When is the baby ready for feeding?
Baby is typically fed within 6 hours after birth (may need to wake up baby to feed. If the mother is planning on breastfeeding the baby should be put to the breast within 30 minutes of birth.
- When is the healthy, term neonate ready to feed?
- If alert and vigourous
- No abdominal distension
- Has good bowel sounds
- Has a normal hunger cry (laryngeal nerve palsy can risk aspiration)
Breastfeeding
Breastfeeding should be initiated early
In healthy women breastfeeding is advantageous for both short-and long-term outcomes (for mom and baby). If mother is contraindicated or choses not to breast feed several formulas are available.
- Benefits of breast milk to baby
- Immunological and anti-microbial benefits
- Cellular and protein components that decrease the risk of GI and upper respiratory tract infection
- Decreases likelihood and severity of the development of asthma and eczema
- Improved mother-infant bonding
- Better neurodevelopmental outcome
- Benefits of breast feeding to mothers
- Lower long-term risk for breast and ovarian cancer
- Burns calories
- prevents PPH due to release of oxytocin
- promotes involution of the uterus
- acts as a contraceptive
- Contraindications to breastfeeding
- Maternal infectious disease (HIV, active TB, T-cell lymphotropic virus, active herpes rash on breast, etc.)
- Illicit drug use
- Breast cancer
- Chemotherapy
- Radiation
- Baby w/galactosemia
- Situations that are NOT contraindications for breastfeeding
- Smoking
- Moderate alcohol use
- Maternal hepatitis B sAg+
- Maternal hepatitis C
- Maternal fever (unless contraindicating infection)
- Mastitis (encouraged to breastfeed)
Mother should nurse both breasts for at least 10 minutes. Nipple tenderness is normal early on, and tends to get better after the first week. It is ideal to use both breasts in each session to allow them to both fill afterwards. It is helpful to keep a feeding chart to track how much the baby is nursing.
- When do babies start to exhibit feeding cues (rooting, lip-smacking, bringing hands to face when he/she is hungry)
- Day 3-4
Latch score
| 0 | 1 | 2 | Totals | |
|---|---|---|---|---|
| Latch | Too sleepy or reluctant; No sustained latch or suck achieved | Repeated attempts for sustained latch or suck; Hold nipple in mouth; Stimulate to suck | Grasps breast; Tongue down; Lips flanged; Rhythmical sucking | |
| Audible swallowing | None | A few with stimulation | Spontaneous and intermittent (< 24 hours old); Spontaneous and frequent (>24 hours old) | |
| Type of nipple | Inverted | Flat | Everted (After stimulation) | |
| Comfort (breast/nipple) | Engorged, cracked, bleeding, large blisters or bruises, severe discomfort | Filling, reddened/small blisters or bruises | Soft, non-tender | |
| Hold (positioning) | Full assist (staff holds infant at breast) | Minimal assist (i.. elevate head of infant, place pillows for support); Teach one side, mother does other staff holds and then mother takes over | No assist from staff, Mother able to position and hold infant |
Common breastfeeding dilemmas
Nipple tenderness
Very common in the first week (soaps and fabrics irritate the skin).
- Treatment
- Reassure the mother
- Ointments or topical olive oil to sooth cracked or dry nipples
“Not enough milk for baby”
Best indicator that the baby is getting enough milk is number of wet diapers as well as baby’s growth (regains birthweight by 2 weeks)
- How will you know that a baby is getting enough milk
- 6-8 wet diapers by the end of the first week
- At least 4 normal stools
- What can help mom optimize milk production
- Adequate rest
- Adequate nutrition
- Adequate fluids
Mastitis
Relatively common breast infection.
- What increases the risk for mastitis
- Breast engorgement
- Nipple cracking
- What reduces the risk for mastitis
- More frequent breastfeeding
- Signs and symptoms
- Breast erythema
- Warmth
- Tenderness
- Fever
- Treatment
- PO semisynthetic penicillin (Cephalexin; completely safe to breastfeed on antibiotics)
- Paracetamol
- Warm/cold compresses
- Comfortably fitting bra
Jaundice related to breastfeeding
Breast Milk Jaundice
Jaundice cause by enzyme in breast milk that delays bilirubin conjugation (Essentially a prolonged physiologic jaundice) Dx of exclusion. D/t the presence of Beta Glucuronidase which promotes enterohepatic circulation
- Signs and symptoms
- Only in breastfed infants
- Presents around day 3-5 of life
- Persists up to 2 months
- Normal urine and stool
- Investigations
- Bilirubin: elevated indirect bilirubin
- Differentials
- Hemolytic disease (Rh incompatibility, inherited hemolytic anemia)
- Neonatal sepsis
- Breastfeeding jaundice
- Hypothyroidism
- Galactosemia
- Crigler-Najjar syndrome, gilbert’s syndrome
- Treatment
- None needed
- Follow up after 2 months if no improvement
Breastfeeding Jaundice
Jaundice d/t insufficiency intake of milk during breastfeeding (decreased feeding , decreased bowel movements, decreases ability to remove bilirubin from the body/increases enterohepatic circulation). Low concentration of bacteria in neonatal digestive tracts results in less bilirubin being reduced to urobilin and excreted. Unconjugated bilirubin is reabsorbed and recycled into the circulation.
- Signs and symptoms
- Jaundice around day 3 of life
- Baby appears dehydrated
- < 4 wet diapers per day
- Poor transition to characteristic yellow seedy breastmilk stools
- 8-10% weight loss
- Investigations
- Bilirubin: elevated indirect bilirubin
- Treatment
- Electric breast pump q 2 hours (increases breastmilk output, can be used later)
- Consult lactation specialist
- Supplemental feeding w/formula (if all else fails)
- Mother should not be advised to discontinue breast feeding
Formula feeding
Babies should be allowed to feed q 2-5 hrs. A new-born’s stomach is about the size of an olive, hence the need to start low amounts of feeds first. Feeding volume starts around 15-30 mL per feed, gradually increasing to about 48-60mL per feed by day 3 of life. The average baby should be feeding about 60ml/kg on day 1, 100mL/kg by day 3 and 180mL/kg by day 7
Vitamin and Mineral supplementation
Breastfed babies are going to need some level of vitamins and supplementation. Contraindicated to give
Vitamin D (400 IU/day first 2 months of life; unless on Vitamin D-fortified formula)
Iron (1mg/kg/ beginning at 4 months of age, unless on iron-fortified formula)
Fluoride (starting at 6 months of age)
Vitamin K (given at birth)
Folate (if baby is only on goat milk)
- Effect of cow and goat milk
- Low iron and folate content
- Low transferrin
- Occult blood loss caused by heat labile protein
- Classic presentation of a baby on goat milk
- Pallor
- Anemia
- Failure to thrive
- Glossitis and stomatitis
- Elevated MCV
- Electrolyte abnormalities
Diapers
Baby passes meconium within the first 24 hours (dark, odorless substance that resembles motor oil). Failure to pass meconium in the first 24 hours must be investigated (start with abdominal XR).
Stool color transition to tan/brown (formula) or seedy yellow (breastfeeding). Urine color should be straw or light-yellow in color.
There should be about 3-4 stools per day and 6-8 wet diapers by the end of week 1.
- Wet diaper rule for week 1
- 1 wet diaper by day (6-8 wet diapers by the end of week 1)
- Stool colours you should never see
- Red (blood)
- Black (melena – UGIB)
- White (no bile)