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If the delivery was uncomplicated and the neonate is alert and healthy, the neonate can be brought to the mother for feeding immediately. Successful breastfeeding is enhanced by putting the neonate to the breast as soon as possible after delivery. Spitting mucus after feeding is common due to lax gastroesophageal smooth muscle but should subside within 48 h. If spitting mucus or emesis persists past 48 h, especially if it is bilious, complete evaluation of the upper GI and respiratory tracts is needed to detect congenital GI anomalies (see Congenital Gastrointestinal Anomalies).
Daily fluid and calorie requirements vary with age and are proportionately greater in neonates and infants than in older children and adults (see
Table 2: Approach to the Care of Normal Infants and Children: Range of Average Water Requirements of Children at Different Ages Under Ordinary Conditions and
Table 3: Approach to the Care of Normal Infants and Children: Calorie Requirements at Different Ages*). Relative requirements for protein and energy (g or kcal/kg body weight) decline progressively from the end of infancy through adolescence (see Table 4: Nutrition: General Considerations: Recommended Dietary References Intakes* for Some Macronutrients, Food and Nutrition Board, Institute of Medicine of the National Academies, although absolute requirements increase. For example, protein requirements decrease from 1.2 g/kg/day at 1 yr to 0.9 g/kg/day at 18 yr, whereas mean relative energy requirements decrease from 100 kcal/kg at 1 yr to 40 kcal/kg in late adolescence. Nutritional recommendations are generally not evidence-based. Requirements for vitamins depend on the intake of calories, protein, fat, carbohydrate, and amino acids.
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Table 2
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Range of Average Water
Requirements
of Children at Different Ages Under Ordinary Conditions
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Age
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Average Body Wt (kg)
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Total Water in 24 h (mL)
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Water/kg Body Wt in 24 h (mL)
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3 days
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3.0
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250–300
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80–100
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10 days
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3.2
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400–500
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125–150
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3 mo
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5.4
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750–850
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140–160
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6 mo
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7.3
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950–1100
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130–155
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9 mo
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8.6
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1100–1250
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125–145
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1 yr
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9.5
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1150–1300
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120–135
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2 yr
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11.8
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1350–1500
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115–125
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4 yr
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16.2
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1600–1800
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100–110
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6 yr
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20.0
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1800–2000
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90–100
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10 yr
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28.7
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2000–2500
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70–85
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14 yr
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45.0
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2200–2700
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50–60
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18 yr
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54.0
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2200–2700
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40–50
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From Barness LA: Nutrition and nutritional disorders. In Nelson Textbook of Pediatrics, ed. 13, edited by RE Behrman, VC Vaughan III, and WE Nelson (Senior Editor). Philadelphia, WB Saunders Company, 1987, p. 115; used with permission.
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Table 3
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Calorie
Requirements at Different Ages*
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Age
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Requirement
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kcal/lb/day
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kcal/kg/day
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< 6 mo
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50–55
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110–120
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1 yr
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45
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95–100
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15 yr
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20
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44
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*When protein and calories are provided by breast milk that is completely digested and absorbed, the requirements between 3 mo and 9 mo of age may be lower.
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Feeding
problems:
Minor variations in day-to-day food intake are common and, although often of concern to parents, usually require only reassurance and guidance unless there are signs of disease or changes in growth parameters, particularly weight (changes in the child's percentile rank on standard growth curves are more significant than absolute changes).
Loss of > 5 to 7% of birth weight in the 1st wk indicates undernutrition. Birth weight should be regained by 2 wk, and a subsequent gain of about 20 to 30 g/day (1 oz/day) is expected for the 1st few months. Infants should double their birth weight by about 6 mo.
Breastfeeding
Breast milk is the nutrition of choice. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for a minimum of 6 mo and introduction of appropriate solid food from 6 mo to 1 yr. Beyond 1 yr, breastfeeding continues for as long as both infant and mother desire, although after 1 yr, breastfeeding should complement a full diet of solid foods and fluids. To encourage breastfeeding, practitioners should begin discussions prenatally, mentioning the multiple advantages to the child (nutritional and cognitive; protection against infection, allergies, obesity, Crohn's disease, and diabetes) and mother (reduced fertility during lactation; more rapid return to normal prepartum condition [eg, uterine involution, weight loss]; protection against osteoporosis, obesity, and ovarian and premenopausal breast cancers).
In primiparas, milk production is fully established in 72 to 96 h, and in less time in multiparas. The first milk produced is colostrum, a high-calorie, high-protein, thin yellow fluid that is immunoprotective because it is rich in antibodies, lymphocytes, and macrophages, and also stimulates passage of meconium. Subsequent breast milk has a high lactose content, providing a readily available energy source compatible with neonatal enzymes; contains large amounts of vitamin E, which may help prevent anemia by increasing erythrocyte life span and is an important antioxidant; has a Ca:P ratio of 2:1, which prevents Ca-deficiency tetany; favorably changes the pH of stools and the intestinal flora, thus protecting against bacterial diarrhea; and transfers protective antibodies from mother to infant. Breast milk is also a natural source of ω-3 and ω-6 fatty acids. These substances and their very long-chain polyunsaturated derivatives (LC-PUFAS), arachidonic acid (ARA) and docosahexaenoic acid (DHA), are believed to contribute to the enhanced visual and cognitive outcomes of breastfed as compared with formula-fed infants. Breast milk also contains cholesterol and taurine, which are important to brain growth regardless of the mother's diet.
If the mother's diet is sufficiently diverse, no dietary or vitamin supplementation is needed for the mother or term breastfed infant, with the possible exception of vitamin D 200 units once/day beginning in the 1st 2 mo for all infants exclusively breastfed. Premature and dark-skinned infants and those with limited sunlight exposure (residence in northern climates) are especially at risk.
Infants < 6 mo should not be given additional water because of the risk of hyponatremia.
Technique:
The mother should use whatever comfortable, relaxed position works best and should support her breast with her hand to ensure that it is centered in the infant's mouth, minimizing any soreness. The center of the infant's lower lip should be stimulated with the nipple so that rooting will occur and the mouth will open wide. The infant should be encouraged to take in as much of the breast and areola as possible, placing the lips 2.5 to 4 cm from the base of the nipple. The infant's tongue then compresses the nipple against the hard palate. Initially, it takes at least 2 min for the let-down reflex to occur. Volume of milk increases as the infant grows and stimulation from suckling increases. Feeding duration is generally determined by the infant. Some women require a breast pump to increase or maintain milk production; in most women, a total of 90 min/day of breast pumping divided into 6 to 8 sessions produces enough milk for an infant not directly breastfeeding.
The infant should nurse on one breast until the breast softens and suckling slows or stops. The mother can then break suction with a finger before removing the infant from one breast and offering it the second. In the 1st days after birth, infants may only nurse on one side, in which case the mother should alternate sides with each feeding. If the infant tends to fall asleep before adequately nursing, the mother can remove the infant when suckling slows, burp the infant, and move the infant to the other side. This “switch” nursing keeps the infant awake for feedings and stimulates milk production in both breasts.
Mothers should be encouraged to feed on demand or about every 1½ to 3 h (8 to 12 feedings/day), a frequency that gradually diminishes over time; some newborns < 2500 g may need to feed even more frequently to prevent hypoglycemia. In the first few days, newborns may need to be wakened and stimulated. A schedule that allows the newborn to sleep as long as possible at night is usually best for both newborn and family.
Mothers who work outside the home can pump breast milk to maintain milk production while they are separated from their infants. Frequency varies but should approximate the infant's feeding schedule. Pumped breast milk should be immediately refrigerated if it is to be used within 48 h, and immediately frozen if it is to be used after 48 h. Refrigerated milk that is not used within 96 h should be discarded because of high risk of bacterial contamination. Frozen milk should be thawed by placing it in warm water; microwaving is not recommended.
Infant
complications:
The primary complication is underfeeding, which may lead to dehydration and hyperbilirubinemia. Risk factors for underfeeding include small or premature infants and mothers who are primiparous, who become ill, or who undergo difficult or operative deliveries. A rough assessment of feeding adequacy can be made by daily diaper counts; by 5 days of age, a normal neonate wets at least 6 diapers/day and soils 2 to 3 diapers/day; lower numbers suggest underhydration and undernutrition. Weight is also a reasonable parameter to follow (see Approach to the Care of Normal Infants and Children: Feeding problems); failure to attain growth landmarks suggests undernutrition. Constant fussiness before age 6 wk, when colic may develop unrelated to hunger or thirst, may also indicate underfeeding. Dehydration should be suspected with decreases in vigor of the infant's cry and skin turgor; lethargy and sleepiness are extreme signs of dehydration and should prompt testing for hypernatremia.
Maternal complications:
Common maternal complications include breast engorgement, sore nipples, plugged ducts, mastitis, and anxiety.
Breast engorgement, which occurs during early lactation and may last 24 to 48 h, may be minimized by early frequent feeding. A comfortable nursing brassiere worn 24 h/day can help, as can applying cool compresses after nursing and taking a mild analgesic (eg, ibuprofen ). The mother may have to use massage and warm compresses and express her milk manually just before nursing to allow the infant to get the swollen areola into his mouth. Excessive expression of milk between feedings facilitates engorgement so expression should be done only enough to relieve discomfort.
For sore nipples, the infant's position should be checked; sometimes the infant draws in a lip and sucks it, which irritates the nipple. The mother can ease the lip out with her thumb. After feedings, she can express a little milk, letting the milk dry on the nipples. After nursing, cool compresses reduce engorgement and provide further relief.
Plugged ducts manifest as mildly tender lumps in the breasts of a lactating woman who shows no other systemic signs of illness. The lumps appear in different places and are not tender. Continued nursing ensures adequate emptying of the breast. Warm compresses and massage of the affected area before nursing may further aid emptying. Women may also alternate nursing positions, because different areas of the breast empty better depending on the infant's position at the breast. A good nursing brassiere is helpful, as regular brassieres with wire stays or constricting straps may contribute to milk stasis in a compressed area.
Mastitis is common and manifests as a tender, warm, swollen, wedge-shaped area of breast. It is caused by engorgement, blocking, or plugging of an area of the breast; infection may occur secondarily, most often with penicillin-resistant Staphylococcus
aureus and less commonly with Streptococcus sp or Escherichia coli. With infection, fever ≥ 38.5° C, chills, and flu-like aching may develop. Diagnosis is by history and examination. Cell counts (WBCs > 106/mL) and cultures of breast milk (bacteria > 103/mL) may distinguish infectious from noninfectious mastitis. If symptoms are mild and present < 24 h, conservative management (milk removal via nursing or pumping, compresses, analgesics, supportive brassiere, and stress reduction) may be sufficient. If symptoms are not improving in 12 to 24 h or if the woman is acutely ill, antibiotics that are safe for nursing infants and effective against S. aureus (eg, dicloxacillin , cloxacillin , or cephalexin 500 mg po qid) should be started; duration of treatment is 10 to 14 days. Complications of delayed treatment are recurrence and abscess formation. Nursing may continue during treatment.
Maternal anxiety, frustration, and feelings of inadequacy may result from lack of experience with breastfeeding, mechanical difficulties holding the infant and getting the infant to latch on and suck, fatigue, difficulty assessing if nourishment is adequate, and postpartum physiologic changes. These factors and emotions are the most common reasons women choose to stop breastfeeding. Early follow-up with a pediatrician or consultation with a lactation specialist is helpful and effective for preventing early breastfeeding termination.
Drugs:
Breastfeeding mothers should avoid taking drugs if possible. When drug therapy is necessary, the mother should avoid contraindicated drugs (see
Table 4: Approach to the Care of Normal Infants and Children: Drugs Contraindicated for Breastfeeding Mothers ) and drugs that suppress lactation (eg, bromocriptine , levodopa, trazodone ) and take the safest known alternative immediately after nursing or before the infant's longest sleep period; this strategy is less helpful with neonates who nurse frequently and exclusively. Knowledge of the adverse effects of most drugs comes from case reports and small studies. Safety of some (eg, acetaminophen , ibuprofen , cephalosporins, insulin ) has been determined by extensive research, but others are considered safe only on the basis of the absence of case reports of adverse effects. Drugs with a long history of use are generally safer than newer drugs for which few data exist.
Weaning:
Weaning can occur whenever the mother and infant mutually desire after 12 mo. Gradual weaning over weeks or months during the time solid food is introduced is most common; although some mothers and infants stop abruptly without problems, others continue nursing 1 or 2 times/day for 18 to 24 mo or longer. There is no correct schedule.
Formula
Feeding
The only acceptable alternative to breastfeeding in the 1st yr is formula; water can cause hyponatremia, and whole cow's milk is not nutritionally complete. Advantages of formula feeding include the ability to quantify the amount of nourishment and the ability of family members to participate in feedings. But all other factors being equal, these advantages are outweighed by the undisputed health benefits of breastfeeding.
Commercial infant formulas are available as powders, concentrated liquids, and prediluted (ready-to-feed) liquids; each contains vitamins, and most are supplemented with iron. Formula should be prepared with fluoridated water; fluoride drops (0.25 mg/day po) should be given after age 6 mo in areas where fluoridated water is unavailable and when using prediluted liquid formula, which is prepared with nonfluoridated water.
Choice of formula is based on infant need. Cow's milk–based formula is the standard choice unless fussiness, spitting up, or gas suggests sensitivity to cow's milk protein or lactose intolerance (rare in neonates), in which case a soy formula may be recommended. All soy formulas in the US are lactose free, but some infants allergic to cow's milk protein may also be allergic to soy protein, in which case a hydrolyzed (elemental) formula that may be derived from cow's milk, but which has triglycerides, proteins, and monosaccharides predigested to smaller, nonallergenic components, is indicated. Special carbohydrate-free formulas are also available. These formulas vary in vitamin content and preparation.
Bottle-fed infants are fed on demand, but because formula is digested slower than breast milk, they typically can go longer periods between feedings, initially every 3 to 4 h. Initial volumes of 15 to 60 mL (0.5 to 2 oz) can be increased gradually during the 1st wk of life up to 90 mL (3 oz) about 6 times/day, which supplies about 120 kcal/kg at 1 wk for a 3-kg infant.
Solid
Foods
The WHO recommends exclusive breastfeeding for about 6 mo, with introduction of solid foods thereafter. Other organizations suggest introducing solid food between age 4 mo and 6 mo while continuing breastfeeding or bottle-feeding. Before 4 mo, solid food is not needed nutritionally, and the extrusion reflex, in which the tongue pushes out anything placed in the mouth, makes feeding of solids difficult.
Initially, solid foods should be introduced after breastfeeding or bottle-feeding to ensure adequate nourishment. Iron-fortified rice cereal is traditionally the 1st food introduced because it is nonallergenic, easily digested, and a needed source of iron. It is generally recommended that one new, “single-ingredient” food be introduced per week so that food allergies can be identified. Foods need not be introduced in any specific order, though in general they can gradually be introduced by increasingly coarser textures, eg, from rice cereal to soft table food to chopped table food. Meat, pureed to prevent aspiration, is a good source of iron and zinc, both of which can be limited in the diet of an exclusively breastfed infant, and is therefore a good early complementary food. But vegetarian infants can get adequate iron from iron-fortified cereals and grains, peas, and dried beans, and adequate zinc from yeast-fermented whole-grain breads and fortified infant cereals.
Home preparations are equivalent to commercial foods, but commercial preparations of carrots, beets, turnips, collard greens, and spinach are preferable before 1 yr if available, because they are screened for high concentrations of nitrates, which are present when the vegetables are grown using water supplies contaminated by fertilizer and which can induce methemoglobinemia in young children. Eggs, peanuts, and cow's milk are generally avoided until the child is 1 yr to prevent food sensitivities. Honey should be withheld until 1 yr because of the risk of infant botulism. Foods that could obstruct the child's airway if aspirated should be avoided (eg, nuts, round candies), pureed (eg, meat), or cut into small pieces (eg, grapes). Nuts should be avoided until age 2 or 3 because they do not fully dissolve with mastication and small pieces can be aspirated with or without bronchial obstruction, causing pneumonia and other complications.
At or after 1 yr, the child can begin drinking whole cow's milk; reduced-fat milk is avoided until 2 yr, when the child's diet will essentially resemble that of the rest of the family. Parents should be advised to limit milk intake to 16 to 20 oz/day in young children; higher intake can reduce intake of other important sources of nutrition and contribute to iron deficiency.
Juice is a poor source of nutrition, contributes to dental caries, and should be limited to 4 to 6 oz/day or avoided altogether.
By about 1 yr, growth rate usually slows. Children require less food and may refuse it at some meals. Parents should be reassured and advised to assess a child's intake over a week rather than at a single meal or during a day. Underfeeding of solid food is only a concern when a child fails to achieve expected weights at an appropriate rate.
Last full review/revision November 2005
Content last modified November 2005
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