Breastfeeding and Infant Feeding

1. Breastfeeding and Infant Feeding Nelly Schottel, MD

2. Breastfeeding • AAP recommends that infants be exclusively breastfed through 6 months, continued up to 1 year and beyond if mutually desired

3. Advantages of Breastfeeding • More bioavailable, easily digestible • Decreased incidence of infectious disease, allergies, celiac disease, IBD, SIDS, diabetes, obesity • Improved neurodevelopmental outcomes • Maternal infant bonding

4. Maternal health advantages • Reduces incidence of ovarian cancer and premenopausal breast cancer • Earlier return to pre-pregnancy weight, decreased incidence of Type 2 DM, osteoporosis and PP depression • Ovulation suppression – 98% protection from pregnancy with full time breastfeeding in first 6 months

5. Economic advantage • Estimated that if 90% of US mothers complied with the recommendation to breastfeed exclusively for 6 months -savings of $13 billion per year1 1 Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125(5).

6. Exclusively breastfeeding mothers – eligible to receive enhanced WIC food package and longer duration of benefits than mothers who formula feed • WIC also offers breast pumps, nipple shields and supplements to breastfeeding mothers

7. Breastfeeding Basics • Newborns should breastfeed q 2-3 hrs (about 8-12 times per day) • 10 minutes per breast provides 90% of the available milk • Important to have proper latch and position • Place newborn to breast as soon as possible after birth • Avoid bottles/pacifiers as much as possible • Recognize early signs of hunger – increased alertness, activity, mouthing, rooting

8. Prolactin increases milk production • Oxytocin causes myo-epithelial cells to contract • Both primarily stimulated by suckling • May diminish after as little as 16-24 hours without nursing • Emptying of the breast also affects milk production, prolactin levels decline if breast not regularly emptied

9. Good latch • Entire areola into baby’s mouth with nipple against posterior palate and tongue under areola • Baby’s top and bottom lip should be everted • Baby’s chin should be pressed into the breast • Nose should also be resting on the breast

10. Sucking on tip of nipple causes frustration for both mother and baby • Use rooting reflex • Stimulate baby to stay awake after first few minutes of feeding

11. Troubleshooting • Flat or inverted nipples • Previous breast surgery • No change in breast size during pregnancy • Medications or medical conditions • Lack of support

12. Sore/cracked nipples • One of the major causes of terminating breast feeding in the first week post-partum • Generally caused by improper technique • Assess position, latch and suckling process • Check for ankyloglossia • Remedies: • Expressed breast milk • Lanolin cream • Warm moist compress • Hydrogel pads • Wet tea bags

13. Flat or inverted nipples Nipple shield: temporary solution for difficult latch • Small or preterm infants • Flat or inverted nipples

14. Vitamin supplementation • Trivisol (Vit A, C, D) for all exclusively breastfed infants • Most formula-fed infants do not receive 400 IU of Vitamin D/day so generally recommend for all infants • Need 1L (33 ounces) per day to receive 400 IU of Vitamin D

15. Essential that breastfeeding be discussed during office visits • Early involvement of lactation specialists www.lalecheleague.com www.breastfeeding.com

16. Contraindications to Breastfeeding • Infant with galactosemia • Mother with active, untreated tuberculosis • Maternal exposure to radioactive isotopes • Maternal exposure to chemotherapeutics and/or drugs of abuse (and other contraindicated meds) • HSV lesion of breast • HIV (in developed countries)

17. Breastfeeding History How often do you breastfeed? Does the baby latch on well? Do you hear frequent sucking and swallowing? How many minutes per breast? Any complications? (sore nipples, mastitis, etc)

19. Formula Feeding • If breastfeeding is not possible, then an iron-fortified infant formula should be used • Low iron formula not adequate (need 12mg/L iron)

20. Formula Diet History How do you prepare the formula? How much per feeding? How often does the baby feed? How many total bottles per day?

21. Routine Diet History How many wet diapers/BM’s does the baby have each day? Does the baby drink any thing else besides formula/breastmilk? (water, juice) Have you started solid foods?

22. Pediatric Formulas • Standard formulas 20 kcal/oz (Enfamil Lipil and Similac Advance) • Extensively hydrolyzed: Nutramigen, Alimentum, Pregestimil • Amino-acid based formulas: Elecare, Neocate • Soy: Isomil

23. Extensively hydrolyzed/AA based • Intended for use by infants with milk-protein allergy (MPA) or at high-risk for allergy • MPA can manifest as: • IgE mediated: urticaria, wheezing, vomiting, anaphylaxis • Non-IgE mediated: pulmonary hemosiderosis, eosinophilic proctocolitis, enterocolitis, esophagitis • Expensive! Require approval from insurance.

24. Pediatric Formulas: Soy-Based • Free of cow-milk protein and lactose (carbohydrate is corn or tapioca starch) • Use in disorders of carbohydrate metabolism (ex. Galactosemia) • Use in acute diarrhea and secondary lactase deficiency • Can try for infants with IgE assoc allergy symptoms (urticaria, eczema) to cow’s milk formulas (10-15% will have soy protein allergy and need hydrolyzed formula)

25. Pediatric Formulas • Come in a variety of formulations • Ready to feed, concentrated liquid, or powder Concentrate – dilute 1:1 with water Powder – one scoop to 2 oz of water • Only warm in tepid water, not in microwave • Only infants 6 mos or older who receive exclusively ready to feed formula or formula made with well water or are exclusively breastfed need flouride supplementation

26. How do I know my baby is getting enough?? • Wet diapers – approximately 6-8 per day by the end of the first week of life • Stooling will vary; usually 4-8 per day • Initial stool is meconium; dark green to black, thick • Stools change to a yellow, seedy composition

27. Infant Growth Patterns • Infants lose weight in the first few days of life • By DOL 14, should regain birth weight • Initial weight gain is 20-30 grams/day • Doubles birth weight by 4-6 months • Triples birth weight by 12 months

28. How much? • Infants need 100-120kcal/kg/day • Equivalent to 150-180ml/kg/day [100kcal*30ml/20kcal] • Birth - 1 week • 1-3 ounces • 1 week - 1 month • 2-4 ounces • 3 - 6 months • 6-7 ounces • 6 - 12 months • 7-8 ounces

29. Routine Diet History • Solids What solids does your baby eat? Have you started self-feeding/finger foods? Review allergy and choking risks

30. Introduction of Solids • Infant is eating 32 ounces of formula/breastmilk in a day and still wants more • Look for developmental readiness to determine when to give solids • Sitting supported, loss of extrusion reflex, good head control • Solids should not be introduced before 4-6 months of age

31. Introduction of Solids • Start with iron-fortified single grain cereals - always use a spoon (not in the bottle) • Then progress to single fruits, vegetables, and meats • Introduce 1 new food every 3-5 days • May have to offer food several times before infant accepts it

32. Fruit juices can be introduced, but limit to 4-6 oz/day • No need for water before 6 mos • Introduce soft finger foods by 6-8 months • Solid foods must be mashed or pureed in 1st year of life to avoid aspiration • No honey until after 1 year • Limit milk to 16-24 oz per day

33. No cow’s milk before 1 year • Low bioavailability, risk for IDA • Skim or low fat milk after 2 years of age • Lack essential fatty acids needed for myelin production before 2 years • Soy milk is adequate over 1 year only if pasteurized and vitamin fortified

34. Lactose intolerance • Congenital carbohydrate enzyme deficiencies are extremely rare • Acquired lactose intolerance – may begin by 2 years of age • Dose dependent phenomenon • Allergy to cow’s milk or soy protein (prevalence 1-8%) • Vomiting, diarrhea, bloody stools, eczema, urticaria, wheezing, rhinitis, congestion

35. Wean to cup at 15 months • Make bottle uninteresting • Fill with water • Make child sit while having bottle • Put a toy in the bottle

36. Babies Know How Much to Eat • Houston anthropologist Linda Adair followed a demand fed boy’s intake 1 wk - 9 mo of age • Although he ate three times as much some days as others, his growth was consistent and his size was average • When he started solids, he took less formula and continued to regulate well Adair, L.S. “The Infant’s Ability to Self-Regulate Caloric Intake: A Case Study.” JADA, 1984.

37. Kids Want to Eat • Innate • Imitate adults: why role-modeling good eating behavior is important! • However… • Children who are pressured, eat less well, not better • It can take 10-15 exposures to a new food for a child to eat it* *Birch, Johnson, and Fisher. “Appetite and Eating Behavior in Children.” Pediatric Clinics of North America. 1995

38. Kids Know How Much to Eat • Instinctive regulators of hunger and fullness • Desire to control intake can undermine natural process • In a study of healthy infants, infants grew less well with mothers who force fed1 • Internal regulation of satiety becomes blunted in those with food insecurity: they eat as much as they can, whenever it’s available2 1Crow, Fawcett, and Wright, “Maternal Behavior During Breast and Bottle Feeding”. JBM, 1980. 2Birch, Fisher, and Davison, “Learning to Overeat”. AJCN, 2003

39. What makes a meal? • 4 or 5 food groups • Protein source (chicken, tofu, beans, eggs, peanut butter) • 2 grains or starchy foods (rice, potato, bread, pasta, tortilla, biscuit) • Fruit, vegetable, or both • MILK • Fat source (olive oil, butter, salad dressing, cheese sauce)

40. What makes a snack? • Two to three food groups – starch and fat, starch and protein • Cheese and crackers • Half a peanut butter and jelly sandwich • Yogurt and fruit • Hummus and vegetable

41. Why are Family Meals Important? • Support food regulation and appropriate growth • Meals reassure children they will be fed • Meals teach children to like a variety of food

42. Family Meals • Children who have family meals (5 or more per week) achieve more, behave better, and do better nutritionally • Time spent with family members at meals is more related to psychological and academic success than time spent in any other activity* *Videon, T.M. and C.K. Manning. “Influences on Adolescent Eating Patterns: The Importance of Family Meals”. Journal of Adolescent Health, 2003.

43. Family Meals • In recent years, the trend is away from family meals • Between the ages of 9 and 14, the fraction of children who eat a daily family dinner decreases from one-half to one-third

44. Infant: Andy • Healthy 10 month old. He is growing well, but is a picky eater. His mother is eager to wean him off breastfeeding and start milk. She read about a particular brand of goat’s milk in the New York Times and plans to start this. • What do you tell her?

45. Infant • Folate deficiency • Continue formula until 1 year of age • Will continue to need the fat in whole milk for brain development until 2 years of age • Multivitamin

46. Toddler: Pamela • Healthy, playful 21 month old who is meeting all of her developmental milestones. Her parents report having to force her to eat, and have several questions about feeding. Her growth curve shows a decrease in weight and length measurements for the past two visits. • What questions do you ask?

47. Toddler: Pamela • Does she drink milk? What kind? How much? • Does she drink water or juice? • What is offered at mealtime? • When, where, and with whom are meals eaten?

48. Toddler: Pamela • Drinks about 16 oz whole milk most days. • Loves plain water, and will tote a sippy cup around all day. • Parents offer a variety of foods; Pamela will take a few bites and complain of being full; she throws a fit if fed. • Mom gives her cereal in a baggie to tote around because she won’t eat her meals.

49. Toddler: Pamela • She is drinking an appropriate amount of milk for her age, and her parents are offering a variety of food groups. • It’s likely her constant drinking of plain water is causing her to be too full when it’s time to eat. • Toddlers need the security of structured meals and snacks at the table, as well as the opportunity to exercise independence – don’t force feed.

50. Toddlers • There is a natural slow down in the the rate of growth • Tend to be skeptical about new foods • Parents shouldn’t expect: • Predictablility • Eat a certain amount • Eat a new food two days in a row • Eat only three meals a day – need 1-2 snacks