Identify the nutritional requirements during infant stage.

List the Benefits of breastfeeding for mothers and infants Demonstrate technique of breast feeding. Differentiate between component of human milk cow's and formula feeding.

List principles of weaning

Optimal nutrition during the first year of life is very important because growth is proceeding very rapidly and requiring adequate amounts of various nutrition. Feeding provide time for meeting the emotional needs of infants.

Nutritional Requirements during Infancy

Calories: 110 Kcal/kg/day 2: Fluid: 150 ml/Kg/day. Protein: 2 gm/Kg/day. Vitamin C: 40 mg/day. Vitamin A: 4000 IU/day. Vitamin D: 400 800 IU/day. Iron: 6 mg/day. Calcium: 600 mg/day

weaning

Breastfeeding

Artificial feeding Bottle Feeding

Breastfeeding is the most suitable for human infant. It contains all the elements for growth and development in easily digested forms. It contains all the necessary vitamins and of course no other food is as complete for the infant as breast milk. It provides psychological and emotional satisfaction for both mother and child.

The breasts or mammary glands are secreting milk after childbirth to nourish the infant. The small raised nipple is at the center of each breast. Surrounding the nipple is a larger circular areola. Both the nipple and areola are darker than surrounding skin.

Montgomery tubercles are sebaceous glands in the areola. They are inactive except during pregnancy and lactation, when they enlarge and secrete a substance that keeps the nipple soft.

SFCC: Figure 14.14

The breast is composed of glandular tissue, some fatty tissue and covered by skin. The glandular tissue is divided into about 15-20 lobes which are separated by fibrous tissue.

Each lobe is composed of the following structures:

Alveoli are small sacs that contain acinar cells to secrete milk. Around each alveolus lie myoepithelial cells, which contract and eject the milk into the lactiferous duct when signaled by secretion of the hormone oxytocin from the posterior pituitary gland.

 The lactiferous ducts become wider under the areola and are called lactiferous sinuses in this area. The lactiferous sinuses narrow again into ducts as they open to the outside in the nipple.

During pregnancy estrogen and progesterone secreted by the placenta prepare the breasts for lactation. The estrogen inhibits milk production until the end of pregnancy. The blood level of estrogen and progesterone fall by the 3rd stage of labor and during the next 48 hours. This stimulates the anterior pituitary gland to produce the Prolactin hormone.

The milk is pushed along the lactiferous ducts and some is stored in the lactiferous sinuses which lie just under the areola. When the baby sucks, he takes the nipple and the areola into his mouth and partly by a vacuum which is created mostly by a chewing action of his jaws. Milk is pushed into his mouth and he swallow.

When lactiferous sinuses and lower ducts are emptied, milk is pushed from the alveoli by contraction of the myoepithelial cells. So, the act of sucking by the baby is the stimulus which keeps lactation going on by some neurohormonal reflex mechanism which activates the anterior pituitary gland to produce lactotrophin and the posterior pituitary lobe to produce oxytocin which reaches the breast through the blood stream leading to contraction of myoepithelial cells and expulsion of milk results.

neuro-hormonal reflex mechanism which activates the anterior pituitary gland to produce lactotrophin and the posterior pituitary lobe to produce oxytocin which reaches the breast through the blood stream leading to contraction of myoepithelial cells and expulsion of milk results. Oxytocin also stimulates the uterine contractions as well as after pains and lochial discharge during breastfeeding.

For mother
More convenient than bottle feeding and needs no preparation. Many mothers find great satisfaction in feeding the infant at the breast. Prevention of postpartum hemorrhage oxytocin helps uterine contraction that controls postpartum hemorrhage.

Cheapest and most economical method of feeding. Lower the incidence rate of uterine and breast cancer in woman. Women regain their normal weight and activities faster.

For infant

Human milk is warm, ready,

and sterile and perfectly balanced and nutritionally complete food for babies. It is more easily digested than cow's milk. Breast-fed infants have greater immunity to certain childhood diseases.

Breast milk is available all times. Infants are less likely to have gastrointestinal disorders, anemia and vitamin deficiency. Infants are less likely to acquire infection in homes where cleanliness is difficult to attain. Infants are secure through constant contact with his mother and this has an effect on the child's psychology and development.

Breastfeeding should be started immediately after delivery because of:

This is suitable time for the baby to learn to suck. Rooting and sucking reflexes are maximal. The nipple stimulation from sucking releases oxytocin, promoting uterine contraction, thus reducing the chance of post-partum hemorrhage.

 The first hour or soon after birth is the best time for bonding and make the mother love and care for her baby. Early mother infant contact in post-partum period increases the incidence and / or duration of breastfeeding thereafter.

Variability of breast milk according to stage of lactation

Colostrum
Is the bright lemon yellow, alkaline, viscous fluid secreted from breast during the first 5-7 days and it is beneficial because of:
Rich in protein but contains less amount of CHO and Fat. Rich in antibodies and leukocytes. Rich in cholesterol. Rich in Vit A. It has laxative effect.

 B-Transition Milk:
Follow the Colostrum

Mature Milk:
it secreted by the 10 th -20 th after delivery. its fat contents are higher in early months of lactation.

Fat content of the last amount of milk of each feed (hind- milk) is more than in beginning of feed (Fore-milk).

Technique of breastfeeding

Breast should be cleansed every day with plain water and dries thoroughly. Mother's clothes should not be tight over the breast and clean. The mother should wash hand thoroughly before nursing her infant. The infant should be hungry, dry and warm.

Mother should comfortably sit in order to relax. characteristic of good positioning: Infant body is close to the mother. Infant body is turned towards the mother Infant whole body is well supported The infant's nose should be at the level of the nipple. Infant neck is straight or bent slightly back.

7. Feeding positions:
Cradle position. Cross cradle position. Foot-ball holds position. Horizontal position. Back-ward position. Positions for two babies.

The mother cup her breast(C hold) Rub the nipple or finger gently against the infant's cheek or lips to stimulate rooting reflex. When mouth is fully open, the baby is pushed toward the breast.

the part under the nipple inside the infant's mouth because the tongue and lower jaw do the job of stripping the milk from the breast. When the lips seal the areola, the baby sucking will compress the milk reservoir behind the areola then milk will be swallowed. The baby should latch on or grasp the nipple and outer areola into the mouth.

Eructate the infant 1-2 times during and once at the end of the feed. Regurgitation of 5-15 cc of milk when eructate or after feeding is normal. When nursing is completed, the infant should be placed in a crib on his right side.

Time and frequency of feedin

Unrestricted breastfeeding, self-demand method All newborn infants need some night feeds. Some may need to feed as many as 10-15 times or as few as 6-8 times within 24 hours.

Exclusive breastfeeding means:

No food or drink other than breastfeeding is offered to breastfeeding baby up to 6 months Fed on demand, day and night No restriction on the length or frequency of breastfeeding. (Vitamins drops are allowed).

Criteria for adequate breast feeding

Infant is calm and satisfied after feeds. Infant sleeps well 2-4 hours after feeds. Normal motions (bowel movements 4-8 / 24 hours). Normal amount of urine (6 or more /24 hours).

 Normal weight gain (150/210 grams/week) This can be assessed by: Weight chart Test weighing: The infant is weighed at 4 days interval at a fixed time of the day and under the same circumstances. E.g. the same clothes and before feeding. If weight gain is 100 grams or more the amount of breast milk is adequate.

I-Maternal breastfeeding problems

Breast engorgement

It is an accumulation of increased amount of blood and other body fluids as well as milk in the breast.

Causes: Delay in starting breast feeding after delivery. Poor attachment to breast Poor sucking Incomplete emptying of breast

. Clinical manifestation: Breast is painful, tender and swollen with shiny overlying skin, distended veins and hard palpable nodules felt behind the areola. Fever may be present.

Nursing management
Apply moist warm packs to the involved breast 2-3 minutes before each feeding. Massage and hand express to facilitate attachment. Cold packs after feeding. Stress reduction relaxation techniques. Neck and back massage. Mild analgesics.

Sore nipple and cracked or fissure nipple

Tenderness and soreness of the nipple are usually the result of the trauma and irritation

Cause: Incorrect positioning and technique. Engorgement. Irritants such as soap or lotions. Infection washing of nipple and areola with water and soap

Nursing management
Apply moist heat and massage before feeding (3-5 minutes). Begin each feeding on the least involved side/or stop feeding from the affected breast for 1-2 days and express milk from it manually or by breast pump. Frequent, short feedings (2-2.5 hours). Proper positioning, attachment, and removal technique. Air/sun exposure. Avoid engorgement. Avoid use of drying agents. Treatment for infection Mild analgesics.

Candidiasis/thrush
Persistent sore nipple may be caused by Candida albicans also called monillia or thrush. Causes: Thrush or candidal diaper rash in the infant. Recurrent candidal vaginitis in the mother.

Nursing management: For mother: Wash hands well, especially after changing infant's diaper. Wash clothes and other articles that come into contact with breasts in very hot water. Keep area dry: expose nipples to air or sun and use a fresh bra liner every feeding. Apply medication to nipples after every feeding for 14 days as ordered.

For infants: Apply oral medication directly to affected areas for 14 days. Boil articles that come in contact with infant's mouth for 20 minutes daily. Treat diaper rash until healing is complete.

 It results in a tender area or painful lump in the breast. Causes: Infrequent nursing. Incomplete emptying. Local pressure.

Nursing management: Moist warm packs to area before nursing. Massage prior to and during nursing. Proper positioning, attachment, and removal technique. More frequent nursing. Check fit of clothing.

It is infection of breast tissues surrounding the milk ducts.

Causes: Nipple trauma. Untreated obstructed lactiferous duct or engorgement. Contributing factors: as Stress, fatigue

Clinical picture: A tender reddened area of the breast accompanied by:

Fever. Chills. Headache. Generalized aches.

Nursing management:
Start feeding the baby on the healthy side. Nurse frequently (2-2.5 hours) Proper positioning, attachment, and removal technique. Moist warm packs (3-5 minutes). Bed rest for 24 hours. Mild analgesics. Antibiotics.

Breast abscess
Delayed or inadequate treatment of mastitis leads to breast abscess. Causes: Improper treated mastitis.

 Nursing management:
Antibiotics. Incision and drainage. Warm packs. Breast feed from affected side if the incision is away from the areola or mother need to hands express her milk until healing is complete. Rest.

II-Problems on part of the newborn

Pre-maturity
Breast milk changes in its composition according to length of pregnancy. Milk from a mother giving birth pre-maturity is well suited to the need of the premature infants. It has more protein and a different pattern of immune bodies than milk of full term infants.

Management:
Mother must maintain their milk supply either manual or by pumping at least 68 times day with one night time session. Give the expressed breast milk to infant by a dropper or gavage Mothers can increase the frequency of feeding up to every 2 hours.

Cleft lip and cleft palate

An infant with a cleft palate is usually unable to suckle at the breast. These infants may be given milk by tube or through a special long teat.

Congenital malformation-cardiac diseases

Cardiac disorders may weaken the infant is that nursing is too exhausting. Mother may pump her breasts and maintain the sick infant on breast milk given by a fine tube, which passes from container (cup or bottle) to the baby's mouth while the baby is suckling.

Community resources, which support the

mother for breast feeding

Alexandria University Children's Hospital. Ministry of Health. Children Hospital. MCH Centers.

Include traditional Birth attendant Rural women leaders teachers mothers in low experienced mothers social workers religious leaders Non-governmental Organizations (NGOS).

The ten steps to successful breastfeeding

 Have a written breastfeeding policy that is routinely communicated to the health care staff. Train all health care staff necessary to implement this policy. Inform all pregnant women about the benefits and management of breastfeeding. Help mothers initiate breastfeeding within half hour of birth.

 should be separate from their babies. Give newborn babies no food or milk other than breast milk unless medically indicated. Practice rooming in allows mothers and babies to remain together 24 hours a day.

 Encourage breastfeeding on demand. Give no artificial teats or pacifiers to breastfeeding babies. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.