When is the baby ready for feeding?
Feeding should ideally be started within 6 hours after birth.
If the mother is planning on breastfeeding, the baby should be put to the breast within 30 minutes of birth if possible.
Babies start to exhibit feeding cues at around day 3 – 4 of life. These include rooting, lip-smacking, and bringing their hands to the face when hungry.
- When is the healthy, term neonate ready to feed?
- If they are alert and vigorous
- No abdominal distension
- Has good bowel sounds
- Has a normal hunger cry (laryngeal nerve palsy can risk aspiration)
Feeding Frequency and Quantity
Babies should be allowed to feed every 2-5 hrs. Low amounts of feed are started first since the newborn’s stomach is about the size of an olive.
Feeding volume starts around 15-30 mL per feed
Gradually increase to about 48-60mL per feed by day 3 of life.
Feeding frequency
| Age | Frequency of feeding |
|---|---|
| Newborn | q 1 – 2 hours |
| 1 month | q 2 – 3 hours |
| 2 – 4 months | q 4 hours |
| 4 months – one year | 3 – 4 feeds per day |
Average feeding volume per day for the first week
| Age | Feeding volume per day |
|---|---|
| Day 1 | 60 ml/kg/d |
| Day 3 | 100 ml/kg/d |
| Day 7 | 180 ml/kg/d |
Feeding volume
| Age | Feeding volume per feed |
|---|---|
| Day 1 | 15 – 30 ml |
| Day 3 | 48 – 60 ml |
| 1 – 2 weeks | 60 – 90 ml |
| 2 months | 120 – 150 ml |
| 2 – 3 months | 150 – 180 ml |
| 4 – 5 months | 180 – 210 ml |
| 6 months – 1 year | 210 – 240 ml |
Caloric requirements per day
| Age | Caloric requirements |
|---|---|
| First 3 months | 100 – 120 kcal/day |
| First year | 100 kcal/day |
Breastfeeding
Breastfeeding should be initiated early.
The mother should nurse both breasts for at least 10 minutes.
If breastfeeding is contraindicated, formula feeding can be used instead.
Forms of breastmilk
| Form of breastmilk | Characterisics |
|---|---|
| Colostrum (day 1 – 5) | Thick yellowish milk rich in protein, IgA, lactoferrin and leukocytes. Has a lower fat and carbohydrate component. Provides passive immunity and promotes the passage of meconium. Colostrum also has increased Vitamin A, sodium and chloride. |
| Transitional milk (day 6 – 14) | Gradual shift from colostrum to mature milk as fat, lactose, and water-soluble vitamin content increase while antibody and protein content decrease |
| Mature milk (from 2 weeks) | Has more carbohydrates, fat and potassium. Includes foremilk and hindmilk. |
| Foremilk | Mature milk. The first milk at the beginning of a feed. Has high water and lactose but low fat. It hydrates the infant |
| Hindmilk | Mature milk. Milk at the end of a feed. Has high fat and calories. Promotes satiety and weight gain |
- Benefits of breast milk to the baby
- Benefits of breastfeeding to mothers
- Lower long-term risk for breast and ovarian cancer
- Burns calories
- Prevents post-partum hemorrhage due to the release of oxytocin
- promotes involution of the uterus
- acts as a contraceptive
- Contraindications to breastfeeding
- Situations that are NOT contraindications for breastfeeding
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.e. elevating the head of the infant, or pillows for support); | No assist from staff, Mother able to position and hold infant |
Diapers
Babies should pass meconium within the first 24 hours.
Meconium appears as a dark, odourless substance that resembles motor oil. Stool colour transitions to tan/brown (formula) or seedy yellow (breastfeeding).
Urine colour should be straw or light-yellow.
Failure to pass meconium in the first 24 hours must be investigated, beginning with an abdominal X-ray.
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
- Increase by 1 wet diaper per day for the first week
- 6-8 wet diapers by the end of week 1
- Stool colours you should never see
- Red
- haematochezia = blood
- Black
- Melena = upper gastrointestinal bleed
- White
- acholic = no bile
- Red
Vitamin and Mineral Supplementation
Breastfeeding babies are need some level of vitamins and supplementation.
Vitamin and Mineral supplementation in newborns
| Vitamin and mineral | Supplemetation |
|---|---|
| Vitamin D | 400 IU/day for the first 2 months of life, unless on Vitamin D-fortified formula |
| Iron | 1 mg/kg/day beginning at 4 months of age, unless on an iron-fortified formula |
| Fluoride | Supplemented starting at 6 months of age to 3 years if water supply contains less than 0.3 ppm fluoride |
| Vitamin K | Routinely administered at birth to reduce the risk of hemorrhagic disease of the newborn |
| Folate | This is given if the baby is taking goat milk |
| Phosphorus | 60 – 90 mg/kg/d |
| Calcium | 120 – 140 mg/kg/d of elemental calcium |
Formulas
Formulas are designed to provide nutrition when breastfeeding is not possible or insufficient.
Types of formulas
| Type | Characteristic |
|---|---|
| Humanized formula | Modiifed cow’s milk that resemb;es human milk |
| Lactose-free formula | Used for infants with transient lactose intolerance, e.g. post-viral lactose intolerance |
| Hydrolysed formula (Hypoallergenic) | Includes partially hydrolysed and extensively hydrolysed formula. An extensively hydrolysed formula is used for cow’s milk protein allergy (CMPA) |
| Amino acid-based formula | Used for infants with severe CMPA OR multiple food protein intolerance |
| Soy-based formula (lactose-free and plant-based) | Used for galactosemia or CMPA (if IgE-mediated). Not recommended for preterm infants due to phytoestrogens |
| Preterm formula | Has a higher caloric density, protein, and minerals for preterm or low-birth-weight infants |
| Thickened formula | Contains added rice starch or carob bean gum to reduce reflux |
Cow and Goat Milk
Cow’s milk has more protein content than human milk. It contains 80% casein protein, which is more difficult to digest. Neither cow’s nor goat’s milk should be given to children before 1 year of age. If an alternative is needed, a fortified formula or human donor milk is preferred.
- Effect of cow’s milk on the infant
- Iron deficiency anaemia: Inhibition of iron absorption due to high calcium and casein. Can also cause occult gastrointestinal bleeding
- Occult blood loss caused by the heat-labile protein
- Cow’s milk protein Allergy (CMPA)
- Effect of goat’s milk on the infant
- Classic presentation of a baby on goat milk
- Pallor
- Anaemia
- Failure to thrive
- Glossitis and stomatitis
- Elevated MCV
- Electrolyte abnormalities
Weaning
Weaning is the introduction of solid food other than milk in children. Complementary feeding is usually introduced at 6 months of age when the infant matures, and breast milk alone is insufficient to meet the infant’s nutritional needs.
Phases of weaning
| Phase | Food |
|---|---|
| Initial phase (6 – 8 months) | Single foods. Start with smooth, pureed food (mashed fruits, iron-fortified cereal). Introduce one food at a time every 3 – 5 days to monitor for allergies. Continue breastfeeding and formula as the main source of nutrition |
| Transitional phase (8 – 10 months) | Textured foods. Introduced soft, mashed, or finely chopped food. Start finger foods (soft-cooked carrots, bread). Encourage self-feeding with a spoon |
| Advanced phase (10 – 12 months) | Family foods. Shift to family meals with modifications, e.g. less salt and soft textures. Include protein sources, e.g. eggs, fish, poultry and dairy. Begin cup drinking instead of bottles |
- Why is weaning started at 6 months of age?
- Neurological maturation: able to sit and coordinate mastication and swallow non-liquid foods. The extrusion reflex also resolves by 6 months of life
- Gastrointestinal maturation: able to digest and absorb proteins, fats and carbohydrates
- Signs of readiness to wean
- Able to sit upright with support
- Good head and neck control
- Shows interest in food (reaches for food, watches others eat)
- Loss of extrusion reflex (does not push food out of the mouth)