Newborn Nutrition Presentation Outline Ch.

25 (all referes to Hockenberry pediatrics book) DEVELOPMENTAL STAGES Newborn 1st month Infant 2-12 months Newborns Establish effective respirations in transition from intra- to extra-uterine life First breaths inflate the lungs & stimulate changes to establish the systemic and pulmonary circulation to support all organs allowing a healthy development (p. 570 & all your knowledge from Pedi). Newborns learn that crying will lead to feeding by one month (p. 484) Change from a flexed position with predominantly closed hands to an infant in a less flexed position with open hands by 2 months (p. 481) Some reflexes that the newborn will have are "sucking and rooting, swallowing, and grasp (palmar and plantar), and absence of any of these indicates major neurologic problems ( p. 545) Breathing is coordinated with the sucking and swallowing reflexes and any impairment in these will impair feeding NUTRIENT needs of NEWBORNS (pgs. 610-611) Calories: 1st 3 months: 110 kcal/kg/day Breast milk & formula contain 20kcal/oz, Protein: younger than 6 months: 9.1 g/day Fat: younger than 6 months: 31g Fat/day Carbohydrate: 1st 6 months: 60 g/day Water: breastfed/formula fed = No extra water needed Vitamins: supplement Vitamin D & B12 and K is supplemented at birth Minerals: Calcium: younger than 6 months: 210 mg/day for infants Iron: supplement all & breastfed weaned after 6 months Fluoride: younger than 6 months: no supplements There may be mothers who have the time to use this information and calculate whether or not their infant is obtaining sufficient nutrients. The majority just want to know how often to feed their infants and the benefits of one method vs. the other. Breast feeding: Feed every On demand Breast milk expressed and only given by bottle (mom controls frequency of direct breastfeeding) Some do breastfeeding and formula warn that this confuses baby!

Breast fed and Bottle fed: (630) Feed at least every 3-4 hours (may need to wake newborn)

No need for rigid scheduling Need 6 to 8 feedings in 24 hours (decreases as infant matures and becomes more efficient) There will be an increase in feeding intake during growth spurts: 10 D, 3 wks, 6 wks, 3 mos, 6 mos. Emphasize that: both breast fed and bottle fed newborns and infants will have the bonding between mother and infant and father and infant. Parental bonding develops from feeding but all interaction is needed and it is not solely from feeding! Breast milk: 610 offers sufficient Calories, Fat, Protein, Carbohydrates (CHO), H2O, Vitamins & Minerals provides protective substances (described below) that protect infant against infection Formula is modified to resemble breast milk so formula fed infants get appropriate nutrition but when teaching patient explain that their breast milk is specifically engineered for their newborn. (It is my understanding and opinion that modification allows adding all things necessary for the objective the manufacturers are meeting, but is substandard to the composition of breast milk!) Composition p. 613 Changes during the feeding and during the time of day Breast feeding session takes about 10-15 minutes per breast Feed until infant stops sucking or turns away or falls asleep Time of breast feeding session decreases as infant gets older Specific (p. 613) Breast milk for a Pre term infant will have a different composition than Breast milk for a Term infant Calories (610)

Newborns need 110 kcal/kg/day, and breast milk and infant formula contain 20kcal/oz

Breastfeed at least 3 X day (moms may need to express milk to go to work and have someone else care for infant, so mom must plan for infants food source and during the times that she is gone) Takes from 15-20 minutes per breast

Fat: (610) Changes during feeding (foremilk (has less fat) & hindmilk (has more fat) & during time of day Foremilk: lactose, protein and water soluble vitamins

Hindmilk: fat Has lipids, triglycerides, cholesterol, essential fatty acids (linoleic & linolenic acids) and Polyunsaturated fatty acids (PUFA) (arachidonic (ARA) & docosahexaenoic acid (DHA)) o All provide for brain growth, neurological development & visual function In general, there are essential and nonessential amino acids and fatty acids are substances that describe substances that are needed by the body but have different origins. When able to and given the necessary substrate (building blocks), then the body can produce nonessential entities!! Protein: (611) All essential (only from external source) & nonessential (body composes from other structures) Whey & Casein = main proteins in breast milk Whey (Lactoalbumin) & Casein (curd) natural in breast milk o Provide all essential and nonessential amino acids (aa) o Their ratio (60:40) is more easily digested than cows milk (80:20) Whey (Lactoferrin) o Fe binding capabilities & bacteriostatic properties against gram (+) and gram (-) aerobes, anaerobes and yeast Casein enhances Fe absorption & prevents Fe-dependent bacteria from growing in GI Cystine & Taurine = high & Phenyalanine and methionine = low CHO (610) Latose = main CHO Oligosaccharides = needed to establish microflora Promotes an acidic environment in GI and prevent bacterial growth H2O (610) Breast fed and formula fed infants offer sufficient water so no need to give more Otherwise they fill up and by end of the day do not obtain all necessary calories

Vitamins (611) Breast milk (all supplied) Cows milk: vitamins C, E, & D must be added Recommendation (regarless): all infants should have supplementation Vitamin K is administered at birth bc it is dependent on microflora establishment!!! All infants should receive 400 IU Vitamin D per day Vitamin B12: depends on mothers diet so a vegetarian mother is at risk of producing breast milk deficient in vitamin B12 Minerals (611)

Calcium & Phosphorus Ca:P ratio (2:1) promotes optimal bone mineralization (bone growth)

Breast Milk: Mineral concentration is higher early after birth & decreases slightly throughout lactation Cows milk: has higher Ca content than breast milk but its Ca:P ratio is low Infants fed Unmodified cows milk = at risk of hypocalcemia, seizures and tetany! Iron (611) Low in all types of milk Fe in breast milk is Better Absorbed than Fe from cows milk Infants weaned at or after 6 moths and all formula fed infants should be supplemented with Fe Fe supply improves when they start cereals and other food
Fluoride (611) No need to supplement infants younger than 6 months Fluoride supplement= based on water supply for infants 6 months to 3 years

Breastfeeding (p. 616) Not painful If painful, break suction by inserting finger in side of babys mouth between gums and leave it there until the nipple is out completely Cheek and chin should touch breast Audible swallow Do not use soap on breasts because Montgomery glands secrete a natural oil that protects breasts from cracking and soap can take oil away (625) Use modified lanolin on dry or sore nipples (625) Latching technique is in trifold (615) Bottle feeding: (p. 630) Do not prop bottle To prevent colic: o Hold infant in a semi-upright position with good head support o Hold bottle so that milk fills the nipple so no air is allowed o Burp infant several times during feeding o Do not position infant on abdomen after feeding Follow manufacturer mixing instructions if powder formula milk p. 632 o If not enough H2O with powder milk infant at risk of having kidney problems bc their kidneys are immature o If too much water, they get water and not enough calories o From most expensive to least expensive: o Read to feed, concentrated and powdered formula o Other milk from an animal source (goat milk, skim or low fat milk, condensed or evaporated milk should not be used because it does not support growth and contains inadequate calcium/phosphorus ratio which can cause seizures (p. 631)

Spitting (p. 630) May be from overfeeding Symptomatic for GER (gastroesophageal reflux) Report vomiting 1/3 or more of feeding Report projectile vomiting Do not change infant formula without consulting with physician Hand or mechanical expression: p. 622 Choose the more comfortable method for mothers lifestyle For both methods: wash hands & all breast pumps must be washed and dried before using

Advantages of Breast milk: Perfect & immune factors Helps mom lose weight and get back to figure (mom must control her caloric intake- it is not magical!!) May Px obesity No cost- pre-packaged Mom can feed anywhere (at restaurants, churches, with baby in car seat! etc) Disadvantages of Breast milk: Must express for other caregivers to feed infant Engorgement (627) Leakage (up to about 6 months) (mom can use breast pads in her bra to prevent embarrassing moments)

(625) Plugged ducts (629)

Advantages of Formula feeding: Many caregivers Disadvantages: Spit up Formula allergies (may need to try different formulas) Cost (formula, bottles & nipples)

Nutritional screening and assessment of infants: Goal of nutritional screening: to identify patients with poor nutritional status (Worthington, 2011, p.1). Nutritional assessment involves a 24 hour history, then possibly a diet history (2 weekdays and 1 weekend day) and assessment of hair, skin and mouth because these have rapid turnover and deficiencies noted may indicate various nutritional deficiencies (Hockenberry, 2011, p. 135). The use of weight, length and head circumference as a component of nutritional assessment is well established (Guidelines, 2011, p. 2) Growth measurements are taken and compared (Hockenberry, 2011, p. 138) Undernourishment occurs in children from all socioeconomic levels but those from low socioeconomic levels, homeless and from rural areas have a higher risk (Rabinowitz, 2011, p. 3) For your information: Current trend: Hospitals are supposed improve their patient education to promote breastfeeding. (Lewallen, L. and Street, D. (2010). Initiating and sustaining breastfeeding in african-american

women. Journal of Obstetric, Gynecologic and Neonatal Nursing. 39, 667-674) Obesity seems to be lower in children who were breast fed because they (apparently) learn to recognize their satiety. So, for instance, the breastfed infant quickly learns that to have fun with Dad, he or she needs to get off the breast. Bottle fed infants really keep the bottle as long as the caregiver can provide it for them. (Vital signs: hospital practices to support breastfeeding-US, 2007 and 2009. Morbidity and Mortality Weekly Report. 60 (30), 1020-1025)

References CDC. (2005). Guidelines for growth charts and gestational age adjustment for premature infants and children up to the age of 24 months. Retrieved 11/14/11 from

http://www.health.state.mn.us/divs/fh/wic/localagency/nutrition/riskcodes/lbwandvlbw.pdf Headstart. (2011). Child and adult care food program-infant meals: food and nutrition service. Retrieved 11/14/11 from http://eclkc.ohs.acf.hhs.gov/hslc/ttasystem/health/Health/Nutrition/Nutrition%20Program%20Staff/health_mul_11043_03070 6.html Hockenberry, M. & Wilson, D. (2011). Wongs nursing care of infants and children. (9th ed.). Mosby, Elsevier: St. Louis, Mo. Lewallen, L. and Street, D. (2010). Initiating and sustaining breastfeeding in african-american women. Journal of Obstetric, Gynecologic and Neonatal Nursing. 39, 667-674 Lowdermilk, D., Perry, S., Cashion, K., Alden, K. (2012). Maternity and womens health care (10th ed.). Mosby, Elsevier: St. Louis, Mo. WIC. (2011). Women, infants and children program. City of Houston. Retrieved 11/14/11 From http://www.houstontx.gov/health/WIC/index.html Rabinowitz, S. (2011). Nutritional considerations in failure to thrive. Retrieved 11/14/11 from http://emedicine.medscape.com/article/985007-overview#a0199 Worthington, P. (2011). Nutritional assessment and planning in clinical care. Retrieved 11/14/11 from http://www.jefferson.edu/gi/education/documents/NutritionalAssessment.pdf Vital signs: hospital practices to support breastfeeding-US, 2007 and 2009. Morbidity and Mortality Weekly Report. 60 (30), 1020-1025