NSG210 Durham Ch. 16: Newborn Nutrition

Source: Durham & Chapman, Maternal-Newborn Nursing 4e, Chapter 16, pp. 531-546 (textbooks/DURHAM_OB_CH16.pdf, also in textbooks/exam03/). Week 10 reading; on Exam 3. Lecture slides: raw/nsg210_wk10_OBLecture4.md (Breastfeeding Basics). Maternal breast assessment, engorgement and mastitis are also in nsg210-durham-ch12-postpartum-care and nsg210-durham-ch14-high-risk-postpartum; newborn stool and diaper counts are in nsg210-durham-ch15-neonate-and-family.

Learning Outcomes

1. Discuss the nutritional needs of the newborn.
2. Outline the benefits of breastfeeding for mother and newborn.
3. Assess proper latch and positioning.
4. Identify prevention and treatment of common breastfeeding problems.
5. Teach signs of adequate intake and output for a breastfed newborn.
6. Explain how to select an appropriate formula and amount.
7. Articulate preparation and supplies for formula feeding.

Nursing diagnoses: knowledge deficit about feeding; anxiety about breastfeeding; pain from sore nipples (improper latch); discomfort from engorgement; knowledge deficit about mastitis.

I. Feeding Decisions and Recommendations

• The feeding choice is shaped by prior experience, culture, partner support and family support; prepare prenatally (classes, reading, support groups, or gathering bottle supplies)
• About 85% of US newborns are breastfed at birth, but only 47% are still breastfed at 3 months. Reasons for early weaning: sore nipples, low supply, poor support, return to work, anxiety
• WHO, AAP and HHS: EXCLUSIVE breastfeeding (nothing else by mouth except medication) for the first 6 MONTHS, then continued breastfeeding with complementary foods up to 2 years (AWHONN: first year and beyond)
• WHO: exclusive breastfeeding has the single largest potential impact on child mortality of any preventive intervention
• Breastfeeding decisions are strongly shaped by culture; provide culturally sensitive support

Benefits for the newborn:

• Short term: less gastroenteritis, RSV, otitis media, necrotizing enterocolitis, sudden unexplained infant death
• Long term: less asthma, atopic dermatitis, cardiovascular disease, celiac disease, inflammatory bowel disease, obesity

Benefits for the mother:

• Less blood loss, less infection, more postpartum weight loss
• Long term: lower risk of diabetes, metabolic syndrome, osteoporosis, autoimmune disease, ovarian and breast cancer
• Less anxiety and stress

Contraindications (do not breastfeed or give expressed milk):

• Infant with galactosemia (inherited disorder of carbohydrate metabolism)
• Active untreated tuberculosis
• Active herpes simplex lesions on a breast
• Radiation therapy; antimetabolite or chemotherapy drugs
• Illicit drug use (amphetamines, PCP, cannabis, cocaine)
• HIV-positive (in the US). In developing countries without clean water or safe formula, WHO encourages mothers with HIV to breastfeed

II. Breast Milk

A. Composition

• Gold standard; contains fats, carbohydrates, proteins, lactose, vitamins, minerals, hormones
• About 87% water, 1% protein, 3.8% fat, 7% lactose
• Fat (3.5% to 4.5%) is the most important component: energy and CNS development; fat provides 50% of calories, lactose 40%
• Provides essential nutrition even if the mother’s diet is poor
• Contains all essential vitamins EXCEPT vitamins D and K
• Composition adapts to the infant: milk for a preterm infant has more protein and less fat and lactose

B. Stages of milk

• Foremilk: stored between feedings, released first; more dilute; satisfies thirst
• Hindmilk: produced during the feeding, comes at the end; higher fat and calories

C. Milk production

• Mammogenesis: breast growth in pregnancy under estrogen (ductal system) and progesterone
• Lactogenesis I: pregnancy to postpartum day 2; secretory cells develop; prolactin stimulates milk; breasts are ready by about 20 weeks of gestation
• Lactogenesis II: days 3 to 8; triggered by delivery of the placenta and the drop in progesterone; control shifts from ENDOCRINE (hormonal, happens whether or not she breastfeeds) to AUTOCRINE (supply and demand)
• Galactopoiesis: day 9 to end of lactation; maintenance; milk removal is the main control of supply
• Involution: production decreases with weaning

Hormones:

• Prolactin (anterior pituitary): alveolar cells secrete milk; rises with breast stimulation at each feeding and during the night into the early morning
• Oxytocin (posterior pituitary): released with nipple stimulation; contracts myoepithelial cells, causing the let-down (milk ejection) reflex; occurs several times per feeding, strongest at the start; inhibited by stress, anxiety, pain and fatigue; triggered by hearing the baby cry; also relaxes the mother and promotes bonding

Critical Component, supply and demand: both breastfeeding and non-breastfeeding mothers make colostrum the first few days. Supply depends on breast stimulation and milk removal. Offer the breast every 2 to 3 hours and on demand. If mother and infant are separated, start pumping as soon as possible after birth.

III. Skin-to-Skin

• Kangaroo care stabilizes newborn temperature and blood glucose
• For the mother: stimulates oxytocin and prolactin, increases milk supply, decreases stress
• Skin-to-skin before feeding times helps wake the newborn
• Evidence-based practice: skin-to-skin right after birth increases success and duration of the first breastfeeding (newborns show innate searching and sucking in the first hour; separation disrupts it). Place the diapered newborn on the mother’s bare chest facing her with the head turned to one side, maximum skin contact, and guide to the breast with feeding cues

IV. Initiating Breastfeeding

• Start as soon as possible after birth; the strong suck reflex lasts only a couple of hours before recovery sleep
• The nurse helps with positioning to support the newborn’s neck and the breast; a deep latch prevents sore nipples (a main cause of early weaning)

Positioning:

• Comfortable position with pillows; “tummy to tummy”; infant’s arms around the breast like a hug
• Support the neck with the hand, thumb and fingers below the ears
• Initial positions: FOOTBALL hold and CROSS-CRADLE hold. Cradle and side-lying are used once breastfeeding is established and the neck is stronger
• Bring the baby to the breast, not the breast to the baby

Latching:

• Start with a fully awake newborn
• Wait for a WIDE open mouth (like a yawn), then bring the baby quickly onto the breast
• Chin touches the lower breast; bring the baby up and over the nipple for an ASYMMETRIC latch (more areola visible above the top lip than below)
• Mouth covers the areola with the nipple at the back of the mouth, stimulating the suck-and-swallow reflex
• To remove, slide a clean finger into the corner of the mouth to break suction (prevents nipple trauma)

Feeding cues (may last up to 30 minutes; crying is a LATE cue): licking or smacking lips, extending the tongue, hand to mouth, sucking fingers, turning toward the mother’s voice, quiet alert state. If no cues, wake the infant and offer the breast every 2 to 3 hours until breastfeeding is established.

Supporting the relationship:

• Let the baby finish the first breast before offering the second; always offer the second
• If the baby fed on both breasts, start the next feed on the breast finished last; if only one, start with the other
• Watch for a nutritive suck pattern, satiety cues and breast softening
• Try to burp after each breast (breastfed babies swallow little air)
• Nurse observes a feeding at least once per shift

Nutritive vs non-nutritive sucking:

• Nutritive: rhythmic; during colostrum about 4 to 6 sucks then a 5 to 10 second pause to swallow, sometimes a soft sigh; with transitional milk only 1 to 2 sucks per swallow
• Non-nutritive (comfort): nonrhythmic, transfers little milk
• A good feeding is at least 10 minutes of nutritive sucking; average 15 to 20 minutes per breast. Past 30 minutes, check whether the sucking is still nutritive; remove only when it is not

Signs of a good latch and feeding (Patient Education):

• Comfortable latch with as much areola in the mouth as possible
• No clicking or smacking sounds
• Nutritive sucking with audible swallows
• No nipple pain or trauma; nipple round and slightly elongated after feeding
• Nurses at least 10 to 30 minutes before the second breast
• Wakes and feeds at least every 2 to 3 hours, 8 to 12 times in 24 hours
• Satiated and relaxed after feeding
• Minimum wet diapers and stools met
• Back to birth weight by 2 weeks

Output: breastfed infants stool more often than formula-fed (often with every feeding). From day 3 to 4, stools change to yellow and seedy; 5 to 6 wet diapers and 2 to 3 stools a day indicate adequate intake (pathway: 6 to 8 wet and 3 or more stools once mature milk is in).

LATCH score (Table 16-1), each item 0 to 2, maximum 10; a score under 2 in any area means more help is needed:

Care plan goal: LATCH score of 8 or greater.

Nipple types: everted (protrudes), flat (level with areola), inverted (drawn below the skin; a true inverted nipple does not evert with stimulation), retracted (drawn in but everts easily). Nipple size or shape does NOT determine success; flat or inverted nipples work if the areola is compressible enough for a deep latch.

V. Breastfeeding Problems

Clinical Judgment, preventing sore nipples, breakdown and mastitis:

• Correct latch-on and release of suction
• Express colostrum onto sore nipples after feeding to aid healing
• Start on the LEAST sore breast (sucking is most vigorous at the start)
• Change positions to change pressure points
• Wash breasts with WATER only (soap and alcohol dry the nipples)
• Cool compresses or breast milk on the nipple; analgesia as needed
• Request a lactation consult for latch problems

Critical Component, mastitis: breast infection with redness, warmth, moderate to severe pain and flu-like symptoms (fever, chills, nausea, vomiting, aches, fatigue). Contact the provider immediately; CONTINUE breastfeeding, even on the affected side; antibiotics are the only effective treatment; untreated mastitis can become an abscess needing hospitalization or surgery.

Engorgement: fullness from blood and lymph congestion (and large IV volumes in labor) as transitional milk comes in around days 3 to 5; diminishes as lactation is established. Later engorgement comes from missed feedings or poor milk removal; pump or express when breasts become firm and uncomfortable if the baby is not available.

Lactation consultant (IBCLC): supports difficult cases; works with but does not replace the nurse’s teaching. Give community resources before discharge.

Alternative feeding methods used by the LC:

• Nipple shield: thin silicone shell over the areola for prematurity or maternal anatomy
• Supplemental nursing system: tube from a bottle taped about 1/4 inch past the nipple so the infant gets supplement while nursing (infant must be able to suckle)
• Cup: small soft cup at the lips; infant awake and upright
• Spoon: drops of colostrum in the early postpartum period

Critical Component, promoting success (hospital policies): offer the breast right after birth if stable; skin-to-skin; unlimited feeds on demand or at least every 2 to 3 hours; trained staff and LC referrals; avoid pacifiers and formula; rest when the baby sleeps; keep the mother comfortable. Delay pacifier use until breastfeeding is established and latching well, usually by the third week.

Critical Component, Baby-Friendly Hospital Initiative (WHO and UNICEF, 1991), Ten Steps:

1. Written breastfeeding policy communicated to all staff
2. Train all staff to implement it
3. Inform all pregnant women about benefits and management
4. Help mothers start breastfeeding within 1 HOUR of birth
5. Show mothers how to breastfeed and maintain lactation even when separated
6. No food or drink other than breast milk unless medically indicated
7. Rooming-in 24 hours a day
8. Breastfeeding on demand
9. No pacifiers or artificial nipples for breastfeeding infants
10. Foster breastfeeding support groups and refer at discharge
    • Under 3% of US births in 2007 vs more than 28% in 2019 occurred in Baby-Friendly facilities

VI. Milk Expression, Pumps and Storage

• Teach every breastfeeding mother hand expression; early on, hand-express colostrum to supplement if the baby feeds poorly
• Pumping when the baby nurses well can overstimulate; begin regular pumping once breastfeeding is established and the baby is back to birth weight (usually by 3 weeks)

Hand expression:

• Wash hands; massage each quadrant from chest wall toward the nipple in circles
• Thumb at 12:00 and forefinger at 6:00 forming a C
• Push straight back toward the chest wall (behind the ducts), then forward toward the nipple; do not spread the fingers
• Collect in a clean container; rotate to 3:00 and 9:00 and repeat

Pumping:

• Best in the MORNING (prolactin peaks overnight); pump halfway between feeds; double pumping yields more; 15 to 20 minutes
• A pump does not remove milk as efficiently as a well-nursing baby
• Hospital-grade electric: every 2 to 3 hours for NICU mothers to maintain supply
• Professional-grade: working mothers pumping 4 to 5 times a day; usually double pumps
• Small electric or manual: occasional use

Storage:

• Glass bottles, hard BPA-free plastic or breast milk bags; label with date and time; freeze at the back of the freezer
• Room temperature (77 F, 25 C): up to 6 to 8 hours
• Refrigerator: 7 to 8 days
• Freezer attached to a refrigerator: 6 months
• Deep freezer: 6 to 12 months
• Thaw in the refrigerator overnight or in a cup of warm water; NEVER microwave (uneven heating, burns, destroys antibodies); may feed cold from the refrigerator

Medications and nicotine: most drugs and vaccines are safe in lactation, but she should check with her provider, including OTC and herbal products. Contraindicated: anticancer agents, antimetabolites, radioactive drugs. Smoking is discouraged, but breast milk benefits outweigh nicotine risk; never smoke while breastfeeding; smoking right AFTER a feeding gives less nicotine in milk than before.

Nutrition for lactating mothers: extra 500 calories a day; healthy diet and light exercise rather than calorie restriction; her diet does not affect her ability to make milk; water or juice while nursing for thirst; spicy foods and caffeine are fine; ask the pediatrician about alcohol.

Donor milk: a human milk bank is preferred for adoptive or surrogate parents with a medically needy infant (requires a prescription; cost can be prohibitive). Induced lactation is possible with pumping and hormones. Informally shared milk carries risks (disease, contamination, drugs); give information so she can decide.

VII. Formula Feeding

• Acceptable alternative; types include cow’s milk-based (whey-predominant is most common), soy, higher-calorie preterm, hypoallergenic; ready-to-feed, concentrate, or powder
• Feed on demand or at least every 3 to 4 hours
• Amount: 0.5 to 1 oz (15 to 30 mL) per feed the first days; 2 to 3 oz (60 to 90 mL) per feed by day 4; gradually up to 32 oz (950 mL) a day. Rule of thumb: 2.5 oz per pound of body weight per day
• Advantages: partner can feed; mother can be away without pumping; fewer feeds (slower digestion)
• Disadvantages: cost; preparation and cleaning time; more infections (no antibodies); more childhood illness, obesity and insulin-dependent diabetes

Formula intolerance (often to casein): vomiting, diarrhea with mucus or blood, weight loss or slow gain, colic. Hypoallergenic formulas exist; talk with the pediatrician.

Feeding teaching:

• BPA-free bottles; rubber or silicone nipples (silicone lasts longer and holds fewer odors); wash in warm soapy water
• Nipple flow: slow (newborns), medium (under 6 months), fast (older)
• Hold the baby close in the crook of the arm with the HEAD HIGHER than the body (prevents formula pooling in the mouth and entering the middle ear, which causes otitis media)
• Tilt the bottle so the nipple stays full (less air)
• NEVER prop bottles (choking, otitis media, tooth decay)
• Hole too big: sudden mouthful and near-choking, or milk flows rather than drips when inverted. Too small: infant works hard, or slower than 1 drip per second
• Burp halfway and at the end
• Discard formula left in the bottle after a feeding

Critical Component, preparing formula:

• Clean the area; wash hands; washed bottles, nipples and can opener
• Check the expiration date; wash the top of the can
• Mix with boiled nonfluoridated water or bottled water, cooled to room temperature
• Follow package dilution exactly: OVERDILUTION causes water intoxication; UNDERDILUTION causes dehydration
• Prepared bottles and opened ready-to-feed or concentrate: refrigerate and use within 24 HOURS; do not freeze mixed formula; do not refrigerate unmixed powder
• Swirl or gently shake to mix
• Warm a refrigerated bottle in warm water; NEVER microwave

VIII. Nutrition Beyond the Newborn Period

• Birth weight doubles by 5 months and triples by 1 year
• Growth spurts at 3 to 5 days, 1 week, 6 weeks, 3 months and 6 months: feed more often
• Track adequacy by plotting weight and length at well-child visits
• Solids: AAP and WHO recommend waiting until about 6 MONTHS (allergy risk); before 4 to 6 months the extrusion (sucking) reflex pushes food out
• Readiness: sits independently, draws in the lower lip as the spoon is removed, opens the mouth when hungry, refuses by closing the mouth and turning away
• First foods: pureed fruits and vegetables and single-grain cereal (rice, oats). NEVER put cereal in a bottle (choking, aspiration)

Critical Component, baby bottle tooth decay (sugar plus mouth bacteria forms acid within 20 minutes):

• No bottles of milk, juice or sugar water in bed
• No sugar water or soda in bottles
• Wipe gums with gauze after each feeding; brush once the first tooth erupts
• Fluoride as advised if the water is not fluoridated; first dental visit by the first birthday

High-Yield Numbers

• Exclusive breastfeeding 6 months; continue to 2 years (WHO)
• 85% start breastfeeding; 47% still at 3 months
• Milk: 87% water; fat 50% of calories, lactose 40%
• Colostrum 7 to 14 mL per feeding on day 1 (Ch. 15 gives 2 to 10 mL); mature milk about day 10 to 12, 22 to 23 calories per ounce
• Lactogenesis II days 3 to 8; galactopoiesis from day 9
• Feed every 2 to 3 hours, 8 to 12 times in 24 hours (breastfed); every 3 to 4 hours (formula)
• Nutritive pattern with colostrum: 4 to 6 sucks, 5 to 10 second pause; good feed at least 10 minutes of nutritive sucking; 15 to 20 minutes average
• Back to birth weight by 2 weeks
• LATCH 0 to 10; goal 8 or more
• Pump 15 to 20 minutes; begin regular pumping about 3 weeks
• Storage: room 6 to 8 hours; fridge 7 to 8 days; freezer 6 months; deep freeze 6 to 12 months
• Prepared formula: use within 24 hours
• Formula amounts: 15 to 30 mL per feed first days; 60 to 90 mL by day 4; 2.5 oz per lb per day; max about 32 oz a day
• Lactating mother: plus 500 calories a day
• Solids at about 6 months; birth weight doubles by 5 months, triples by 1 year

Priority Nursing Actions and Red Flags

• Breastfeeding within 1 hour; skin-to-skin first
• Football or cross-cradle to start; wide mouth, asymmetric deep latch; break suction before removing
• Pain during feeding means a poor latch: reposition rather than push through
• Crying is a late hunger cue
• Separated mother and infant: start pumping as soon as possible
• Mastitis: keep breastfeeding, call the provider, antibiotics
• Contraindications: galactosemia, HIV (US), active TB, herpes on the breast, chemotherapy or radiation, illicit drugs
• Never microwave breast milk or formula; never prop a bottle; no cereal in the bottle; no bottle in bed
• Follow formula dilution exactly (water intoxication vs dehydration)
• Avoid pacifiers until breastfeeding is established (about 3 weeks)

Medications

Related

• nsg210-durham-ch15-neonate-and-family
• nsg210-durham-ch12-postpartum-care
• nsg210-durham-ch14-high-risk-postpartum
• nsg210-durham-ch17-complications-of-neonate
• INDEX