Symptoms of INFANT NUTRITIONAL INFORMATION

Human milk has the highest lactose content of the mammalian milks, providing a readily available energy source compatible with neonatal enzymes; it contains large amounts of vitamin E, which may help prevent anemia by increasing erythrocyte life span, and is an important antioxidant. Human milk has a calcium:phosphorus ratio of 2:1, which prevents calcium-deficiency tetany (the ratio in cow's milk is almost reversed). Breast milk favorably changes the pH of stools and the intestinal flora, thus protecting against bacterial diarrheas; it (especially colostrum) also transfers antibodies from mother to infant. Indeed, all infectious diseases are less frequent in infants who are breastfed rather than bottle fed. A goal of some health advocates is that 75% of women will leave the hospital breastfeeding and at least 50% will still be nursing their infants at 6 mo old. If the mother's diet is adequate, no dietary supplement is needed for the breastfed infant, except in areas with little sunshine, where infants, especially those with dark skin, may require 400 U of vitamin D daily, especially in the winter. The American Academy of Pediatrics (AAP) no longer recommends fluoride supplementation unless the water supply in the region is deficient in fluoride. Almost all mothers can produce good milk even if their diet is not perfect. Human milk contains omega-3 fatty acids, cholesterol, and taurine, which are important to good brain growth, regardless of mother's diet. The mother's diet should be well-balanced, and she should avoid foods that may cause colic, such as garlic, onions, legumes, cabbage, chocolate, and excessive amounts of exotic or seasonal fruits (melons, rhubarb, peaches), unless trial shows that they are tolerated by the infant. Maternal fatigue and emotional stress more often result in failure to satisfy the infant via breastfeeding than do any other factors. Special dietary increases for the breastfeeding mother during lactation include an extra 600 kcal, of which 20 g should be protein; 400 mg extra calcium also must be added (dairy products are an excellent source). If milk products are not tolerated, nuts and green vegetables should be increased, or calcium gluconate supplements by capsule may be used. In a well-balanced diet (containing vitamin C and animal protein for B6 and B12), vitamin supplementation is unnecessary. The average U.S. diet is low in B6, and vegetarian diets also may be low in B12. A daily vitamin supplement such as one used prenatally may be used but usually is unnecessary. The physician should discuss breastfeeding with the mother prenatally, presenting the many benefits received by the breastfed infant (nutritional and psychologic benefits, and protection against infection, allergies, and other chronic diseases). The benefits to the mother include reduced fertility, more rapid return to normal prepartum condition, and reduced risk of obesity, osteoporosis, and breast cancer. At delivery, if the mother has had little medication and a normal delivery and the newborn is alert and active, breastfeeding may start immediately for a few minutes until the newborn is satiated. The newborn will receive a small amount of colostrum, a high-caloric, high-protein, thin yellow fluid present in the breast before birth and for the first few days thereafter, which contains antibodies, lymphocytes, and macrophages as well as nutrients and is protective against infection. Colostrum also stimulates the passage of meconium. The newborn, regardless of whether or not nursed in the delivery room, can be taken to the mother for nursing within the first 4 h of birth. The mother should assume a comfortable, relaxed position, such as lying almost flat and turning from one side to the other to offer each breast. The newborn should face the mother, ventral surface to ventral surface. The mother should support her breast with thumb and index finger above and three fingers below the nipple to ensure that it is centered in the newborn's mouth, minimizing any soreness. The center of the newborn's lower lip should be stimulated with the nipple so that rooting will occur and the mouth will open wide and grasp the nipple and areola. The newborn's tongue compresses the teat against the hard palate. Suction should be broken before removing the newborn from the breast. Feedings should be started on alternate sides. Initially, it takes at least 2 min for the let-down reflex to act. Excessive suckling should be avoided initially. Sore nipples are usually due to poor positioning and are easier to prevent than to cure. However, milk production is dependent on adequate suckling time. Nursing times are gradually increased until the "milk is in." At least 10 min is needed at the first breast to allow the fat-rich hind milk to flow. The infant should continue to nurse until he is ready to be burped. If the infant is still hungry, the second breast can be offered. In primiparas, lactation is fully established in 72 to 96 h; less time is required in multiparas. If the mother is fatigued the first night or two in the hospital, the 2 AM feeding may be replaced with a water supplement until full milk secretion begins, but with never > 6 h between breastfeedings during the first few days. Feedings should be on demand rather than by the clock, and feeding duration should also reflect newborn needs. In most women, a total of 90 min/day suckling at the breast is minimal to produce enough milk. Newborns discharged within 48 h, especially breastfeeding ones, should be seen by the physician within 7 days to evaluate progress, particularly if the mother is a primipara. Although the infant's sleeping for long periods between breastfeedings may be a sign of a good milk supply, it can be associated with inadequate supply and starvation. A normal newborn wets 6 to 8 diapers a day or more, defecates daily at least 3 times, and has a vigorous cry, good skin turgor, and a good sucking reflex. Weight gain confirms adequate feeding. By 7 days, the weight should plateau, and by 10 to 14 days it should be back to birth weight. Weight gain should be 1 oz (30 g)/day for the first few months. Birth weight should double by age 4 mo. When an infant is to be fed artificial milk, the first feeding offered should be regular-strength infant formula according to the pediatrician's instructions. A test feeding of water or 5% D/W is usually not needed unless the infant's sucking and swallowing ability is in question, eg, as indicated by an excessive amount of mucus regurgitated. If this feeding is not regurgitated, the infant should continue to be offered formula with each subsequent feeding. Bottle fed infants are fed on demand and tend to wake for feedings every 3 to 4 h. The volume consumed in the first feeding is up to 15 mL (0.5 oz). The volume offered in the next 48 h is gradually increased to about 2 to 2 1/2 oz per feeding. Prepackaged formulas are available in the hospital in sterile 4-oz bottles providing 20 (full strength) kcal/oz with adequate vitamins for the normal newborn. Full-term newborns can tolerate 20 cal/oz at birth. The mother should be instructed not to overfeed the infant simply because there are 4 oz of formula in the bottle. Feeding should increase gradually during the first week of life from 1 to 2 oz up to 3 or 4 oz approximately 6 times/day, which supplies about 120 kcal/kg (55 kcal/lb) at 1 wk of age. The newborn should be offered water between feedings, particularly during hot weather or in hot, dry environments. If the infant is exceeding his calculated intake of formula, water should be offered to avoid overfeeding. Newborns should retain at least 65 mL of fluid/kg the first 24 h, 75 mL/kg the second 24 h, and up to 100 mL/kg the third 24 h. Those who fall appreciably below these amounts are given 5% glucose in 0.25% sodium chloride by IV drip to make up the deficit. A cause for poor feeding patterns should be sought.