NWT Clinical Practice Guidelines for Primary Community Care Nursing - Nutrition Feeding Choices Breast-Feeding In the first 6 months of life, an infant's Technique requirements for water, energy and major nutrients • Mother should be in a comfortable position, can best be met by human milk. usually sitting or reclining with baby's head in crook of her arm (side-lying position is often For this reason, as well as for the emotional useful following delivery by cesarean section) benefits to the child and the immunologic benefits • Bring baby to mother (to minimize stress on in terms of protective effects against infection mother's back) (especially in populations where refrigeration is • Baby's belly and mother's belly should face each lacking or water supplies are suspect), breast milk other or touch (belly-to-belly position) is the best choice for feeding infants. • Initiate the rooting reflex by tickling baby's lips with nipple or finger; as baby's mouth opens Advantages wide, mother guides her nipple to back of the • Fewer respiratory, GI and otitis media infections baby's mouth while pulling the baby closer; this • Ideal food: easily digestible, nutrients well maneuver will ensure that the baby's gums are absorbed, less constipation sucking on the areola, not the nipple • Increased contact between mother and baby and, • It is important that the baby be allowed to nurse perhaps, added self-esteem for mother within the first hour after birth • Economical, portable, affords ease of meeting infant's feeding needs quickly Positioning And Latching On • May decrease occurrence of allergies in Source: Baby & Parent Health Program, childhood Community Health Services, Halton Regional • Mothers often like it more than bottle-feeding Health Department • More rapid and complete reversion of mother's pelvis and uterus to non-puerperal state Contraindications • HIV infection or active TB • Substances of abuse will pass into human milk; see Table 7-1, below, this chapter, for information about drugs that are passed into milk Physiology Fig. 7-1: Cradle Position for Breast-Feeding • Stimulation of areola causes secretion of • Breast-feed in a sitting position, with good back oxytocin support, as soon as possible. • Oxytocin is responsible for letdown reflex, • Place a pillow on your lap to bring baby to whereby milk is ejected from cells into milk breast height. ducts • Position baby with his or her head resting on • Sucking stimulates secretion of prolactin, which your forearm, facing you (belly to belly), with in turn triggers milk production your hand supporting the diaper area. • Milk is therefore created in response to nursing, • Baby's face should be across from the breast, the i.e. nursing increases the supply of milk mouth across from the nipple and the head tilted slightly back. September 2004 Feeding Choices - Pediatrics 1 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Nutrition • Place four fingers under breast and thumb on top, well back from nipple and areola. • Lightly tickle baby's lower lip with nipple. Have patience. • When mouth opens wide (as big as a yawn) quickly point nipple at opening and pull baby onto breast. • If baby is positioned correctly, the nose should be resting on top of breast and not buried in breast tissue. Do not press on breast to make "breathing space." • If there is pain, take baby away from breast and repeat. Fig. 7-2: Football Hold for Breast-Feeding • Check "latch." Mouth should be big with lips • Sit in upright position with good back support. turned back. Chin should be well underneath • Place one or two pillows at your side. breast, and nose should be resting on top. • Lie baby on pillows at your side. • Listen for baby swallowing. If baby is feeding well, you will see short bursts of sucking and • Support the back of the neck with your hand. swallowing with pauses between. The jaw This allows the baby's head to tilt back a little. movement goes past the ears, sometimes making • Hold your breast as described for the cradle the ears wriggle. position. • Let baby feed at first breast until he or she • Tickle baby's lower lip. Wait for his or her pushes nipple out of mouth; offer a burp and mouth to open and pull the baby onto the breast. continue on other breast. The baby may not suck for as long on the second breast. Start on that side during the next feeding session. • If baby starts wriggling during the feeding, he or she may need to burp. Take the baby off the breast, offer a burp and then latch on again. • Each baby is different and each will take a different period of time to feed. If a feeding is taking an hour or more, the baby is probably not latched on properly. Contact someone to watch you nurse and check the latch. If you have difficulty feeding your baby in the Fig. 7-3: Alternative Position for Breast- cradle position, try the football hold. Feeding This hold can work well in the following • Sit in upright position with good back support. situations: • Place a pillow in front of you. • Cesarean birth • Lie baby across your body facing you. • Small baby • Hold breast with hand on same side (right breast, • Mother experiencing more difficulty with one right hand). side than the other • Support back of baby's neck and shoulders with • Mother with flat nipples other hand. • Tickle baby's lower lip. Wait for the baby's mouth to open wide and pull the baby onto the breast. • When baby is feeding well, try taking hand from breast and putting it around the baby for support. September 2004 Feeding Choices - Pediatrics 2 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Nutrition Mother's Diet While Nursing • Solids may be introduced at 4-6 months (WHO • Adequate caloric and protein intake now recommends 6 months for introduction of • Plenty of fluids solids) • Prenatal vitamins Mothers who are planning to return to work should Signs Of Adequate Nursing start switching the baby to chosen alternative feeding about a week ahead of time, for the hours • Breasts become hard before and soft after of the day when the mother will be away. feeding (noted in the first few weeks after the birth) Breast Care • Six or more wet diapers in 24 hours • Porous breast shields collect any milk that drips; Baby satisfied and weight gain appropriate • shields should be changed when wet to prevent (average 1 oz or 30 g per day in the first few skin maceration months) • Correct positioning, with nipple and areola well • Growth spurts should be anticipated around 10 into the infant's mouth, helps prevent nipple days, 6 weeks, 3 months and 4-6 months soreness and cracked nipples • During growth spurts, baby will nurse more • For cracked nipples, express some milk, and often over a period of several days, which will allow the milk to air dry on the nipples; ensure increase milk production to allow for further the infant is latching on correctly adequate growth • When one nipple is sore, feedings should be started on the side that is not sore; it may be Client Education helpful to change the feeding position (e.g. from Antepartum sitting to lying) when nipples are sore Promote advantages of breast-feeding early and regularly during the course of the pregnancy. Possible Complications Plugged Milk Ducts Postpartum Mother is well except for sore lumps in one or Counsel women on the following aspects of both breasts, without fever. breast-feeding: • Technique Apply moist hot packs to lump(s) before and • Natural history during nursing. The mother should nurse more • Colostrum present in breast at birth but may not frequently on the affected side. Ensure good be seen technique. • If baby is feeding well, he or she will be adequately nourished Mastitis • Milk will not come in before third day Woman has a sore lump in one or both breasts, postpartum accompanied by fever or redness of the skin • Frequent nursing (at least 9 times/24 hours) will overlying the lump. She may be quite ill. Other lead to milk coming in sooner and in greater possible sources of fever should be ruled out (in quantities particular, endometritis and pyelonephritis). • Mother should allow baby to determine duration of each nursing session Apply moist hot packs to the lump(s) before and • Baby will lose weight over the first few days and during nursing. The mother should nurse more may not regain birth weight until 7 days frequently on the affected side. • Most supplemental vitamins are unnecessary, however as babies in northern communities have Administer antibiotics (e.g. cloxacillin, C class very limited exposure to sun vitamin D should drug) for Staphylococcus aureus (the most be given; see "Vitamin and Mineral common organism) for at least 7 days. The mother Supplements," below, this chapter should get more rest and use acetaminophen as • Breast milk alone is adequate for first 6 months necessary. The fever should resolve within 48 September 2004 Feeding Choices - Pediatrics 3 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Nutrition hours; otherwise, consider changing the antibiotic. Signs The lump should also resolve. A persistent lump • Insufficient weight gain in an infant who is may be an abscess, which must be drained receiving food only by breast-feeding surgically. • Infant may latch on poorly • Infant may suck inconsistently Engorgement • Letdown reflex may be inconsistent Engorgement usually develops just after milk first • Some infants appear hungry (indicated by crying comes in (day 3 or 4). It is characterized by warm, soon after feedings), whereas others are content, hard, sore breasts.