Infant Nutrition Notes

Newborn Feeding

  • Nutritional Needs:
    • Calories:
      • Breastfed: 85−100 kcal/kg85-100 \, kcal/kg of body weight daily.
      • Formula fed: 100−110 kcal/kg100-110 \, kcal/kg of body weight.
    • Complex carbohydrates and fats are less easily digested.
    • Water: Newborns get water from breastmilk and formula; they do not need additional water.

Breast Milk Advantages

  • Breast milk is species-specific.
  • Nutrients are proportioned and appropriate for the neonate.
  • Varies to meet the newborn’s changing needs.
  • Provides protection against infection.
  • Easily digested.

Production of Breast Milk

  • Lactogenesis I - Colostrum:
    • Begins during pregnancy.
    • Continues through the first days after birth.
    • Promotes normal gut flora, has a laxative effect, and is immunoglobulin-rich.
  • Lactogenesis II - Transitional milk:
    • Begins 2-3 days postpartum.
    • Changes over 10 days.
    • Increased production of milk and lactose, fat, and calorie content.
    • Immunoglobulins and proteins decrease.
  • Lactogenesis III - Mature milk:
    • Contains 20 kcal/oz20 \, kcal/oz, sufficient nutrients.
    • Bluish color and thin.
    • Provides some protection from infection (immunoglobulins and antibacterial components).

Newborn Physiology & Nutrition - Size and Volume of a Newborn's Stomach

  • Day One: Size of a Cherry, 5−7 ml5-7 \, ml (1/2 Tsp1/2 \, Tsp).
  • Day Three: Size of a Walnut.
  • One Week: Size of an Apricot, 22−27 ml22-27 \, ml (75−1 oz75-1 \, oz).
  • One Month: Size of a large egg, 80−150 ml80-150 \, ml (2.5−5 oz2.5-5 \, oz).

Breast Milk Composition

  • Protein:
    • Amino acids in the form of casein and whey.
    • Allergens may pass to the infant.
  • Carbohydrate:
    • Lactose.
  • Fat:
    • Provides half the calories in the form of triglycerides.
    • Highest amount in the hindmilk.
  • Vitamins:
    • A, E, and C are high.
    • D is low; supplementing 400 IU400 \, IU is recommended.
    • Water-soluble vitamins are dependent on the mother’s diet.
  • Minerals:
    • Iron in breast milk is lower than in formula, but better absorbed.
    • Iron stores are adequate for the first 6 months of life.
    • Begin supplementation of iron at 6 months when solid food is introduced.
  • Additional points:
    • Breast milk contains enzymes that promote digestion of CHO and fat.
    • Immunoglobulins present in breast milk reduce the incidence of infection in the newborn.
    • Despite poor eating habits, the fatty acid content of breast milk is about the same whether the mother is well-nourished or malnourished.
    • Water-soluble vitamins are deficient in breast milk with poor eating habits.

Infant Nutrition Resources

  • WIC program.
  • Lactation Consultant.
  • ILCA – International Lactation Consultant Association.
  • USLCA – United States Lactation Consultant Association.
  • Provides contact information for lactation consultants.

Formula Components

  • Formula:
    • Replace or supplement breast milk.
    • Adapted from cow’s milk.
    • Added iron and vitamins with changes to the protein and fat content.
    • Also, 20 kcal/oz20 \, kcal/oz.
  • Alternate Options:
    • Formulas for special needs.
    • Ex: soy-based, lactose-free, low-phenylalanine formulas.
  • No Cow’s milk for newborns or babies < 1 year!!!

Formula Preparation & Storage

  • Teaching about formula:
    • Formula types.
    • Equipment.
    • Preparation.

Bottle Feeding Readiness

  • Bottle feeding assessment:
    • Mother’s knowledge of bottle feeding.
    • Evaluate positioning of the baby and the bottle.
    • Evaluate burping technique.
    • Instruct in infant feeding cues.

Bottle Feeding Education

  • Positioning.
  • Burping.
  • Frequency.

Breastfeeding vs Bottle Feeding

  • Breastfeeding provides many benefits over bottle feeding but may not be a good fit for every mother.
  • Be sensitive to the mother’s choice.
  • Provide information and encouragement when the mother is indecisive.
  • Remember also, bottle feeding doesn’t necessarily mean formula feeding.

Breastfeeding Readiness

  • Influencing factors:
    • Support from partner, family, friends, HCP.
    • Pre-delivery preparation.
    • Cultural influences and rituals.
    • Employment or school considerations.
    • Inaccurate and conflicting information from birthing facility employees.
    • Other reasons.

Breastfeeding Preparation

  • Nipple preparation should be discouraged.
  • Protect natural oils that lubricate the nipples by avoiding soaps.
  • Nipple assessment should occur sometime during pregnancy, looking for flat or inverted nipples that reduce the baby’s mouth placement.
  • Normal nipples protrude allowing the baby to latch onto the breast. With the areola (preferably in its entirety) in the mouth, the baby compresses the areola and nursing occurs.

Breastfeeding Initiation

  • Infant readiness.
  • Positioning the baby.
  • Positioning the mother’s hands.
  • Latch on.
  • Baby’s mouth position.
  • Suckling.
  • Removal of baby from breast.
  • Frequency of feeding.
  • Length of feeding.
  • Adequate feedings.

Breastfeeding Success Tips

  • Provide adequate and appropriate instruction.
  • Minimize interruptions, especially with first-time mothers.
  • Discourage formula gift packs and formula supplementation.
  • Instruct mothers to count diapers to assess the adequacy of milk supply when concerned.
  • Utilize praise and reinforcement to build the mother’s confidence.
  • Provide resources, including the Lactation Consultant.

Feeding Concerns

  • Sleepy Infant
    • Instruct mother on awakening the baby.
    • If the condition worsens, further evaluation may be required.
  • Nipple Confusion
    • Tongue movement is different with breast and bottle feeding.
    • Supplementing with formula when breastfeeding may result in engorgement due to increased length of time between feedings.
    • Discourage pacifier use until suckling well established.
  • Latch-on Problems
    • Assess tongue movement with a gloved finger in the baby’s mouth.
    • Refer to a Lactation Consultant as needed.
  • Infant Complications:
    • Jaundice
    • Prematurity
    • Illness and congenital defects

Breast and Bottle Weaning

  • Replace breast or bottle feedings with drinking from a cup
  • Begins @ 6-12 months of age when solids are introduced
  • After 18 months of age, infant may resist due to attachment
  • Indications for weaning:
    • Discarding bottle
    • Chewing on the nipple
    • Taking only a few ounces of formula
    • Refusing the breast or dawdling
  • Eliminate 1 feeding, of least interest, at a time
  • Eliminate nighttime feeding last

Enteral Feedings

  • Enteral feeding
    • Bolus or continuous
    • Instruct child and parent prior to initiating feeding
    • Check residual (check hospital policy and physician’s order)
    • Holding young children allows for bonding and promotes positive associations with the feeding
    • Provide a pacifier for infants to promote non-nutritive sucking
    • Older children may sit at the table during the feeding to facilitate family interaction and the child’s participation and inclusion
  • Gastrostomy Tubes and Buttons
    • Assess tube length, dislodgement, and check site for cues of infection
    • Assess for tension on the gastrostomy tube which can cause leaking and irritation
  • Discharge Instructions:
    • Parent or caregiver demonstration is required
    • Checking for correct position
    • Monitoring the insertion site
    • Symptoms that should be reported
    • Actions when dislodgement occurs
    • Provide instruction sequentially and document presentation, validation of learning, and return demonstration

Failure to Thrive

  • Weight or rate of weight gain is significantly below that of comparably aged children
  • Organic, medical causes
    • Chromosomal abnormalities
    • Heart or lung defects
    • CNS damage
    • Exposure to toxins
  • Etiology
    • Poverty and poor social support systems
    • Maternal depression, poor bonding, or maladaptive interactions between mother and child
    • Irritable, resistant-to-touch infant
  • Results in intellectual and developmental delays
  • 10%10\% of children
  • Clinical cues:
    • Weight-for-length is below the 5th percentile
    • Weight-for-age is below the 3rd percentile
    • Sudden or rapid deceleration in the growth curve
    • Delay in reaching developmental milestones
    • Decreased muscle mass
    • Muscle hypotonia
    • Abdominal distention
    • Generalized weakness and cachexia
  • Therapeutic Management
    • Nutritional therapy to increase protein and caloric intake and speed growth
    • Multivitamins
    • Calorie enrichment with an increase to 24 cal/oz24 \, cal/oz (max)
    • Family therapy
  • Nursing Considerations
    • Assessment of:
      • Finances, presence of depression, availability of food, support systems, family violence or alcoholism
    • Parent/child interactions should be evaluated looking for cues to the parent’s response to the child and the child to the parent
    • Focus on:
      • Improvement in the child’s physical and developmental status
    • Promote positive parenting
    • Provide:
      • Positive role modeling
      • Parental instruction that develops the parents’ confidence in caring for their child
    • Promote realistic expectations based on the child’s developmental needs