Newborn feeding

Feeding of the newborn babies

1. NEWBORN FEEDING
DR. AYODELE, NOSRULLAH
FMC, BIRNIN KEBBI

2. OUTLINE
INTRODUCTION
TYPES OF FEEDING
BREASTFEEDING
–PHYSIOLOGY OF MILK SECRETION AND MILK LET -DOWN
–ADVANTAGES OF BREASTFEEDING
–CONTRAINDICATIONS TO BREASTFEEDING
–DRUGS AND BREASTFEEDING
–BREASTFEEDING AND HIV
–PROBLEMS OF BREASTFEEDING
FORMULA FEEDING
FEEDING IN SICK NEONATES
SUMMARY
CONCLUSION
REFERENCES

3. INTRODUCTION
Adequate infant and young child feeding practices
are among the most effective interventions to
improve child health.
In 2016, 4.2 million (75% of all under-five deaths)
occurred within the first year of life
1
Under-nutrition is associated with at least 35% of
these child deaths.
2
Even without death, undernutrition is a major
disabler preventing children from reaching their full
developmental potential.

4. INTRODUCTION
Around 32% of children less than 5 years of age in
developing countries are stunted and 10% are
wasted
2
Sub-optimal breastfeeding, especially non-exclusive
breastfeeding in the first 6 months of life, results in
1.4 million deaths and 10% of the disease burden in
children younger than 5 years.
In Nigeria, malnutrition is the underlying cause of
morbidity and mortality of a large proportion of
children under-5, it accounts for more than 50% of
deaths of children in this age bracket
2

5. INTRODUCTION
Therefore, to improve this situation, mothers and
families need support to initiate and sustain
appropriate infant and young child feeding practices.
Health professionals also need to have basic
knowledge and skills to give appropriate advice,
counsel and help solve feeding difficulties, and know
when and where to refer a mother who experiences
more complex feeding problems.

6. TYPES OF FEEDING
Breast feeding
–Direct breastfeeding
–Expressed breast milk feeding
Breast milk substitute (BMS) –formula feeding
Total parenteral nutrition

7. BREASTFEEDING
Breastfeedingis an unequalled way of providing
ideal food for the healthy growth and development of
infants.
WHO-recommended breastfeeding is defined as
1.Initiation of breastfeeding within the first hour of life
2.Exclusive breastfeeding for the first six months of life (that
is, the infant only receives breast milk without any
additional food or drink, not even water); followed by
3.Continued breastfeeding for up to two years of age or
beyond (with the introduction of appropriate
complementary foods at six months);and
4.Breastfeeding on demand –that is, as often as the child
wants, day and night
2

8. BREASTFEEDING
Baby should be commenced on feeding soon after
birth as can be safely tolerated, as judged by normal
activity, alertness, suck and cry
Most infants can start breast-feeding immediately
after birth, almost always within 1–4 hr.
Feeding should be withheld in infants who may have
problems tolerating enteral feeding
Breastfed neonates feed 8-12 times a day with a
minimum of 8 times per day.
5
Exclusive breastfeeding from birth is possible except
for a few medical conditions

9. BREASTFEEDING
Parenteral fluids should be administered if it appears
that feedings must be withheld for some time
Breastfeeding has documented short and long-term
medical and neurodevelopmental advantages and
rare contraindications
A healthy mother will produce about 440–1220 ml,
averaging about 800 ml per day
2

10. TYPES OF BREAST MILK
Colostrum (Days #2-4)
–deep lemon yellow, alkaline, high protein, immunoglobulins,
minerals, vitamins but low in lactose and fat.
–is a laxative and helps the baby to pass meconium. This
helps to prevent jaundice
Transitional milk (Days #5-10)
–high in fat, lactose; lower in protein and minerals
Mature milk (Day #14)
–Contains fore milk (grey or watery –satisfies thirst) and
hind milk (whiter, more fat thus more energy)
–60-80% whey protein, 50% fat, 40% lactose, growth factor,
low in Vitamin D

11. PHYSIOLOGY OF BREAST -MILK
SECRETION & MILK LET-DOWN

12. ADVANTAGES OF BREAST -
FEEDING
1.Promotes and enhances maternal –infant bonding
2.Cheap
3.Freely available, requires no preparation time
4.Easily accessible for the infant
5.Fresh and free of contaminant
6.It is of normal temperature –not too warm and not
too cold
7.Human milk and colostrum contain macrophages
which produce complement and lysozymes
8.Contains lactoferrin that inhibits growth of E.coli
thereby preventing gastroenteritis

13. ADVANTAGES OF BREAST -
FEEDING
9.Contains secretory IgA against a large number of
viruses and bacteria
10.The lower pH of the stool of breast-fed infants is
thought to contribute to the favourable intestinal
flora
11.Human milk also contains bile salt-stimulated
lipase, which kills Giardia lambliaand Entamoeba
histolytica
12.Avoids the problems of cow-milk allergy or
intolerance
13.Decreases the frequency and severity of childhood
eczema and asthma

14. ADVANTAGES OF BREAST -
FEEDING
14.Contributes to women's health by reducing the risk
of breast and ovarian cancer
15.Helps in increasing the spacing between
pregnancies
16.Provides social and economic benefits to the family
and the nation
17.Provides most women with a sense of satisfaction
when successfully carried out
18.Oxytocin induces a state of calm, and reduces
stress
2

15. CONTRAINDICATIONS TO
BREAST-FEEDING
Infant factors
–Inborn errors of metabolism e.g. galactosemia, maple syrup
urine disease, and phenylketonuria
Maternal factors
–Infections –active TB, Herpes, human T-cell lymphotropic
virus types 1 and 2, HIV (USA)
–Chemotherapy –anticancer, antithyroid
–Radioactive compound treatments
–Severe illness

16. DRUGS AND BREAST -FEEDING
Increase lactation Decrease lactation
Metoclopramide Bromocriptine(dopamine agonist)
Domperidone Progesterone, estrogen-OCP
Phenothiazine neuroleptics –
chlorpromazine
Clomiphene citrate
Antihypertensives-methyl dopa, b
blockers
Ergotamine
Hypoglycemics pseudoephedrine(in cough syrups)
H2 antagonists-cimetidine Levodopa/carbidopa
SSRI Prostaglandins-PGE/F2alpha
Opioids

17. DRUGS AND BREASTFEEDING
Drugs contraindicated during breastfeeding
6
–chemotherapeutic/antineoplastic agents
–Antithyroid drugs –methimazole, thiouracil
–Ergotamine
–Gold salts
–Phencyclidine
–Radioactive pharmaceuticals
–Retinoids
–Tetracyclines (chronic > 3 weeks)
–Certain psychotropic
–Amiodarone
–Social drugs and drugs of abuse
–Chloramphenicol

18. BREASTFEEDING AND HIV
Mothers living with HIV are to do exclusive
breastfeeding for 6 months
Mothers living with HIV should breastfeed for at least
12 months and may continue breastfeeding for up to
24 months or longer (similar to the general
population) while being fully supported for ART
adherence
4
Although exclusive breastfeeding is recommended,
practising mixed feeding is not a reason to stop
breastfeeding in the presence of ARV drugs.
4

19. BREASTFEEDING AND HIV
Mothers living with HIV and health-care workers can be
reassured that ART reduces the risk of postnatal HIV
transmission in the context of mixed feeding.
4
Mothers living with HIV and health-care workers can be
reassured that shorter durations of breastfeeding of less
than 12 months are better than never initiating
breastfeeding at all.
4

20. BREASTFEEDING AND HIV
National and local health authorities should actively
coordinate and implement services in health facilities
and activities in workplaces, communities and
homes to protect, promote and support
4
breastfeeding among women living with HIV.
Mothers known to be living with HIV who decide to
stop breastfeeding at any time should stop gradually
within one month
4
Stopping breastfeeding abruptly is not advisable.
4

21. BREASTFEEDING AND HIV
When mothers known to be living with HIV decide to
stop breastfeeding at any time, infants should be
provided with safe and adequate replacement feeds
to enable normal growth and development.
Alternatives to breastfeeding include:
–commercial infant formula milk
–expressed, heat-treated breast milk
–Breastmilk provided by HIV negative mothers
The replacement feed must be acceptable, feasible,
affordable, sustainable and safe (AFASS)

22. BREASTFEEDING AND HIV
Infants born to mothers with HIV who are at high risk
of acquiring HIV should receive dual prophylaxis with
AZT (twice daily) and NVP (once daily) for the first 6
weeks of life, whether they are breastfed or formula
fed
3
Breastfed infants who are at high risk of acquiring
HIV, including those first identified as exposed to HIV
during the postpartum period, should continue infant
prophylaxis for an additional 6 weeks (total of 12
weeks of infant prophylaxis) using either AZT (twice
daily) and NVP (once daily) or NVP alone
3

23. BREASTFEEDING AND HIV
Infants of mothers who are receiving ART and are
breastfeeding should receive 6 weeks of infant
prophylaxis with daily NVP. If infants are receiving
replacement feeding, they should be given 4–6
weeks of infant prophylaxis with daily NVP (or twice-
daily AZT)
3
Infants and young children known to be living with
HIV are fed like the general population of infants and
will be on ART for life
3

24. HOW TO FEED A BABY
Babies of 36 weeks gestational age or more can
often suckle well enough at the breast to feed
themselves fully.
Babies of 32 to 36 weeks gestational age need to be
fed partly or fully on EBM by cup or spoon until full
breastfeeding can be established. Allow to suck the
nipple to stimulate lactation.
Babies less than 32 weeks gestational age usually
need to be fed by gastric tube.
–They should not receive any enteral feeds in the first 12–24
hours
2

26. POSITIONING FOR BREASTFEEDING
Position of the mother
–Can be sitting, lying down or standing
–Should be relaxed, comfortable and not back straining
–If sitting, support back, no leaning forward
Position of the baby
–Can be across the chest or abdomen of the mother, under
her arm or alongside her body
–Baby’s body should be straight, not bent or twisted
–Head can be slightly extended to give access to the breast
–Baby should be facing the breast
–Baby’s body should be touching the mother’s body

27. POSITIONING FOR BREASTFEEDING
Position of the baby
–body should be supported on the bed or a pillow, or
mother’s lap or arm not only baby’s head and neck
Sitting
Lying down

28. BREAST ATTACHMENT
Good attachment Poor attachment

29. BREAST ATTACHMENT
Signs of good attachment to the breast
1.More of the areola is visible above the baby’s top lip than
below the lower lip
2.The baby’s mouth is wide open
3.The baby’s lower lip is curled outwards
4.The baby’s chin is touching or almost touching the breast.
Signs of poor attachment
1.More of the areola is visible below the baby’s bottom lip
than above the top lip –or the amounts above and below
are equal
2.The baby’s mouth is not wide open;
3.The baby’s lower lip points forward or is turned inwards;
4.The baby’s chin is away from the breast.

30. SIGNS THAT BABY IS SUCKING IN A
GOOD POSITION.
Baby takes slow deep sucks followed by swallowing
You may be able to hear baby swallow
Baby is relaxed; happy satisfied at the end of the
feed.
Mother does not feel nipple pain

31. CAUSES OF POOR SUCKLING
Prior bottle feeding (Nipple confusion)
Inexperienced mother
Very small or weak babies

32. EFFECTS OF POOR SUCKLING
Sore and cracked nipples
Poor milk supply and poor growth
An unsatisfied baby who wants to feed all the time
A frustrated baby who refuses feed
Enlarged breasts

33. COMMON PROBLEMS WITH
BREASTFEEDING
Nipple pain
–commonly due to poor positioning and improper latch.
–If not resolving consider candidiasis
Breast engorgement
–incomplete milk removal, poor technique, infant illness.
–Management
Hot compress before feeding
Milk expression
Supportive bra
NSAIDs
Inadequate milk intake =>dehydration=>malnutrition
Jaundice –breastfeeding or breastmilk jaundice

34. COMMON PROBLEMS WITH
BREASTFEEDING
Mastitis –inflammation of the breast tissue
–From 2
nd
week of life
–Organisms –Staph. Aureus, Kleb. pneumo, E. coli, GAS,
Bacteroides
–Management
Oral antibiotics
Analgesics
Promote breastfeeding / empty affected breast
Breast abscess –less common complication of
mastitis but more serious
–Management
Incision and drainage of abscess with parenteral antibiotics
Temporarily stop breastfeeding till infection resolves

35. REASONS WHY A BABY MAY NOT
GET ENOUGH MILK
Breastfeeding factorsMother: Psychological
factors
Mother: Physical
condition
Baby’s condition
Delayed start Lack of confidence Contraceptive pills,
diuretics
Illness
Feeding at fixed
times
Depression Pregnancy Abnormality
Infrequent feeds Worry, stress Severe malnutrition
No night feeds Dislike of
breastfeeding
Alcohol
Short feeds Rejection of baby Smoking
Poor attachment Myths / taboos Retained piece of
placenta
Bottles, pacifiers Pituitary failure (rare)
Other fluids or feeds
(water, teas)
Poor breast
development (very rare)

36. BABY FRIENDLY HOSPITAL
INITIATIVE
It is a worldwide programme of the World Health
Organization and UNICEF, launched in 1991
following Innocenti declaration of 1990.
7
It is a global effort to implement practices that
protect, promote and support breastfeeding.
It aims to increase the numbers of babies who are
exclusively breastfed worldwide
WHO estimates that this could contribute to avoiding
over a million child deaths each year, and potentially
many premature maternal deaths as well

38. FORMULA FEEDING
Indications include:
1.Contraindication to breastfeeding/breastmilk
2.Breastmilk not available e.g. non-lactating mother,
very sick or dead mother, no healthy wet nurse
3.Support inadequate weight gain with breastmilk

39. TYPES OF FORMULA
Cow milk protein-based formula
Soy formulas –used in galactosemia, hereditary
lactase deficiency, vegetarian diet
Protein hydrolysate formulas
–Partially hydrolysed (oligopeptides with m.wt <5000Da, fat
similar to cow milk)
–Extensively hydrolysed (peptides m.wt. <3000Da, lactose
free, use in cow or soy formula intolerant babies)
Amino acid formulas –peptide free, contains
essential and non-essential amino acids, used in
dairy protein intolerant infants

40. BREAST MILK vs COW MILK
Constituent %/100gm Human milkHuman Cow’s Milk
 Colostrum
Water 88 87 88
Protein 0.9 2.7 3.3
Casein lactalbumin 0.41.2 2.7
Lactoglobulin 0.2 1.5 0.2
Fat 3.8 2.9 3.8
% Polyunsat. fat 8.0 7.0 2.0
Lactose 7.0 5.3 4.8
Energy value of each is 67Kcal/100mls.

41. DIFFERENCES BETWEEN
BREASTMILK AND OTHER TYPES

42. FORMULA FEEDING
Ready-to-feed products generally provide 20 kcal/30
mL (1 oz) and approximately 67 kcal/dL.
i.e 30ml = 20kcal
1ml = 20/30 kcal = 0.67kcal
Concentrated liquid feeds when diluted and powder
forms when mixed will give similar caloric density

43. DAILY CALORIC REQUIREMENT
Average caloric requirement of full term infants are:
–110 –120kcal/kg/24hours during the first few months
of life
–100kcal/kg/24hours by one year of age.
Preterm infants need equivalent 120-140kcal/kg/24hr

44. FORMULA FEEDING
Problems
–Powder forms are not sterile
–Mixing inappropriateness –hypo/hyper concentration, safe
water
–General hygiene problems e.g. hand washing

45. FLUID THERAPY IN SICK
NEONATE
IV fluid must be gradual and well-regulated to avoid
complications
A special infusion set (SOLUSET) is used to regulate
the fluid –administers 1ml of fluid in 60 drops
On the 1
st
day of life, start with
–60-70ml/kg/day for term infants
–70-80ml/kg/day for preterm infants
Thereafter, increase by 10-20ml/kg/day to maximum
of 150ml/kg/day
First 48hrs give 10% DW, then change to
4.3%D/0.2%S subsequently

46. FLUID THERAPY IN SICK
NEONATE
For babies under radiant warmer or receiving
phototherapy, give 10% additional fluid to make up
for higher insensible loss
Restrict fluid to 70-80% of maintenance fluid in
infants with severe asphyxia, encephalopathy,
circulatory overload (cardiac failure), severe oedema

47. TOTAL PARENTERAL NUTRITION
The goal is to deliver sufficient calories from glucose,
protein, and lipids to promote optimal growth
Indication
–when enteral feeding is impossible for prolonged periods
Route of administration
–percutaneously
–surgically placed indwelling central venous catheter
–peripheral vein.
–umbilical vein ( for up to 2 wk)

48. TOTAL PARENTERAL NUTRITION
The infusate should contain
–2.5-3.5 g/dL/day of synthetic amino acids and
–10-15 g/dL/day of glucose,
–2-3g/kg/day of fat emulsion e.g. intralipid 20%
–appropriate quantities of electrolytes, trace minerals, and
vitamins.
The content of each day’s infusate should be
determined after careful assessment of the infant’s
clinical and biochemical status

49. TOTAL PARENTERAL NUTRITION
Complications
Complication from catheter Complication from infusate
metabolism
Infection Hyperglycemia
Thrombosis osmotic diuresis
Extravasation of fluid Dehydration
Accidental dislodgment Azotemia
Phlebitis Nephrocalcinosis
Cutaneous sloughing, Hypoglycemia
Hypoxemia
hyperammonemia

50. SUMMARY
Breastfeeding is the best food for infants.
Feeding should be initiated as son as possible after
birth and should be given in appropriate manner to
ensure adequate growth of the baby.
In certain circumstances, formula feeding may be
needed, should be well prepared and given in
appropriate amount and concentration.
Breast symptoms should not deter a woman from
breastfeeding, however, should be well addressed.
HIV infection should not prevent a woman from
breastfeeding her baby, especially in low resource
settings

51. CONCLUSION
Optimal infant feeding is important for the
appropriate growth and development of an infant and
prevention of morbidity and mortality. Therefore,
adequate counselling, education and support of the
mothers with appropriate policies, guidelines and
well motivated healthcare professionals will help in
achieving a successful breastfeeding and wellbeing
of children.
“A healthy nation is a wealthy nation”.

52. REFERENCES
1.World Health Organization. Global Health Observatory (GHO) data
http://www.who.int/gho/child_health/mortality/neonatal_infant_text/en/
Accessed 24
th
March 2018
2.World Health Organization. Infant and young child feeding: model
chapter for textbooks for medical students and allied health
professionals. 2009
3.World Health Organization. Consolidated guidelines on the use of
antiretroviral drugs for treating and preventing HIV infection:
recommendations for a public health approach. World Health
Organization; 2016.
4.World Health Organization. Guideline: updates on HIV and infant
feeding: the duration of breastfeeding, and support from health
services to improve feeding practices among mothers living with HIV.
2016
5.Kliegman, Robert, Richard E. Behrman, and Waldo E. Nelson. Nelson
textbook of pediatrics. 20
th
edition. 2016.

53. REFERENCES
6.American Academy of Paediatrics. Breasfedding and Medication
https://www.aap.org/en-us/Pages/Breastfeeding-and-Medication.aspx
Accessed 24
th
March 2018
7.UNICEF. Innocenti Declaration
https://www.unicef.org/programme/breastfeeding/innocenti.htm.
Accessed 24
th
March 2018
8.Kliegman RM, Behrman RE, Jenson HB, Stanton BM. Nelson textbook
of paediatrics18
th
edition. 2007.
9.UNICEF. Maternal and Child Health
https://www.unicef.org/nigeria/children_1926.html. Acessed 24
th
March
2018
10.Ogunfowora OB. Infant feeding. Lecture notes for medical students.
OOUTH Sagamu. 2009
11.Runsewe-Abiodun IT. Infant feeding. Lecture notes for medical
students. OOUTH Sagamu. 2009

54. THANK YOU
FOR YOUR ATTENTION