Dr.S.Nishan Silva (MBBS). Issues…. Energy requirement Breast milk/ feeding –Contents...

Dr.S.Nishan Silva

(MBBS)

Issues….• Energy requirement• Breast milk/ feeding

– Contents– Technique– Physiology

• Colostrum• Formula feeds• Weaning• IUGR• Nutrition of older children

Energy• Requirements kcal/kg/day

– Basal metabolic rate 40– Physical activity 4+– Specific dynamic action of food (10%)– Thermoregulation

variable– Growth 70

(To match in-utero growth of 15g/kg/day)

Exclusive breastfeeding

• All healthy infants should be breastfed exclusively for the first six months of life

• Exclusive breastfeeding is defined as "an infant's consumption of human milk with no supplementation of any type. (no water, no juice, no nonhuman milk, and no foods)

• except for medications."

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Composition of Mature Milk

BREAST FEEDINGPhysiological Mechanisms

1- Maternal reflexes a.Prolactin reflex : as the baby suckles, impulses

pass from the areola up to the hypothalamus then to the anterior pituitary producing prolactin which makes the breasts produce milk.

b- Oxytocin reflex (let-down reflex): suckling also stimulates the production of oxytocin by the posterior pituitary. Oxytocin causes contraction of the smooth muscles surrounding the alveoli, squeezing milk out.

NF- 7Teaching Aids: ENC

Enhancing factors Hindering factors

Emptying of breast

Good attachment & effective suckling

Early initiation of breastfeeds

Frequent feeds including night

feeds

Delay in initiation of breastfeeds,

Pre-lacteal feeds,Bottle feeding,

Incorrect positioning,Painful breast

Sensory impulse from nipple

Prolactin in blood

Prolactin “milk secretion” reflex

NF- 8Teaching Aids: ENC

•Thinks lovingly of baby

•Sound of the baby

•Sight of the baby

•CONFIDENCE

•Worry

•Stress

•Pain

•Doubt

Stimulated by Inhibited by

Oxytocin reflex

BREAST FEEDINGPhysiological Mechanisms

2- Infant`s reflexesa. Rooting reflex : If the circumoral area or cheek of the

infant are touched by the nipple, leads to turning of the head to the side on which the nipple is felt and the infant draws it into his opend mouth.

b. Suckling reflex: The tactile stimulus caused by the nipple and areolar tissues filling the mouth lead to milking action by the tongue against the hard palate..

c. Swallowing reflex: This enables the baby to ingest the milk that is obtained by suckling, and allows interruption of breathing to prevent choking during swallowing.

NF-10Teaching Aids: ENC

Rooting reflexRooting reflex

Swallowing reflexSwallowing reflex

Sucking reflexSucking reflex

Feeding reflexes in the baby


Key points of positioning

Mother:

• Make the mother sit in a comfortable and convenient

position (she can feed in lying down position)

• Ensure that she is relaxed and comfortable

Baby:

• Baby’s head and body are in a straight line

• Baby’s whole body is supported

• Baby’s face is opposite the nipple and the breast

• Baby’s abdomen touches mother’s abdomen


Good positioning


1. Baby’s mouth is wide open

2. Baby’s chin touches the breast

3. Baby’s lower lip is curled outward

4. Usually the lower portion of the areola is not visible

Key points of good attachment


Good attachmentbaby’s mouth is wide openlower lip is curled outward

lower portion of the areola is not visible

chin touches the breast

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Good and poor attachment

Breast Feeding Video

Adequacy of breastfeeding

• Breastfeeding is considered adequate if the baby– Goes to sleep for 2-3 hrs after each feed– Passes urine 6-8 times in 24 hrs– Gains weight at 10-15 gm/kg/day– Crosses birth weight by 2 weeks

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Monitoring feeding

• Maternal sensation of engorgement and emptying

• Frequency of feeding• Wet nappies • Stools• Jaundice• Weight

Normal output

Daily stool and urine output guidanceDay 0 1 wet nappy and meconium at least once a day

Day 1 2 wet nappies and meconium at least once a day

Day 2 & 3 3 or 4 wet nappies and changing stools at least once a day

Day 4+ 5 or 6 heavy wet nappies and yellow stools at least once daily

A baby who is passing meconium at 3 or 4 days old may not be getting enough milk.

A baby who does not have yellow stools by day 5 may not be getting enough milk.

A baby who is not doing as many wet nappies each day as expected may not be getting enough milk.

Problems in breastfeeding

DIFFICULTIES OF BREAST FEEDING1- Suckling in a poor position.

2- Insufficient Breast Milk.

3- Delayed Appearance of Milk.

4- Inability to Suckle or Refusal of Breastfeeding.

5- Engorgement.

6- Fissured or Cracked Nipples.

7- Flat or Retracted Nipples.

8- Regurgitation after Breastfeeding.

9- Work and Breastfeeding:


Full vs. engorged breasts

Full breasts = NORMALEngorged breasts =

ABNORMAL


Full breasts: – 36/72 hours after birth.– Hot, heavy, may be

hard– Milk flowing– Fever uncommon

Engorged breasts:– can occur at any time

during breastfeeding– Painful; edematous– Tight, especially nipple

area– Shiny– May look red– Milk NOT flowing– Fever may occur– May cause a decrease in

milk supply if it happens often

Full vs. engorged breasts

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Inverted nipple Sore nipple

Other Practical Problems

Mothers Health

• Nutrition for breastfeeding women– Energy and protein

• higher needs than pregnancy

– Vitamins and minerals• Most are higher or same as pregnancy• Iron and folate needs are lower

– Water

• Food choices• Practices to avoid while breastfeeding

– Alcohol, drugs, smoking, excess caffeine

Summary of differences between milksHuman milk Animal milks Infant formula

Protein correct amount, easy to digest

too much, difficult to digest

partly corrected

Fatenough essential fatty acids, lipase to digest

lacks essential fatty acids, no lipase

no lipase

Water enough extra needed may need extra

Anti-infective properties

present absent absent

Adapted from: Breastfeeding counselling: A training course. Geneva, World Health Organization, 1993 (WHO/CDR/93.6).

Slide 2.2

ColostrumProperty• Antibody-rich

• Many white cells• Purgative

• Growth factors

• Vitamin-A rich

Importance• protects against infection and

allergy• protects against infection• clears meconium; helps prevent

jaundice• helps intestine mature; prevents

allergy, intolerance• reduces severity of some

infection (such as measles and diarrhoea); prevents vitamin A-related eye diseases

Slide 2.5

Composition of Mature Milk and Colostrum

Benefits of Breastfeeding babies moms

• balance of nutrients with high bioavail.

• good hormones• cognitive

development• less infections• less diseases• less food allergies

• contracts the uterus• delays menstration• conserves iron

stores• may protect against

breast cancer• convenient• bonding time with

baby

Benefits of breastfeeding for the mother

• Protects mother’s health

– helps reduces risk of uterine bleeding and helps the uterus to return to its previous size

– reduces risk of breast and ovarian cancer

• Helps delay a new pregnancy

• Helps a mother return to pre-pregnancy weight

Slide 2.23

Risks of artificial feeding

Interferes with bonding

More diarrhoea and respiratory infections

Persistent diarrhoea

Malnutrition Vitamin A deficiency

More likely to die

More allergy and milk intolerance

Increased risk of some chronic diseases

Overweight

Lower scores on intelligence tests

May become pregnant sooner

Increased risk of anaemia, ovarian and breast cancer

Mother

Adapted from: Breastfeeding counselling: A training course. Geneva, World Health Organization, 1993 (WHO/CDR/93.6). Slide 2.26

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Expressed breast milkIndications

– Sick mother, local breast problems

– Preterm / sick baby

– Working mother

Storage– Clean wide-mouthed container with tight lid

– At room temperature: 6 hrs

– Refrigerator: 24 hours; Freezer (20°C): for 3 months

Teaching Aids: ENC

EXPRESSING BREAST MILK

Place a clean container below your breast to collect m ilk

Massage the breasts gent lytow ard the nipples

W ash your hands w ell w ith soap and w ater

Now press back tow ard your chest , then gent ly squeeze to release m ilk

Place your thum b and index finger opposite each other just outside the dark circle around the nipple

Repeat step 5 at different posit ions around the areola

EXPRESSING BREAST MILK















Absolute contraindications of breast feeding:

Causes related to the infant: *Inborn errors of metabolism as galactosemia and phenylketonuria.

*Errors of digestion as monosaccharides and disaccharides intolerance.

Maternal causes:• Maternal hepatitis B: Unless the newborn receives Hepatitis B

immune globulin and Hepatitis B vaccine at birth, and then completes the hepatitis B vaccination schedule.

• Maternal HIV/AIDS: Breast-feeding is not recommended if a safe alternative is available.

• Intake of dangerous toxic drugs which are secreted in milk in considerable amounts: -Anticoagulants, antineoplastics (cyclophosphamide, cyclosporine, etc.), thiouracil, ergotamine, phenindione and lithium, -Radioactive substances. -Cocaine, heroin, marijuana.

Temporary Contraindications:

Causes related to the infant: -Severe cleft palate, microgenathia. -Infant infections: Oral herpes simplex.

Maternal causes: *Psychosis, neurosis and epilepsy. *Eclampsia.

*Maternal infections:– Herpes simplex lesions on the breast (until healed).– Chicken pox: Zoster immune globulin (ZIG) is given to non

infected neonate. The neonate is separated from the mother until she is no longer infectious.

– Active tuberculosis: Mother is treated. Infant receives INH and is repeatedly tested with tuberculin test. INH is discontinued if tuberculin is still negative after 3-4 months of age and the mother response to treatment is satisfactory.

– Breast abscess: No feeding from the affected breast until healed.– Septicemia, typhoid fever, pneumonia until treated.

Supplementing breast milk

• Should be unnecessary, but– Vitamin K levels are low– Vitamin D levels are low in areas of little

sunlight– Iron levels are low (but very well absorbed)

Feeding small or preterm infants: Choices

• Human milk– Mother’s own– Banked donor milk– Fortified

• Artificial– Term formula– Preterm formula

• Parenteral Nutrition

Artificial Feeds

• Term formulas are broadly similar– May be whey or

casein based– International agreed

standards for constituents

General guidelines for the choice of a particular formula:-For a normal baby: Better use an adapted "humanized" dry milk formula.

The amount of formula needed is calculated according to weight as follows:

Daily needs = 150ml formula/kg of body weight/ day, then

The calculated amount is divided by the number of feeds per day (usually 6 feeds).

Amount feed (ml):-

150 ml x Body weight in Kg

Number of feeds per day

Example: For a baby weighing 4 kgs. the daily needs is: 150 x 4 = 600 ml/day. So if we give 6 feeds/day, the amount given in each feed = 600 / 6= 100ml.

Short term risks of IUGR

• Paediatric– Hypoglycaemia – Necrotising enterocolitis– Increased risk of problems of prematurity– (hypothermia)– (polycythaemia)

‘Failure to Thrive’

• Term first used to describe delayed growth and development, – also called maternal deprivation syndrome.

• “A failure of expected growth and well being”

• Only growth can be objectively measured

Human milk shortcomings if preterm

• Human milk may not provide enough– Protein– Energy– Sodium– Calcium, phosphorus and magnesium– Trace elements (Fe, Cu, Zn)

– Vitamins (B2,B6,Folic acid, C,D,E,K)

Breast milk fortifiers

• Improved– short term growth– nutrient retention– bone mineralisation

• Concerns– trend towards increased NEC

Catch-up Growth

• Enhanced nutritional intake sufficient to allow ‘catch-up’ growth improves long term neurodevelopmental outcome

Weaning in SL• At 6 months - started• Don’t give water / watery – give semisolid• Start with rice and breast milk• Small quantities, multiple meals• Energy densed• Add – Oil, Dhal, Sprats (powdered)• No salt or sugar till 1 year, No eggs till measles vaccine• Gradually introduce other vegetables, delay green leaves• Fish and then meat• Increase size of particles and quantity• Ensure hygene• No bottles/ tits. Cup and spoon preferred. • Continue breast feeding – up to 2 years• By 1 year – adult food

Assignment on Weaning

• Describe the different recipes and food types that can be used for weaning.

• Describe the relationship between introduction and progression of weaning and the child’s normal development.

Between Infancy and Childhood

• The period between age 1 and 2 is a transition between infancy and childhood. There is dramatic decrease in growth rate reflected in disinterest in food.

• By the end of the first year, the child should be drinking from a cup and eating many of the same foods as the rest of the family although in smaller amounts.

• Around the age of 15 months, food jags may develop reflecting autonomy and independence.

• At 2 years of age, children can completely self-feed and can seek food independently

• Growth, BMR, and endless activity require an energy supply of 1300 kcal/day for ages 1 to 3.

• Hunger, rather than adult meal schedules, guide the child’s perception of time to eat

Children 4 to 6 years old

• Children can have their independent eating styles.

• They understand the time frame of meals and can save their appetite for meals.

• Snacks form an integral part of the child’s nutrient intake

• Children can develop a sense of responsibility for healthy food selection. They can understand that although all foods are fine, some (like fruits, vegetables, and low fat foods) can be eaten more often than others. Food jags may continue for a while.

• Parents should educate children that each food contains a different assortment of nutrients and offer substitute choices that the child can finally select تشكيلةfrom

• Energy requirements increase to 1800 kcal/ day

Children 7 to 12 years old

• Actual growth may slow down at this stage

• The body is preparing for the puberty growth spurt

• Puberty for girls may begin from around age 9 and on and, for boys, puberty maybe reached in early teen years

• This prepuberty time maybe reflected by weight buildup; an increase in chubbiness is not alarming if moderate eating and physical exercises are maintained

• Parents should not overreact to the child’s overeating; otherwise they may plant the seeds of eating disorders

• To rule out overeating, children can be asked if they are truly hungry for food or are they just tired or thirsty

• Energy requirements increase to 2000 to 2200 kcal/day

Disorders Unique to or Beginning in Infancy and childhood and Nursing Interventions

• Failure to thrive: It is inadequate gain in weight and/ or height in comparison with growth and development standards.

• This condition can be caused by disorders of the CNS, endocrine system, congenital defects, or intestinal obstruction, or it can occur due to inability to suck, chew, or swallow related to neuromuscular problems.

• Nursing interventions and considerations for a child with failure to thrive shall take into account that the cause or causes of this condition must first be identified. Nutrition therapy depends on the infant’s age and stage of development. Usually a high-calorie, high-protein diet is indicated.

• Colic: This symptom is characterized by intermittent profuse crying lasting three hours or longer per day. It most often affects the newborn and is more common in bottle-fed infants that those who are breast-fed.

• Nursing intervention should include assessment of feeding practices: frequency of burping; type of feeding used; volume, concentration, and frequency of feeding; and size of nipple (for bottle-fed infants). Also assessment of mother diet is indicated to find out whether she takes cruciferous vegetables, cow’s milk, onion, and chocolate so that these can be eliminated.

• Cleft Palate: Numerous combinations of developmental defects involving the lip and palate can occur and result in an opening in the roof of the mouth or incompletely formed lips.

• The cause may be hereditary or unknown.

• Caregivers should be advised to feed the infant slowly in an upright position with the head and chest tilted slightly backward to facilitate swallowing without aspiration.

• Surgery could be performed within the first 3 months of life for cleft lip and between 6 and 24 months for cleft palate

• Pyloric Stenosis: This disorder is characterised by an obstructive narrowing of the pyloric opening resulting in projectile vomiting within 30 minutes of feeding, weight loss, dehydration, and poor nutritional status.

• The major goal of nutritional therapy is to achieve fluid and electrolyte balance as pre-requisite to surgery.

• Post-operatively, the infant is given glucose water then advanced to full-strength formula as tolerated, after which she can be breast-fed if desired.

• Fat malabsorption is the greatest nutritional problem. Patients should receive pancreatic enzyme supplements with all meals and snacks to enhance fat digestion and absorption.

• Infants are, particularly, susceptible to protein

deficiency and malnutrition because of their high protein requirements.

Dr.S.Nishan Silva (MBBS). Issues…. Energy requirement Breast milk/ feeding –Contents...

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