1- Infant feeding and weaning.pdf

 Infant feeding and weaning Prepared by: Dr: Ahlam abdulmalik  OBJECTIVES Understand the different types of breast milk Know the advantages of breast milk Know the contraindications of breast feeding Differentiate between breast milk and artificial formula Defin...

 Infant feeding and weaning Prepared by: Dr: Ahlam abdulmalik  OBJECTIVES Understand the different types of breast milk Know the advantages of breast milk Know the contraindications of breast feeding Differentiate between breast milk and artificial formula Define weaning and understand it  Introduction Human milk and breast feeding are the ideal normative standards for infant feeding and nutrition The AAP recommends human milk as a sole source of nutrition for the first 6 months of life, with continued intake for the first year and as long as desired thereafter Breast feeding has short and long term advantages for infant neurodevelopment  Physiology of lactation A. Hormonal control of mammary glands development and lactation At puberty: Estrogen: development of mammary ducts Progesterone: development of mammary glands alveoli At pregnancy: Estrogen, progesterone ,placental lactogen: development of the breast Prolactin is secreted but milk production is inhibited After child birth: Prolactin ( anterior pituitary gland): stimulates milk production in the breast  Physiology of lactation B. Reflexes of lactation: Lactating reflexes: Milk production ( prolactin): Stimulus is sucking and response is milk production Milk ejection: ( letdown reflex ): stimulus is sucking , thinking of the baby or hearing his crying and response is milk ejection secondary to release of oxytocin from pituitary gland Sucking reflexes: Sucking Rooting Swallowing: stimulated when the milk is in the mouth  Definitions Rooting reflex: When infant smells milk or his cheeks are touched he moves his face toward the breast Sucking reflex: the contact of the nipple against the palate and posterior tongue elicits sucking, leading to squeezing of the breast Swallowing reflex: Milk in the infant's mouth triggers the swallowing movement Letdown reflex: It is a sign of successful nursing. Sucking or psychological stimuli leads to the secretion of Oxytocin by the posterior pituitary gland which causes contraction of the micro-epithelium that surrounds the alveoli which leads to squeezing of milk in the side which is sucked and the other side  Stages of lactation 1. Colostrum: Colostrum is the secretion of the breast during the later part of pregnancy to 2-3 days after delivery It has a deep lemon color, It contains more protein and minerals but less carbohydrate and fat, It also contains unique immunological components , macrophages and Lactoferrin 2. Transitional milk: Transitional composition between colostrum & mature milk 3. Mature milk: is produced within 2-3 weeks  Types of human milk Colostrum Mature breast milk Timing First 3 days Produced within 2-3 weeks Color Yellowish White Consistency Thick Thin Calories 57 Kcal/dl 67 Kcal/dL Protein content 8 gram%( higher) 1.3 gram% Carbohydrate 5.5 gram%( lower) 6.7 gram% Fat 3 gram%( lower) 3.5 gram% Minerals 4 gram%( higher) 0.25 gram% Types of human milk  Advantages of breast feeding A. Advantages for the Infant Nutritional advantages: composition of various nutrients is in proportions ideal for infant needs Calories : 67 kcal/100ml Carbohydrates: lactose is the main sugar Lipids: triglycerides are the major source of energy in human milk, contains high amount of long chain polyunsaturated fatty acids which are essential for brain development Protein: whey to casein ratio is 60:40 which provides easier digestion, lactoferrin helps in iron absorption and protect infant from bacterial growth, also contain digestive enzymes ( lipase, amylase and protease) which helps in digestion Vitamins and minerals: it has the amounts of vitamins and minerals needed except vitamin D, vitamin K and iron, less phosphorous and calcium also less sodium It eliminates the possibility of cow's milk allergy which causes chronic diarrhea, occult bleeding , anemia, eczema and FTT  Advantages of breast feeding A. Advantages for the Infant Immunological advantages: ( protective mechanisms in human milk ) Bifidus factor: oligosaccharides present in both colostrum and mature milk, it increases the growth of lactobacillus bifidus which is a normal flora that inhibits the bacterial growth Intestinal growth factor: stimulates the repair of damaged intestinal cells Lactoferrin: enhance bioavailability of iron from human milk, reducing its availability for bacteria Immunoglobulins: in colostrum and mature milk especially secretory IgA, provides protection against respiratory tract infection as otitis media and pneumonia, also decrease diarrhea Lysozymes and peroxidase: attack bacterial cell wall Human milk and human colostrum contains viable macrophages which are able to synthesize complements and lysozymes. Lower incidence of DM1, obesity and necrotizing enterocolitis Contains nucleotides that enhance antibody responses and bacterial flora.  Advantages of breast feeding Advantages for the mother: Strengthens mother- General advantages: infant relationship Sterile, cheap, readily Prevention of available regardless of postpartum hemorrhage time or and needs no (Oxytocin) preparation Economic (Cheap) Increased Intellectual Decrease the risk of Quotient (lQ) and breast cancer, ovarian academic performance cancer and osteoporosis Decrease the risk of CVS diseases and DM  Breastfeeding management in the normal infant according to AAP Direct skin-to-skin contact with the mother immediately after delivery until the first feeding is encouraged throughout the postpartum period Delay in routine procedures (weighing, measuring, bathing, blood tests, vaccines, vitamin K injection and eye prophylaxis) until after the first feeding is completed. Ensure 8-12 feedings at the breast every 24 hr ( day and night). Ensure formal training and supervision of breastfeeding by trained caregivers (proper latch, comfortable position) Give no supplements (water, glucose, commercial infant formula, or other fluids) to breastfeeding newborn infants unless medically indicated using standard evidence-based guidelines for the management of hyperbilirubinamia and Hypoglycemia  Technique of breast feeding Positioning: 1. The infant should be elevated to the height of the breast 2. The infant body turned completely to face the mother, with the infant nose at the level of the nipple to encourage proper latching 3. All the body should be supported not just the neck, and the neck should be straight 4. Education of the mother about positions of breast feeding Comfortable Position  Program of breast feeding Initiation of breast feeding: Breastfeeding should be started as soon as the mother can, usually within the 1 st hour Frequency of feeding: According to the infant's desire Number of feeds: at least 8 / day Intervals should not be > 2-3 hours by daytime and 4-5 hours by night Demand feeding is associated with more milk production Scheduled feeding (at regular intervals): should be avoided ( decreases milk production) Duration of feeding: Vigorous baby needs only 5-7 min to evacuate the breast Most of the milk is obtained early in the feeding (50% in the 1 st 2 minutes)  Notes Give no supplements (water, glucose, commercial infant formula, or other fluids) to breastfeeding newborn infants unless medically indicated using standard evidence- based guidelines for the management of hyperbilirubinamia and Hypoglycemia Give vitamin D supplementation from the first week of life and iron supplementation at 4 months of age  Indicators of adequate breast milk intake 1. Weight gain: the most reliable, 200 gm/ week or 250 gm/ 10 days in the first 4 months 2. Feeding: baby feeds at least 8 times/ day, and baby is satisfied and sleep after feeding for 2- 4 hours 3. Urine: good amount of urine 4. Stool: soft yellow stool, commonly with every feed Contraindications of breast feeding Maternal contraindications: Active tuberculosis: the mother should not breastfeed, expressed milk may be provided to the baby, the mother is not infective after 2 weeks of drugs initiation Varicella: Should not breastfeed, expressed milk may be provided to the baby Herpes simplex virus infection: use expressed milk or the other breast Contraindications of breast feeding Maternal contraindications: HIV infection: in industrialized countries mothers are not recommended to breastfeed, in developing countries health risks of not breastfeeding must be weighed against the risk of transmitting virus to the infant HBV and HCV infections: not contraindications, but give vaccine and immunoglobulin in case of HBV Maternal psychosis and substance abuse Maternal use of chemotherapy COVID 19 infection is not a contraindication for breast feeding, the mother should: Wear a mask during breast feeding Wash her hands with soap and water before feeding Wash the breast with soap and water if needed Beast milk may be also expressed and used for the infant There is no evidence till now that COVID 19 is secreted in beast mil Contraindications of breast feeding Infant contraindications: Galactosemia Phenylketonuria Lactose intolerance  Formula feeding Cow՚s milk based formulas are the most major type of formula Most milk base formulas have added iron, the AAP recommends iron fortified formula unless advised otherwise Infant formula contains long chain polyunsaturated fatty acids, nucleotides, prebiotics and probiotics Soy based formula may be used for newborn allergic to cow՚s milk Hypo allergic formula are also used for allergic infants Formula fed infants are at higher risk of obesity later in childhood Comparison between breast milk and formula milk Component Breast milk Infant formula Protein 1.1 gm per dl 1.5 gm per dl fat 4 gm per dl 3.6 gm per dl Carbohydrates 7.2 gm per dl - lactose 6.9 – 7.2 gm per dl - lactose Vit D Variable 400 IU per dl Calories 67 kcal per 100 ml 67 kcal per 100 ml Lactoferrin present 0 Lipase present 0  Pacifier Avoid routine pacifier use in post partum period Pacifier should be offered, while placing infant in back-to-sleep- position, no earlier than 3-4 weeks of age and after breastfeeding have been established  Weaning Weaning is defined as introduction of solid foods other than milk to the infant diet, it is usually started at 4-6 months of age  General rules of weaning Start with one type of food The best type of starting food is Cereals Then start with vegetables Then carbohydrates: rice, bread,.. Then introduce proteins (chicken, cheeses,..) Egg, fish should be delayed if there is a family history of allergy Start with small amount of one type, assess the infant tolerance and atopy Each new food should be tried separately( 3-5 days interval) to identify adverse reactions  General rules of weaning Give no more than 4 Oz /day of fruit juices; not sweetened Zinc intake should be encouraged with foods such as meat, dairy products, wheat, and rice Milk should be reduced by each feeding introduced No added sugars Weaning food should be taken by spoon and cup not by bottle Gradually introduce finger feeding of soft food  General rules of weaning Self-feeding; grasps spoon with whole hand, at 1- 2 years of age Holds cup with 2 hands at one year Particular attention should be paid to foods with a choking risk, Hard candies, nuts, and raw carrots should be avoided. The AAP discourages eating in the presence of distractions such as television, tablets, mobile devices, and other screens, or eating in a car where an adult cannot adequately observe the child  General rules of weaning A new food should be offered multiple times before being considered rejected by the child Toddlers need to eat 3 healthy meals and 2 -3 snacks daily