Infant and Child Feeding

Infant and Child Feeding; Breast Feeding

Objectives:
By the end of this lecture you will be able to:
Review the anatomy of the breast and physiology of lactation
Understand the composition and stages of breast milk, factors affecting it, proper positioning and attachment of the baby during lactation.
Identify the obstacles facing the mother during breastfeeding.
Discuss the differences between breast milk and artificial or cow milk, the advantages of breastfeeding and the medical problems that may occur during lactation.

Breast feeding had always been the natural infant feeding since the creation of mankind. It is the natural feeding practice not only in humans but in all mammals.
There was an observation that mortality & morbidity rates were higher in bottle fed than in breast fed infants. It wasnt until the 20th century that the causes of this phenomenon were clearly understood.
Anatomy of the breast
It is a gland basically formed from the alveoli & lactiferous ducts that gather into the milk lakes & then gather in the areola & pores in the nipple.
Milk is produced in the lobules and are drained by the lactiferous ducts, which converge into the lactiferous sinuses located under the areola.
When lactiferous sinuses are massaged manually or by the gums of the nursing infant ,milk is expressed through a series of 15-25 openings on the surface of the nipple.




Milk production is under the control of the hormone prolactin which is secreted from the anterior part of the pituitary gland.
Oxytosin is produced by the posterior part of the pituitary gland and is responsible for milk ejection.


Colostrums
In the first few days after delivery (2-6 days), the mother feels that her breasts is empty but in fact it is not; this is because her breasts contain a small but adequate amount of Colostrum.
Colostrum is produced in small but adequate amounts to cover the nutritional and immunological needs of the neonate.
This feeling of emptiness gives the mother the false belief that she is not producing enough milk, and will lead her to use formula milk to feed her baby.
The process can be accelerated by putting the infant on the breasts more soon after birth, (within 30 minutes), and to continue breast feeding on demand.
Composition of Breast Milk
The composition of breast milk varies according to the variation of several factors. These are:
Stage of lactation: Colostrum is produced during the first week after birth, followed by transitional milk during the second week, and mature milk thereafter.
Time of the day: Fat content is highest at mid-day.
Sampling time within the same feed:(at the beginning of the feed foremilk there is more water & at the end hind milk there is more fat). Therefore the mother should not end the feed & let the baby end it when he wants. If the feed is ended before the hind milk is taken, the baby will feel hungry soon after the feed.
Maternal Nutrition: The mother should eat a well balanced diet with more energy and proteins. The quality of milk will be affected by maternal under-nutrition only in its severe forms.
Climate: In hot climates there will be more water so the mother does not have to give water to the infant in addition to her breast milk. In cold climates the fat content is higher lead to increase energy intake.
Individual variation: from one mother to another.

Phases of Lactation

Other Characteristics

Colostrum is a yellowish thick fluid that washes out excess bilirubin so if the infant has neonatal physiological jaundice, breast milk will help him to get rid of the excessive bilirubin from the GIT.
Composition of milk
The major constituent is water, so there is no need for any other fluid, if infant is exclusively breast fed. Water can act as a vehicle to transmit water-borne diseases, if not properly boiled. Water can make the baby feel full, and therefore will decrease suckling and inhibit milk production.
Other constituents are fat, proteins, carbohydrates, vitamins and minerals. Some nutrients are present in higher concentrations in cow milk than breast milk but the type is not the appropriate one for absorption.
Breast milk is very easily digested & absorbed & the child will pass a pasty, yellowish stool that should not be mistaken for diarrhoea.
Breast milk is clean & sterile, while bottle milk is not sterile leading to diarrhoea & other complications.


Breast feeding process; Reflexes
Rooting Reflex:
If the cheeks or lips of the infant are stimulated (touched) he will open his mouth and turn his face to the nipple.

Suckling Reflex:

The infant will suckle anything that enters his mouth and touch the roof of the mouth (palate). This reflex is very vigorous at birth.

Swallowing Reflex:

The infant will swallow the milk, which is present in his mouth, and will coordinate this reflex with the suckling reflex.
If the reflexes are not well developed (as in a preterm baby), we give the infant breast milk (were the mother ejects it by a pump & puts it in sterile containers). This milk can be given by a Naso-Gastric tube.
If the baby opens his mouth widely, he will take the areola with the nipple & press on the milk lakes so the milk is expelled. If the mouth is not opened widely, he will take only the nipple & bite on it & no milk will be expelled. This will result in nipple cracks, which are very painful.

Positioning in breast feeding

Correct positioning will determine the success of breast feeding. There are various steps to correct positioning:

Positioning of the mother: She must breast feed in a comfortable & relaxed position because if not she will feel tired & end the feed quickly. The mother should be sitting with a straight back (supported with a pillow or if she cant sit straight then she can feed the baby while lying down on her back & the baby on top of her, or on her side and the baby beside her.

Positioning of the infant:

* Head and body in one line with a straight neck.
* Infant facing the mother.
* Infant well supported (when he is still small one hand is enough for support but later on both hands are used).
* Infant close to the mother.


Attachment to the breast: well attached or not ?
* Mouth should be wide open Chin touching the breast.
* Lower lip turned outward.
* The lower part of the areola should not be seen & the upper part of the areola should be partly visible.

Effective suckling:

Slow deep sucks, pauses from time to time, swallowing can be seen, the mother feels no pain.

Advantages of Breast Feeding

1) Nutritional
Breast milk contains all nutrients needed by the infant in the appropriate composition and quantity, especially during the 1st 4-6 months of life.

Proteins are mainly of alpha and beta lactalbumin type, which is easily digested by the infant.
Cow milk on the other hand contains mainly casein which is difficult to digest and will form a curd in the stomach of the infant. This is why the child goes to sleep after cow milk.
This will give the wrong impression that the infant is getting enough nutrients from the artificial milk, which is not true.
Lactose is higher in human than in cow milk.
Vitamins, iron and minerals are adequate in human milk. Iron in breast milk is low in quantity but adequate.
Human milk contains Lactoferrin which is an iron binding protein that binds to the iron & accompanies it to the absorption sites & releases it there.
Formula milk, on the other hand, contains extra iron and no lactoferrin, therefore, it will be free in the GIT and will promote the growth of pathogenic bacteria leading to gastro-enteritis.
The amount of water is adequate.
Breast milk also contains lipase for the digestion of fat.


2) Immunological Properties and Protection against Infection
Breast milk is sterile and clean, it contains Abs specific to the organisms in the birth canal of the mother, leukocytes (4000cells/mm3).
It promotes the growth of lactobacillus in the GIT and contains lactoferrin.
Even when breast fed infants develop diarrhoea, it is usually mild, with a lower risk of hypernatraemia and metabolic acidosis.
Breasts fed infants develop less allergic conditions, less asthma & less eczema because they are not exposed to substances strange to their bodies.

3) Psychological Bonding between Mother and Infant

Breast feeding will lead to the establishment of a strong relationship between the mother and the infant. The first sound the baby hears is the sound of his mothers heart when he is inside the uterus & when he is close to her while breast feeding he will hear the same familiar sound.
This bonding will be strengthened on the infant side through touch, eye to eye contact, voice, odour and warmth.
On the side of the mother, it will be strengthened through eye to eye contact, crying and odour.
This interaction will lead to the production and release of prolactin and oxytocin by the pituitary of the mother, as well as the production of T and B lymphocytes, and macrophages in the milk.

4) Fertility Control

Exclusive breast feeding which enhances the production of prolactin by the pituitary and the maintenance of its level in blood, will inhibit the pituitary-ovarian axis and therefore inhibit ovulation.
This is the natural method of contraception known as the Lactational Amenorrhoea Method (LAM).
As long as the mother is breast feeding exclusively, giving 2-3 night feeds and is not menstruating, the risk of a new pregnancy is minimal.
This method is known to be reliable until complementary feeding is introduced, which means that breast feeding is going to be less frequent and therefore a lower blood level of prolactin is expected, which may not be inhibitory to the ovaries.

5) Decrease Post-partum Blood Loss: The release of Oxytocin will help the uterus to contract and will therefore lead to decrease in blood loss. This will help in the decrease of the prevalence of anaemia after pregnancy.

6) Protection against Breast Cancer: It was found that breast feeding protects the mother against breast cancer.
8) Convenience: Breast Milk is convenient, always ready, in the correct composition and concentration, correct temperature and is not costly.


Disadvantages of bottle feeding
Contamination resulting in diarrhoea and malnutrition.
Cost is high so the mother will over-dilute feeds which will lead to malnutrition.
Vitamin deficiency.
Iron deficiency leading to anaemia.
Hypernatraemia leading to acidosis especially in LBW infants leading to kidney disease. Bottle fed infants are more prone to develop hypernatraemic acidosis when they have diarrhoea because of the high sodium content of formula milk.
Hypercalcemia
Higher content of saturated fatty acids in cows milk but. Infants need unsaturated fatty acids for brain development. Cow milk is deficient in lenolenic acid and cholesterol which are needed for brain growth & formula milk is low in fat which means that it gives insufficient energy.
High casein content of cow milk leads to indigestion and curd formation leading to constipation.
Allergic conditions are more prevalent among bottle fed infants due to the presence of unfamiliar proteins in cow milk leading to antibody production.
Nipple confusion and refusal to breast feed because the mechanism of suckling the breast is different from that of sucking the bottle. The child will be confused & will abandon the suckling mechanism preferring the sucking which is easier.

Contraindications of Breast Feeding: Very rare & practically non-existent. Some of the conditions claimed to be contraindications are not absolute but relative. These are:
Breast Ca: Is one of the contraindications because of the hormonal effect on the tumour. If it is only a lump which was removed and the follow-up indicates no recurrence, the mother is allowed to breast feed if she chooses to.
Inborn errors of metabolism (PKU and galactosaemia). These are rare conditions. Specially prepared milk is needed to prevent brain damage and mental retardation.
Breast milk jaundice which is a very, very, very rare condition starting 2 weeks after birth. It must be differentiated from physiological jaundice which starts on the third day after birth.
Beta-Streptococcal infection of the throat of the infant because it can lead to severe bilateral mastitis in the mother. Breast milk should be expressed and given to the baby by cup and spoon.
Puerperal psychosis: In the past the mother used to be hospitalized and kept away from her baby so she can not harm him. Currently, the practice is to hospitalize the baby with the mother, but under strict observation. The point is that this will help in the recovery of the mother.
Radioactive therapy to the mother, where the baby should be kept away from her.

In the following conditions, breast feeding is NOT contraindicated

Viral infection of the mother such as HBV, where the infant is immunized soon after birth and can also receive passive immunity. As for HIV/AIDS, there are different opinions. Some authorities say that breast feeding should be prevented as it may be a way of transmitting the disease from mother to infant. The other school say that particularly in developing countries, the chances of the infant dying from diarrhoea resulting from bottle feeding is much higher than that of dying from AIDS.
TB of the mother because the infant usually receives BCG and chemoprophylaxis, and the mother should receive anti TB drugs.
Neonatal jaundice is not a contraindication, and breast milk helps the infant to get rid of the excessive bilirubin.
Prematurity & low birth weight, where breast milk will supplement the nutrients which should be transmitted to foetus during the last weeks of pregnancy. If the infant is very premature and the suckling reflex is not well developed, milk can be expressed from the breast and given through a naso-gastric tube.
Pregnancy (a new pregnancy) is not a contraindication, as the well-nourished mother can breast feed and support a growing foetus.
Congenital malformation of the mouth as in cleft palate where breast milk can be expressed and given by cup & spoon.
Foetal distress & hypoxia where the mother should stop feeding temporarily (2-4 days), but should also express her milk in preparation for the resumption of breast feeding.
Multiple births, where the mother can breast feed twins successfully.


Problems of Breast Feeding
Engorged & congested breast: Mainly due to the increase of fluid and blood in the breasts. Early initiation of breast feeding will prevent this condition. If the infant is put on the breast in the correct position, he will not be able to empty the breast. Milk expression manually or mechanically by a pump will alleviate the symptoms. Analgesics, massage & cold sponging can also be used.
Milk fever: This happens when the breast is filled with milk, the milk will be pumped back into the circulation leading to an immune reaction, which is self-limiting & resolves spontaneously.
Nipple pain & cracks: This happens when only the nipple is taken by the infant, and not the areola. This happens due to incorrect positioning & is treated by correcting the position of the child & not by using antibiotics or creams.
Refusal to suckle: This happens when the infant is sick or in a very premature or LBW infant (<1800gm) where the reflexes are not developed. Nipple confusion is another cause. Separation of the child from his mother for a few days (if the mother is hospitalized for example) may also cause this condition.
Mastitis and breast abscess: Due to blocked ducts superimposed by bacteria leading to mastitis, which may develop into abscess. If detected early (before pus accumulation) it can be managed by massaging the breast, expressing milk, giving antibiotics, recommending bed rest & giving analgesics. If pus is detected drain the breast surgically and give antibiotics. Do not stop breast feeding in Mastitis & use the other healthy breast.
Complementary Feeding; (Weaning Period)

Definition:

It is the transitional stage when a young childs diet gradually changes from one of milk alone, to a diet based on what the family eats.
Weaning begins when the child is introduced to food other than milk & is completed when the child is fully accustomed to the regular family diet.
This period differs from one child to another. During weaning the child should continue to breast feed, since breast milk is an important nutritional supplement to the weaning food.
Dangers of this period: It is a dangerous period because of the high mortality rates in it due to:
Diarrhoea which results from the incorrect preparation & storage of food. The water used for food preparation may be contaminated and the food may be stored for a long period of time which will promote the putrefaction of food. This will lead to gastroenteritis due to bacterial growth.
Malnutrition which is caused by diarrhoea as well as not giving the infant enough proteins and energy in the diet.

When & How are Complementary Foods Introduced

Weaning usually starts between 4-6 months of age where the child can swallow & digest semisolid food at this age, but it mainly depends on the growth of the child.
If the growth curve of the infant is getting slower & the mothers milk is no more sufficient for his growth needs, then we start at 4 months.
If the growth curve is satisfactory, then we start at 6 months. It also depends on the ability of the infant to swallow semisolids, and on the interest he shows in food.
Weaning can be completed at any time between 12-24 months when the child can consume solid family food.
Problems:
Early weaning (at 40 days as is the common practice in Iraq) increases the incidence of diarrhoea and allergic conditions. The foods given are not useful and they will not be absorbed by the GIT as it is not yet ready to digest and absorb these foods.
Late weaning, after the age of six months, will make the child unable to deal with solid foods, and it may lead to malnutrition.


How do we wean?
Weaning should be done gradually using a small teaspoon, few spoonfuls at a time, giving mashed or pureed food. Initially we give one meal of one food type per day, watch how the infant adapts & tolerates it. If the child adapts (no vomiting or diarrhoea) we can add another food & so on (increase the quantity, variety & frequency).
Give about 2-4 additional meals at the age of 6 months by using the cup & spoon. The energy content of meal should be increased by increasing oil & fat. Add solid food at the age of 7 months & the meals should reach to 5-6 per day.
Thing to consider:
Separate the childs food from that of the family in a separate dish because the child eats slowly, and by the time other members have finished, he would still be eating. This will help the mother to see how much the child has eaten from his dish. Active feeding by an adult will help the child to eat all the food in his plate.

What to give the baby? Depends on

What is traditionally fed to the child (each region & each country has its own traditional food).
What food is available to the family.
Time available for the mother for preparation food & feeding the child.
Notes:
Start with Fruit juices, rice soup, vegetable soup & mainly vegetable food until 6 months, then later on add white meat (chicken), then red meat (beef & lamb) providing the child is adapting so ending up with what is called a multimix (supplements of carbohydrates, proteins, vitamins, minerals, oil & fat for calorie supplementation).
Honey should not be given before the age of 1 year because it may be contaminated.
Eggs should not be given until the age of 1 year (although it is an excellent source of ptn) because the egg may be contaminated with salmonella. It needs to be hard boiled, which a young infant can not swallow. Egg white may cause allergic reactions.










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