INFANT FEEDING
• “Nutrition” – “nutricus” – “to suckle at the
breast”
• Critical window period for nutritional
programming – first 1000 days of life
• 270 days in utero
• Upto 2 years of age
• Healthy baby into a healthy environment
• By 2y of age
– Weight 20% of adults
– Height 50% of adults
– Brain growth 75-80%
• Nutrition in this critical period is solely
dependent on the health, nutrition, wellbeing and empowerment of the mother
IYCN/IYCF
• 5 key facts and 10 steps of IYCF proposed
by UNICEF in 2002
5 key facts
1. Indian children have the growth &
developmental potential as all children
worldwide
2. Child malnutrition remains one of the
greatest developmental challenges of
India.
3. Stunted children have stunted bodies,
stunted brains & stunted lives.
4. Child undernutrition starts early in life to
make a lifelong lasting difference.
5. No need to discover new vaccines or new
drugs: ‘We know what works’
10 key interventions
1. Timely initiation of breast feeding within 1 hour
of birth
2. Exclusive breastfeeding during the first 6mo of
life
3. Timely introduction of complementary foods at
6mo
4. Age-appropriate foods for children 6mo to
2years.
5. Hygienic complementary feeding practices.
6. Immunization & bi-annual vitamin A
supplementation with deworming
7. Appropriate feeding during and after illness
8. Therapeutic feeding for children with severe
malnutrition
9. Adequate nutrition & support for adolescent
girls to prevent anemia
10. Adequate nutrition & support for pregnant &
breastfeeding mothers.
• BFHI
• WABA
• BPNI
• World Breastfeeding Week 1st – 7th August
BFHI
• “Baby friendly Hospital Initiative” 1992
• Global programme organised by UNICEF
• Cochin – 1st baby friendly city in India
• BFHI Plus - incorporates immunisation,
antenatal care, ORT, ARI control program
etc.
• Exclusive demand feeding is the only
mode of early infant feeding
• Breastfeeding is accepted as a human
right, a right of the baby as well as the
mother.
10 steps in BFHI
1. Have a written breastfeeding policy
routinely communicated to all staff
2. Train all healthcare staff in skills
necessary to implement this policy
3. Educate all pregnant women about
benefits & management of breastfeeding
4. Help mothers initiate breastfeeding within
1 hour of delivery
5. Show mothers how to feed, how to
maintain lactation even when they are
separated from their infants
6. Newborns should not be given anything
besides breast milk unless medically
indicated
7. Practice rooming-in 24h a day
8. Encourage breastfeeding on demand
9. No artificial teats/pacifiers to
breastfeeding infants
10.Foster the establishment of breastfeeding
support groups and refer mothers to them
on discharge
Preparing Mother for
Breastfeeding
•
•
•
•
Antenatal motivation and preparation
Primigravidas – more motivation required
Last trimester – check nipples & breast
Oiling, massaging, ‘inverted syringe’
technique
• Antenatal mother should take:
– Extra 300kcal & 15g protein
• Lactating mother should take:
– Extra 400-500kcal & 25g protein
• 2 extra helpings of family food
• Green leafy veggies, seasonal fruits, fluids
Initiation of Breastfeeding
• Newborn baby must be put to the breast
within half an hour after normal delivery
and within 4hours after cesarean section.
• Prelacteal feeds should not be given
• “Biologically ready”
• First 2-4days, small quantity of colostrum
(10-40ml) is secreted
• Colostrum is rich in
• Protein
• Immunoglobulins
• Followed by ‘transition milk’ then ‘mature
milk’
• Average quantity: 500-800 ml/day
• Gradual increase till 6mo then plateaus
• Prolactin is secreted more at night
• Night time feeding is crucial
Prerequisites
• Mother and baby should be relaxed and
comfortable
• Proper positioning & posture
• Allow sucking for as long as the baby
desires
• “Foremilk” & “hindmilk”
• Feed from both breasts each time; 20min
• Rooming in
• Bedding in
• Mothering in
• In case of twins – exclusive breastfeeding
should be the choice
• Might need supplementation
• “Tummy to tummy, chest to chest, chin to
breast and mouth to areola”
Reflexes involved in
Breastfeeding
1. Rooting reflex
2. Milk Production reflex
3. Let down reflex
Problems during
Breastfeeding
1. Flat or inverted nipples:
Normal – areola & the breast tissue
beneath should be capable of being
pulled out to form the teat
• Remedy: i. Inverted syringe technique
ii. Double syringe technique
2. Fullness & engorgement of the breast
• Remedy: Feed frequently (2-2.5hourly for
20min) followed by expression of milk
• Apply moist heat 3-5min before a feed,
followed by gentle massage
• Express enough milk to soften the areola
• Paracetamol if required
3. Sore and cracked nipples:
• Remedy: proper latching on, proper
technique to break the latch on
• Treat oral thrush with 1% Gentian violet
• ?Systemic antifungals to mother
• Wash the nipple with water, exposure to
air
• Application of hindmilk after each feed
4. Blocked duct:
• Remedy: Proper technique, avoid tight
clothes, warm compresses, massage
5. Mastitis & Abscess:
• Continue breastfeeding!
• Antibiotics & symptomatic treatment
• Rest
• I & D if abscess forms
How often to feed?
• Exclusive demand feeding
• On an average, the baby should feed 810times, 15-20min per feed
• Burping after feeds
• Position after feed?
How do you know if breast milk
is sufficient or not?
• Baby is gaining weight
• Passing plenty of pale colored urine
• Passing 1-6 liquid stools per day – golden
yellow
• Sleeps for about 2hours at a time
• Avoid ‘nipple confusion’
• EBM – palada (gokarnam), spoon, dropper
• Continue breastfeeding well into 2nd year
of life
• Continue even if baby is ill (unless
contraindicated)
• By 6mo complementary foods should be
introduced
• Most easily digestible food for the ill baby
• Benefits: Satisfies nutritional & fluid
demands, provides anti-infective and
immunological factors, good pacifier
• If sucking is poor, offer more frequent
feeds or EBM
• Gut priming
Do NOT stop
breastfeeding if:
• Mother has viral fever, UTI etc.
• Open Pulmonary TB – start ATT, put baby on
chemoprophylaxis
• Hepatitis B – baby should get Hep B vaccine +
Hep B Ig
• Mastitis, breast abscess – stop temporarily from
affected breast, continue to express
• Postpartum psychosis – under supervision
Contraindications to
Breastfeeding
• Congenital lactose intolerance
• Galactosemia
• Intake of: - Antimalarials
- Antithyroid drugs
- Antipsychotics
- Anti cancer drugs
- Radioactive drugs
HIV?
• Chance for perinatal transmission: 30%
• LSCS, artificial feeds – if affordable
• Mother should be on anti-retroviral
treatment during pregnancy, continued
during labor, 6wks after
Fore milk Syndrome
• Failure to thrive, colicky pain, diarrhoea
with excoriation
• High lactose content in foremilk
Advantages of
Breastfeeding
1.
2.
3.
4.
Optimum fluidity and warmth
Economical
Convenient
Physiological – sweetest milk with highest
lactose content
5. Biochemically superior (Whey:casein =
80:20)
6.
7.
8.
9.
Sterile
Immunologically safe and non-allergenic
Ensures mother-child bonding
Maternal benefits: Reduce PPH, helps in
involution of uterus, reduce weight,
reduce incidence of breast & ovarian
cancers
Options for a working
mother
Storage of EBM
• Should be stored in freezer in clean,
capped, glass or hard polypropylene
plastic containers or special freezing bags
• NOT in the door or in the feeding bottle
How long?
• Back of freezer – upto 12 months
• Back of fridge – upto 5days
• Room temperature – upto 6hours
How to use?
• Thaw – place in fridge the night before,
place in bowl of warm water
• DO NOT REFREEZE
• Use within 24hours
• Pasteurization (62.5oCx 30min) is
acceptable, sterilization (120oC x 30min) is
not
“Breast milk for brain growth,
Cow’s milk for body growth”
Breast milk contents
• Rich in sulphur containing amino acids
• Essential fatty acids and LCPUFAs
• Hormones & growth factors – TSH, GHRF,
insulin.......
• Better bioavailability of Cu, Mg, Co, Se, Zn
Alternatives to Breastmilk
• Cow’s milk
• Formula milk
Comparison
• Cow’s milk – high protein and solute content
• Equal quantities of calories – 67 kcal/100ml
• Proteins in cow’s milk – biochemically
different, less digestible
• Whey:casein = 20:80
• Less vitamins than human milk
• Whey proteins in human milk:
-
Αlfa lactalbumin
Lactoferrin
IgA
Serum albumin
Lysozyme
• In cow’s milk:
- β lactoglobin
- Αlfa lactalbumin
- Traces of IgG, lactoferrin, lysozyme
• Human milk has probiotics, growth
mediating factors, growth regulating
factors
• Human milk has more polyunsaturated
fats
• Better bioavailability of the small quantities
of minerals
• Do NOT dilute
• Offer boiled & cooled water in between
feeds to reduce solute load & prevent
constipation
• Buffalo milk – higher fat content, mostly
saturated
• Goat’s milk – less allergenic, more EFAs &
K+, predisposes to folate deficiency
• Milk closest to human milk?
To be continued........
Infant Formula
• Adapting composition of cow’s milk to
achieve a composition closer to human
milk
• Key steps: diluting, adding carbs/fat,
modifying mineral profile
• Many options
• 1 level spoon to 30ml of clean water
• 6-8 feeds per day
• Bottles not preferred
Adverse Effects
• Malnutrition due to dilution
• Infection due to contamination
• Cow’s milk – salt sensitive HTN
- iron deficiency
- cow’s milk protein intolerance
Types of Formula
1. Whey-Adapted : most commonly used;
whey:casein ratio ≥ 1, amino acid
pattern closer to human milk
2. Casein-predominant: longer to pass
through stomach, satiating effect
3. Acidified Formula: biologically acidified by
microorganisms or by lactic acid; benefit
of less contamination, more digestible
4. HA formula: hydrolyzed protein content
5. Therapeutic/Specialty formula:
•
•
•
AR
LF
For LBW babies
Newer Components
• Probiotics, prebiotics
• LCPUFAs (DHA)
• Antioxidants (beta carotene, Vit E,
Selenium)