast milk may be used to soothe the crack. Other ointments and nipple shields should not be used. Generally sore, cracked nipples are due to improper positioning or prolonged suckling that is non-nutritive.
11. Most women decide to breast-feed before or during their first trimester. Discussion of the benefits of breastfeeding should be included in preconception counseling, and it should be part of the initial prenatal visit. The Baby-Friendly Hospital Initiative introduced by UNICEF and WHO has resulted in increased likelihood of and length of time for breastfeeding in communities where the initiative is followed. Putting the baby to breast within 30 minutes after delivery, avoiding bottles and pacifiers, and encouraging rooming in with the mother are all important for helping a woman to breast-feed successfully (Box 98-1). The opinion of the husband or significant other is important in the woman’s decision to breast-feed. Women who breast-feed are typically older, more educated, and more concerned with baby benefits than are those who do not.
12. Regurgitation, or spitting up, is a common problem in infants. The mechanism appears to be an ineffective gastroesophageal sphincter. Regurgitation can be reduced by adequate eructation of swallowed air during and after eating, by gentle handling, and by holding the infant against the shoulder or placing in a semi-upright position (e.g., infant car seat or “bouncer”) after eating. The head should not be lower than the rest of the body during rest periods. Unless the child (especially a boy) demonstrates projectile vomiting or weight loss or has a palpable mass in the pylorus, pyloric stenosis is not likely. Use of medications is generally not recommended unless the infant is having weight loss, poor weight gain, or pulmonary complications.
13. The mother should be questioned carefully and, ideally, observed regarding feeding technique. Before it is assumed that the mother has insufficient milk, other possibilities should be excluded: errors in feeding technique responsible for the infant’s inadequate progress; remediable maternal factors related to diet, rest, or emotional distress; or physical disturbances in the infant that interfere with eating or with weight gain. On occasion, infants who seem to be nursing well may not thrive because of milk insufficiency; in this case, increased frequency of feedings, and increased maternal nutrition and hydration, may be required. Usually, with a demonstrated slow weight gain, insufficient maternal milk supply is a strong possibility (most often because of infrequent or inadequate milk removal), and the mother needs to pump every 2 or 3 hours with a heavy-duty, double-pumping, hospital-grade electric pump to bring it back. In the meantime, there may not be enough of her milk to get this baby back from the brink. This is one of the few situations in which formula really is needed. Referral to the La Leche League or a certified lactation consultant is an alternative that can be recommended to this mother. The La Leche League  is a volunteer organization composed of successfully nursing mothers willing to assist other mothers desiring to nurse. If the mother is exhausted but able to successfully express sufficient milk, the husband or significant other may be able to assist the mother in feeding. This alternative is attractive because it gives the mother time to rest and to recover her strength. This infant should be reassessed soon after the previously mentioned interventions are undertaken to monitor nutritional progress. Infant formulas provide adequate nutrition for the infant and may be the last alternative. Although “breast is best,” a dogmatic approach to breastfeeding should be avoided. However, most breastfeeding problems can be solved without having to give up the multiple benefits of breast milk.
14. Constipation is a common problem in formula-fed infants. It is extremely rare in breast-fed babies. In most infants, parents should understand that a daily bowel movement is not required, and glycerin suppositories may be used if necessary. Mineral oil and laxatives used for adults are not appropriate. For mothers who are breastand bottle-feeding, this is an opportunity to encourage breastfeeding. For older infants, small amounts of prune juice may be given, and in a warm climate, water may be given; however, for young infants, water is not generally recommended. Less common conditions, such as Hirschsprung disease or, in the case of meconium ileus, cystic fibrosis, should be considered in severe cases.
15. Formula has no immunologic properties. The benefits of breast milk immunologically in the short and long term cannot be exaggerated. Breast milk is a living fluid, packed full of healthy antibodies.

Suggested Reading

American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827–e841.

Casey C, Dawson D, Neal L. Vitamin D supplementation   in infants, children, and adolescents. Am Fam Physician. 2010;81:745–748.

Fulhan J, Collier S, Duggan C. Update on pediatric nutrition: breastfeeding, infant nutrition, and growth. Curr Opin Pediatr. 2003;15:323–332.

Lawrence RA, Lawrence RM. Breastfeeding: a guide for the medical professions. ed 7. Maryland Heights: Elsevier Mosby; 2011.

Newton E. Physiology of lactation and breastfeeding. In: Gabbe SG, ed. Obstetrics: normal and problem pregnancies. ed 4. New York: Churchill Livingstone; 2002.

Powers N. How to assess slow growth in the breastfed infant. Pediatr Clin North Am. 2001;48:345–363.