Feeding Healthy Infants, Children, and Adolescents

Breastfeeding

The American Academy of Pediatrics (AAP) and World Health Organization (WHO) have declared breastfeeding and the administration of human milk to be the normative practice for infant feeding and nutrition. Breastfeeding has documented short- and long-term medical and neurodevelopmental advantages and rare contraindications ( Tables 56.1 and 56.2 and Table 56.3 ). Thus the decision to breastfeed should be considered a public health issue and not only a lifestyle choice. The AAP and the WHO recommend that infants should be exclusively breastfed or given breast milk for 6 mo. Breastfeeding should be continued with the introduction of complementary foods for 1 yr or longer, as mutually desired by mother and infant. The success of breastfeeding initiation and continuation depends on multiple factors, such as education about breastfeeding, hospital breastfeeding practices and policies, routine and timely follow-up care, and family and societal support ( Table 56.4 and Table 56.5 ).

Feedings should be initiated soon after birth unless medical conditions preclude them. Mothers should be encouraged to nurse at each breast at each feeding starting with the breast offered second at the last feeding. It is not unusual for an infant to fall asleep after the 1st breast and refuse the 2nd. It is preferable to empty the 1st breast before offering the 2nd to allow complete emptying of both breasts and therefore better milk production. Table 56.6 summarizes patterns of milk supply in the 1st week.

New mothers should be instructed about infant hunger cues, correct nipple latch, positioning of the infant on the breast, and feeding frequency. It is also suggested that someone trained in lactation observe a feeding to evaluate positioning, latch, milk transfer, maternal responses, and infant satiety. Attention to these issues during the birth hospitalization allows dialog with the mother and family and can prevent problems that could occur with improper technique or knowledge of breastfeeding. As part of the discharge teaching process, issues on infant feeding, elimination patterns, breast engorgement, breast care, and maternal nutrition should be discussed. A follow-up appointment is recommended within 24-48 hr after hospital discharge.

Nipple Pain

Nipple pain is one of the most common complaints of breastfeeding mothers in the immediate postpartum period. Poor infant positioning and improper latch are the most common reasons for nipple pain beyond the mild discomfort felt early in breastfeeding. If the problem persists and the infant refuses to feed, evaluation for nipple candidiasis is indicated. If candidiasis is present, the mother should be treated with an antifungal cream that is wiped off of the breast before feeding, and the infant treated with an oral antifungal medication.

Tongue-tie (ankyloglossia) has been associated with nipple pain, poor latching, and poor weight gain in breastfed and bottle-fed infants. Frenotomy is a minor surgical procedure with few complications and has been suggested as a treatment option for ankyloglossia. Nonetheless, there is considerable disagreement about the significance of ankyloglossia and the value of frenotomy. It is often difficult to assess the severity of ankyloglossia on physical examination; a combination of physical assessment and functional feeding difficulty is more useful. Nonetheless, about 50% of infants with ankyloglossia have no feeding problems, and most infants with nursing problems do not have ankyloglossia. Lactation consultants often recommend frenotomy, whereas pediatricians provide lactation management approaches and wait at least 2-3 wk before considering frenotomy. During that time many feeding issues resolve, thus avoiding frenotomy.

Engorgement

In the 2nd stage of lactogenesis, physiologic fullness of the breast occurs. Breasts may become engorged: firm, overfilled, and painful as the pattern and volume of milk production adjusts to the infant's feeding schedule. Incomplete removal of milk as a result of poor breastfeeding technique or infant illness can cause engorgement. Breastfeeding immediately at signs of infant hunger will eventually prevent this from occurring. To reduce engorgement, breasts should be softened before infant feeding with a combination of hot compresses and expression of milk. To reduce inflammation and pain, between feedings a supportive bra should be worn, cold compresses applied, and oral nonsteroidal antiinflammatory drugs (NSAIDs) administered.

Mastitis

Mastitis occurs in 2–3% of lactating women and is usually unilateral, manifesting with localized warmth, tenderness, edema, and erythema after the 2nd postdelivery week. Sudden onset of breast pain, myalgia, and fever with fatigue, nausea, vomiting, and headache can also occur. Organisms implicated in mastitis include Staphylococcus aureus, Escherichia coli, group A streptococcus, Haemophilus influenzae, Klebsiella pneumoniae, and Bacteroides species. Diagnosis is confirmed by physical examination. Oral antibiotics and analgesics, while promoting breastfeeding or emptying of the affected breast, usually resolve the infection. A breast abscess is a less common complication of mastitis, but it is a more serious infection that requires intravenous antibiotics and incision and drainage, along with temporary cessation of feeding from that breast.

Inadequate Milk Intake

Insufficient milk intake, dehydration, and jaundice in the infant can occur within the 1st week of life. Signs include lethargy, delayed stooling, decreased urine output, weight loss >7–10% of birth weight, hypernatremic dehydration, inconsolable crying, and increased hunger. Insufficient milk intake may be caused by insufficient milk production, failure of established breastfeeding, and health conditions in the infant that prevent proper breast stimulation. Parents should be counseled that breastfed neonates feed 8-12 times/day with a minimum of 8 times/day. Careful attention to prenatal history can identify maternal factors associated with this problem (failure of breasts to enlarge during pregnancy or within the 1st few days after delivery). Direct observation of breastfeeding can help identify improper technique. If a large volume of milk is expressed manually after breastfeeding, the infant might not be extracting enough milk, eventually leading to decreased milk output. Late preterm infants (34-36 wk) are at risk for insufficient milk syndrome because of poor suck and swallow patterns or medical issues.

Jaundice

Breastfeeding jaundice is related to insufficient fluid intake during the 1st week of life and is a common reason for hospital readmission of healthy breastfed infants (see Chapter 123.3 ). Breastfeeding jaundice is associated with dehydration and hypernatremia. Breast milk jaundice is a different disorder that causes persistently high serum indirect bilirubin in thriving healthy well-fed infants. Breast milk contains inhibitors of glucuronyl transferase and causes enhanced absorption of bilirubin from the gut. Breast milk jaundice becomes evident later than breastfeeding jaundice and generally declines in the 2nd to 3rd wk of life. Infants with severe or persistent jaundice should be evaluated for other medical causes. Persistently high bilirubin levels may require changing from breast milk to infant formula for 24-48 hr and/or treatment with phototherapy without cessation of breastfeeding. Breastfeeding should resume after the decline in serum bilirubin. Parents should be reassured and encouraged to continue collecting breast milk during the period the infant is taking formula.

Breast Milk Collection

The pumping of breast milk is a common practice when the mother and baby are separated. Good handwashing and hygiene should be emphasized. Electric breast pumps are generally more efficient and better tolerated by mothers than mechanical pumps or manual expression. Collection kits should be cleaned with hot soapy water, rinsed, and air-dried after each use. Glass or plastic containers should be used to collect the milk, and milk should be refrigerated and then used within 48 hr. Expressed breast milk can be frozen and used for up to 6 mo. Milk should be thawed rapidly by holding under running tepid water and used completely within 24 hr after thawing. Milk should never be microwaved.

Growth of the Breastfed Infant

The rate of weight gain of the breastfed infant differs from that of the formula-fed infant; the infant's risk for excess weight gain during late infancy may be associated with bottle feeding. The WHO growth charts are based on growth patterns of healthy breastfed infants through the 1st year of life. These standards ( http://www.who.int/childgrowth ) are the result of a study in which >8,000 children were selected from 6 countries. The infants were selected based on being breastfed, having good health care, high socioeconomic status, and nonsmoking mothers, so that they reflect the growth pattern of breastfed infants in optimal conditions and can be used as prescriptive rather than normative curves. Charts are available for growth monitoring. The U.S. Centers for Disease Control and Prevention (CDC) recommend use of the WHO growth charts for infants 0-23 mo of age and CDC growth charts for ages 24 mo to 20 yr (see Chapter 27 ).

Formula Feeding ( Fig. 56.1 )

Despite efforts to promote exclusive breastfeeding through 6 mo, <50% of women continue to breastfeed at 6 mo. Most women make their infant feeding choices early in pregnancy. Parental preference is the most common reason for using infant formula. However, infant formula is also indicated for infants whose intake of breast milk is contraindicated for infant factors (e.g., inborn errors of metabolism) and maternal factors (see Table 56.2 ). In addition, infant formula is used as a supplement to support inadequate weight gain in breastfed infants.

Infant formulas marketed in the United States are safe and nutritionally adequate as the sole source of nutrition for healthy infants for the 1st 6 mo of life. Infant formulas are available in ready-to-feed, concentrated liquid or powder forms. Ready-to-feed products generally provide 19-20 kcal/30 mL (1 oz) and approximately 64-67 kcal/dL. Concentrated liquid products, when diluted according to instructions, provide a preparation with the same concentration. Powder formulas come in single or multiple servings and when mixed according to instructions will result in similar caloric density.

Although infant formulas are manufactured in adherence to good manufacturing practices and are regulated by the U.S. Food and Drug Administration (FDA), there are potential safety issues. Ready-to-feed and concentrated liquid formulas are commercially sterile, but powder preparations are not. Although the number of bacterial colony-forming units per gram (CFU/g) of powder formula is generally lower than allowable limits, outbreaks of infections with Cronobacter sakazakii (previously Enterobacter sakazakii ) have been documented, especially in premature infants. The powder preparations can contain other coliform bacteria but have not been linked to disease in healthy term infants. Care must be taken in following the mixing instructions to avoid over- or underdilution, to use boiled or sterilized water, and to use the specific scoops provided by the manufacturer because scoop sizes vary. Water that has been boiled should be allowed to cool fully to prevent degradation of heat-labile nutrients, specifically vitamin C. Well water should be tested regularly for bacteria and toxin contamination. Municipal water can contain variable concentrations of fluoride, and if the concentrations are high, bottled water that is defluoridated should be used to avoid toxicity.

Parents should be instructed to use proper handwashing techniques when preparing formula and feedings for the infant. Guidance on formula storage should also be given. Once opened, ready-to-feed and concentrated liquid containers can be covered with aluminum foil or plastic wrap and stored in the refrigerator for no longer than 48 hr. Powder formula should be stored in a cool, dry place; once opened, cans should be covered with the original plastic cap or aluminum foil, and the powdered product can be used within 4 wk. Once prepared, all bottles, regardless of type of formula, should be used within 24 hr. Formula should be used within 2 hr of removal from the refrigerator, and once a feeding has started, that formula should be used within 1 hr or be discarded. Prepared formula stored in the refrigerator should be warmed by placing the container in warm water for about 5 min. Formula should not be heated in a microwave because it can heat unevenly and result in burns, despite appearing to be at the right temperature when tested.

Formula feedings should be ad libitum, with the goal of achieving growth and development to the child's genetic potential. The usual intake to allow a weight gain of 25-30 g/day will be 140-200 mL/kg/day in the 1st 3 mo of life. The rate of weight gain declines from 3-12 mo of age.