INFANT FEEDING

Dr.Divyarani.D.C
Assistant Professor
Department of Pediatrics,KoIMS
• FEEDING IN NEWBORN
AND UPTO 6 months
• COMPLEMENTARY FEEDING
FEEDING IN NEWBORNS
 Breast Feeding
• Breast feeding is natural and instinctive.

• Provides unique health benefits both to baby as

well as the mother.

• The best milk for a newborn baby is

unquestionably breast milk.

• The lowest protein content of human milk is in

keeping with the slowest rate of growth of
human infant .
 Benefits to the Baby
1. Is a complete food and it provides all the
nutrients a baby needs during the first 6
months of life. There is presence of special
enzyme LIPASE and high quality of WHEY
protiens
2. Contains Anti infective substances , protective
antibodies and friendly lactobacilli which give
the baby protection against development of :
• Diarrhea
• Pneumonia
• Ear infection
• Necrotising enterocolitis

3.Less likely to suffer from allergic disorders like

asthma and eczema

4.Provides IMMUNOLOGICAL BENEFITS. Develop

better protective response to various vaccines
5. Provides emotional security and promotes
close bonding between mother and baby.

6.Stimulates all the 5 special senses of the baby

i.e touch sight smell hearing and taste.

7. Smarter and higher IQ, enhanced visual

development.
8.Lesser likely to suffer from caries teeth,
diabetes mellitus, obesity, high BP etc.

9. NO risk of adulteration, dilution,

contamination and infection of breast milk.

10. Risk of cot deaths /SIDS is lesser.

 Benefits to mother
• Release of OXYTOCIN to eject the milk, helps in involution of
uterus – so that reduced risk of bleeding and anemia after
delivery

• Delays pregnancy- as there is delay in ovulation and onset of

mensturation which provides natural means to ensure spacing.

• Convenient and less time consuming. Readily available, No need

to buy feeding bottles or powdered milk. Economic saving.

• Lowers risk of breast and ovarian cancer and osteoporosis

• Decreases mother’s work load

• Contributes to child Survival

 Breast Feeding and Brain Growth
• Higher cognition and enhanced visual development.

• 30 times more DHA than in cows milk which is a

predominant structural fatty acid in our brain,
neuronal membranes and retina.

• Highest in Lactose concentration which is facilitated

for synthesis of cerebrosides and myelination of CNS.

• Rich in oligosaccharides especially sialic acid which is

a key component of gangliosides and is mandatory
for neuronal synapes formation.
 Anti Infective agents in Human Milk
• Immunoglobulins : Secretory IgA, IgG, Ig M
• Opsonic and chemotactic activities of c3 and c4
complement system
• Unsaturated lactoferrin and transferrin
• Lysozyme
• Lactoperoxidase
• Oligosaccharrides(protection against infections as their
structural similaraty with bacterial antigen receptors)
• Growth Factors for lactobacillus bifidus
• Para-aminobenzoic acid protection against malaria
 Art and technique of Breast feeding
• The baby should be put on the breast as soon as possible usually half an
hour after birth in normal labour and within 4 hrs in cesareian section.

• No prelacteal feeds like glucose water or honey should be offered.

• Keep baby close to mother. It is safe for baby to sleep with mother.

• Breast feed during day and at night at least eight times, whenever baby
cries with hunger.

• Allow baby to feed at one breast until he leaves the nipple on his own.
Then feed him at the other breast if he continues to be hungry.

• Baby should be given only breast milk for the first 6 months.
• Mother should be in comfortable position. She may sit
on a chair, bed, stool or ground with back properly
supported.

• She should slightly recline backward and should not

lean on the baby. She can feed the baby in lying or
semireclining posture.

• Proper position of baby while breastfeeding includes

– a. Supporting whole of baby’s body.
– b. Ensure baby’s head, neck and back are in same plane.
– c. Entire baby’s body should face mother.
– d. Baby’s abdomen touches mother’s abdomen.
Attachment of baby on
mother’s breast

Four signs of good

attachment are:
a. Baby’s mouth wide
open.
b. Lower lip turned
outwards.
c. Baby’s chin touches
mother’s breast.
d. Majority of areola
inside baby’s mouth.
POSITIONING AND ATTACHMENT

A mother holding her baby in

the arm opposite the breast
Useful for:
• Very small
• Sick babies

A mother holding her baby in the

underarm position (foot ball
position)
Useful for:
• Twins
• Blocked duct
• Difficulty in attaching the baby
• During the first few days, most babies fall
asleep after taking few sucks.
• They should be kept aroused by gentle tickling
behind the ears or on the soles during feeds.
• Most babies take 15-20minutes to take an
adequate feed.
• Baby should be allowed to completely empty
one breast before offering the other breast.
• Mother should be explained the art of burping
the baby after each feed to safeguard against
regurgitation.
• During the first two days it should be
explained to the mother that little colostrum
the baby recieves is enough to meet the
nutritional needs of a normal baby as the
babies have enough glycogen and do not need
any complementary feeds.

• Most babies demand a mid-night feed during

the first 6-8 weeks of life, after which feeding
schedule is established satisfactorily and they
are satisfied with one late night feed and an
early morning feed.
INDICATORS OF ADEQUATE BREASTFEEDING
i) Baby passes urine 6-8 times in 24 hours.
ii) Goes to sleep for 2-3 hrs after the feeds.
iii) Gains weight @20-40 gm/d.
iv) Crosses birth weight by 2 weeks.
• BABY FRIENDLY HOSPITAL INITIATIVE

• Was launched jointly by UNICEF and WHO in

march 1992 in order to encourage and
promote exclusive breast feeding to enhance
child survival.

• A mission approach has been launched

globally .

• Ten steps are recognised as minimum global

criteria for attaining the status of a BABY
FRIENDLY HOSPITAL
TEN STEPS TO SUCCESSFUL BREASTFEEDING
1. Have a written breastfeeding policy that is routinely
communicated to all health care staff.

2. Train all health care staff in skills necessary to implement

this policy.

3. Inform all pregnant women about the benefits and

management of breastfeeding.

4. Help mothers initiate breastfeeding within half-hour of

birth.

5. Show mothers how to breastfeed, and how to maintain

lactation even if they are separated from their infants.
6. Give newborn infants no food or drink other than
breast milk, unless medically indicated .

7. Practice rooming-in. Allow mothers and infants to

remain together 24 hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers (also called

dummies or soothers) to breastfeeding infants.

10. Foster the establishment of breastfeeding support

groups and refer mothers to them on discharge from
the hospital or clinic.
 PROBLEMS IN BREASTFEEDING
Primigravida mother problems:
• Initial difficulties due to anxiety, worry and lack
of confidence.
• The poor milk output during the first few days
further aggravates anxiety.
• Role of sucking for establishment of satisfactory
lactation should be emphasised.
• Also have greater incidence of retracted nipple.
Congenital anomalies may require special management.
a. Craniofacial anomalies (i.e., cleft lip/palate) present
challenges to the infant’s ability to latch effectively to the
breast.
Modified positioning and special devices (i.e.,
obturator, nipple shield) may be utilized to achieve an
effective latch.

b. Cardiac or respiratory conditions may require restriction

and special attention to pacing of feeds to minimize
fatigue during feeding.
c. Restrictive lingual frenulum (ankyloglossia/tongue-
tie) may interfere with the infant’s ability to
effectively breast-feed.

The inability of the infant to extend the tongue

over the lower gum line and lift the tongue to
compress the underlying breast tissue may
compromise effective milk transfer.

Frenulotomy is often the treatment of choice

Inverted / flat nipples
• Flat or short nipples which protract
well (become prominent or pull out
easily) do not cause difficulty in
breast feeding.
• Inverted or retracted nipples make
attachment to the breast difficult.
• They should be diagnosed in the
antenatal period.
• These mothers need additional
support to feed their babies.
• Treatment is started after birth of the baby.

• Nipple is manually stretched and rolled out

several times a day. A plastic syringe is used to
draw out the nipple and the baby is then put
to the breast.

• Management of inverted nipple using syringe

SYRINGING:

• STEP ONE : Use 10 or 20 cc syringe

– Cut along line with blade
• STEP TWO : Insert Plunger from Cut End
• STEP THREE : Mother gently pulls the Plunger
Regurgitation of feeds :

• Most healthy babies regurgitate some feeds but

they continue to gain weight satisfactorily.

• Condition resolves by advising the mother to prop

the baby on her lap or hold the baby against the
shoulder to help eructate the swallowed air.

• After which the baby should be put in right lateral

position with head end slightly raised.
Alterations of bowel movements :
• Breast fed babies pass frequent semi loose,
golden yellow sticky stools due to high lactose
content.
• Should be explained to the mother as normal.
Feeding with a formula or animal milk
only in
• Adopted baby
• HIV positive mother
• Inadequate lactation -Twin or triplet babies
• Mother receiving anti cancer drugs
• Seriously or critically sick mothers
 Feeding of LBW babies
• By 10 weeks of gestation, the gut is formed
and has completed its rotation back into
abdominal cavity.
• Fetus can swallow the amniotic fluid by 16
weeks.
• GI motor activity is present around 24 weeks
and effective peristalisis established by 29- 30
weeks.
• At term fetus swallows 150 ml/kg/day of
amniotic fluid.
 Maturation of oral feeding skills and the choice of initial
feeding method in LBW infants

Gestational Maturation of feeding skills Initial feeding method

age
< 28 weeks No proper sucking efforts Intravenous fluids
(<1200g) No propulsive motility in the gut

28-31 weeks Sucking bursts develop Oro-gastric (or naso-gastric)

(1200-1500g) No coordination between suck/swallow tube feeding with occasional
and breathing spoon/paladai feeding
32-34 weeks ( Slightly mature sucking pattern Feeding by
1500- 1800 g) Coordination between breathing and spoon/paladai/cup
swallowing begins
>34 weeks Mature sucking pattern Breastfeeding
( >1800g) More coordination between breathing
and swallowing
• Special attention should be given to late preterm
and near-term infants (35–37 weeks’ gestation)
Management should include
– (i) mechanical milk expression concurrent with
breastfeeding until the infant is breastfeeding
effectively;
– (ii) weighing the infant before and after breastfeeding
to evaluate adequacy of milk intake and determine
need for supplementation.

b. For premature infants less than 35 weeks, mothers

should be encouraged to practice early and frequent
skin-to-skin holding and suckling at the emptied breast
to facilitate early nipple stimulation to enhance milk
volume and enable infant oral feeding assessment.
Guidelines for breast milk storage include

(i) use fresh, unrefrigerated milk within 4 hours of milk

expression;

ii) refrigerate milk immediately following expression when the

infant will be fed within 72 hours;

(iii) freeze milk when infant is not being fed, or the mother is
unable to deliver the milk to the hospital within 24 hours of
expression;

(iv) in the event that frozen milk partially thaws, either complete
thawing process and feed the milk or refreeze.
DECIDING THE INITIAL METHOD OF FEEDING
• It is essential to categorize LBW infants into two major groups – sick
and healthy - before deciding the method of feeding.
• Sick infants
• This group constitutes infants with
– significant respiratory distress requiring assisted ventilation,
– shock requiring inotropic support,
– seizures, symptomatic hypoglycemia/hypocalcemia, electrolyte abnormalities,
renal/cardiac failure,
– surgical conditions of gastrointestinal tract, necrotizing enterocolitis (NEC),
hydrops, etc.

• These infants are usually started on intravenous (IV) fluids.

• Enteral feeds should be initiated as soon as they are

hemodynamically stable with the choice of feeding method based
on the infants’ gestation and clinical condition .
• All stable LBW infants, irrespective of their initial feeding
method should be put on their mothers’ breast.

• The immature sucking observed in preterm infants born

before 34 weeks might not meet their daily fluid and
nutritional requirements but helps in rapid maturation of
their feeding skills and also improves the milk secretion in
their mothers (‘Non-nutritive sucking’).
HOW MUCH MILK IS TO BE GIVEN?

• It is essential to calculate the fluid requirements and feed

volumes for infants on paladai/gastric tube feeding.

• Fluid requirement: The daily fluid requirement is determined

based on the estimated insensible water loss, other losses,
and urine output.

• Feed volume: After estimating the fluid requirements, the

individual feed volume to be given by OG tube or paladai (2-
hrly/3-hrly) should be determined.
 Amount and frequency of feeds
FLUID REQUIREMENTS OF LBW BABIES (ml/kg/day)
Day < 1000g 1000-1500g >1500g
1st and 2nd 100-200 80-100 60-80
3rd and 4th 130-140 110-120 90-100
5th and 6th 150-160 130-140 110-120
7th and 8th 170-180 150-160 130-140
9th onwards 190-200 170-180 150-160

Additional allowances of 20-40ml/kg/day for phototherapy

and 40-80 ml/kg/day for those babies kept under radiant warmer
 Feeding with a cup and spoon or
PALADAI
• Due to potential risk of infection and NIPPLE
CONFUSION with bottle feeding, recommended to
give feeds to babies with a spoon or paladai.
• Procedure is safe but time consuming.
 Procedure of paladai feeding

i) Put the baby on breast for non-nutritive sucking.

ii) Place the baby in upright posture with cotton napkin around the
neck to mop the spillage.Take the required amount of expressed
milk in the paladai / cup.

iii) Fill the paladai spoon with milk little short of the brim, place it at
the lips of baby in the corner of the mouth and let the milk flow
into the baby’s mouth without spill.

For spoon feeding small amount of milk should be poured directly

into the side of the mouth.
iv) Repeat the process until the required amount has been fed.
• If the baby does not actively accept and swallow the feed, try to
arouse the baby with gentle stimulation.
• While estimating the intake, amount of milk spilled is deducted.
• After feeding, the utensils should be washed thoroughly with
soap and water. Boil for 10 minutes to sterilize before next feed.

Advantages
• Simple and effective method to feed babies who are not able to
suck directly at the breast.
• Reduces risk of infection. This method has replaced bottle feeding
in nurseries. The method is easy to follow and
• socially acceptable.
Why cup or spoon feeding is safer than bottle-
feeding

• Cups are easy to clean with soap and water if

boiling is not possible.

• Cups are less likely to get contaminated than

bottle. Hence, use of cup is better.

• Cup or spoon feeding is an active process. The

person who feeds the baby involves himself and
provides contact.

• A cup does not interfere with the suckling on the

breast.
• Naso-gastric vs. oro-gastric feeding:
Physiological studies have shown that naso-
gastric (NG) tube increases the airway
impedance and the work of breathing in very
preterm infants.
• Hence, oro-gastric tube feeding might be
preferable.
• The introduction of enteral feeds should be
slow and gradual.

• LBW <1500g
– Ng feeds @ 30 ml/kg/day on day1 and remaining
fluids as 10 % Dextrose.
Depending upon tolerance feeds are increased 10-
20 ml/kg/day and IV fluids volume and rate reduced
accordingly.
Nutritional supplements are added ones full feeds
are attained
COMPLEMENTARY FEEDING
 COMPLEMENTARY FEEDING
• DEFINITION –
– Complementary feeding is defined as the systematic
process of introduction of suitable food at the right time in
addition to mothers milk in order to provide needed
nutrients to the baby
WHAT IS COMPLEMENTARY FEEDING?

- The giving of foods to infants starting at six

months, in addition to breast milk.

- NOT sufficient as on their own as a diet

- Should NOT displace breastmilk

 TIME OF COMPLEMENTARY FEEDING
OR WEANING
• Baby is biologically ready to accept semisolids
by 4-6 months of age

• By 4 months of age intestinal amylase matures

and the gut becomes ready to accept cereals
and pulses(legumes)

• Breast milk increases till 6 months of age and

it plateaus off
 WHY START AT SIX MONTHS?
• Infant’s intestinal tracts develops immunologically with
defence mechanisms to protect the infant from foreign
proteins.
• The infant’s ability to digest and absorb proteins, fats, and
carbohydrates, other than those in breast milk increases
rapidly.
• The infant’s kidneys develop the ability to excrete the waste
products from foods with a high renal solute load, such as
meat.
• The infant develops the neuromuscular mechanisms
needed for recognizing and accepting a spoon, swallowing
non liquid foods, and appreciating variation in the taste and
colour of foods.
 What are the risks of starting
complementary feeding too early or
too late?
• Reduce breast milk production or intake
• Contribute to increased rates of infant mortality
and morbidity.
• Increase the risk of mother becoming pregnant.
• Interfere with iron absorption
• Reject foods when they are introduced at a later
age
• Consume an inadequate variety & amount of
food to meet their nutritional needs.
 CONTINUATION OF BREAST FEEDING

• Breast milk should continue to be the main food

of the baby even when weaning is started

• Breast milk should continue as long as feasible

,preferably till 2 years of age

• This is important as the first 2 years is a period of

rapid brain growth and breast milk contains
factors essential for brain growth and
development
 COMPLEMENTARY FOODS
• Complementary foods can be home made or instant foods

• It is better to start with mono cereals, followed by multi

cereals and cereals- pulse combination

• Cereal like rice is best choice to start as it is gluten free and

easily digestable.

• Cereal pulse combination is better due to fortification of

amino acids as cereals generally lack lysine and pulses lack
methionine.
• The advantage of homemade weaning cereals is that they are economical,

easily available, culturally accepted and closer to family food and versatile.

• Addition of jaggery for calories and minerals, milk for protein and oil for

calories can make homemade food more nutrient denser

 FAMILY POT FEEDING
• The acceptance of food from family food should be a part
of mixed feeding regime
• A new food should be introduced in the morning session
and only one item should be introduced at a time
• Around 6 months of age :cereal based porridge( ragi , suji ,
rice) enriched with jaggery / sugar , oil / ghee and animal
milk can be started
• 6-9 MONTHS :
– Introduce mashed items from the family pot enriched with
jaggery /sugar & oil /ghee
– Mashed rice with pulses , mashed tubers & vegetables soups,
mashed fruits can be given 4-5 times a day in addition to breast
milk

• 9-12 M0NTHS :
– Introduce soft food that can be chewed.
– By 1 year of age baby should be taking everything cooked at
home. This is called family pot feeding.
– 1 year old child should eat half of what the mother eats
 BRIDGING THE CALORIE AND OTHER
NUITRIENT GAP
• The calorie gap can be bridged by using oil/ghee
& sugar & selecting high density food item that
will not swell much on cooking. Ex: egg, potato

• Cereals, pulse combinations, roots & tubers,

green leafy vegetables, seasonal fruits, milk
products given to the baby will bridge the
nutrient gap.

• Soaking and malting of grains will increase

digestibility and vitamin content.
• Sprouting or germination will enhance vitamin
content and make it amylase rich food (ARF) and will
decrease bulk on cooking.

• Fermentation enhances vitamin C and digestibility

e.g Curd /yogurt.

• The once a day introduction of instant food could be a

way of balancing nutrient gap and one step solution to
prevent malnutrition
DEVELOPING READINESS FOR FAMILY
FOODS
• It is very essential to introduce varied textures and taste
throughout complementary feeding period.

• It is essential to advice the mother to differentiate the

texture through the preparation and cooking methods.

• Introducing new tastes with addition of vegetables ,fruits

will expose the baby to healthy eating practices
 PREPARATION AND STORAGE OF
WEANING FOODS
• Hand washing with soap and water should be practiced
before cooking and feeding

• The food stuffs should be freshly prepared

• Precooked ready to mix cereal-pulse combinations can

be prepared and stored in air tight containers
ESPHAGAN (EUROPEAN SOCIETY FOR
PAEDIATRIC GASTROENETEROLOGY ,HEPATOOGY , AND
NUTRITION ) AND WHO RECOMMENDATIONS

1. Introducing weaning foods around 6 months of age and

giving follow on formula in a quantity of not less than
500ml daily along with complementary feeds
2. It has recommended that introduction of gluten be
avoided in select families and communities
3. Avoiding foods that may contain high amount of nitrates
during early months
4. Delaying the introduction of highly allergic foods ,such as
egg white and sea fish
 TYPES OF COMMERCIAL WEANING
PREPARATIONS
• STANDARD CEREALS OR PROCESSED CEREAL
BASED COMPEMENTARY FOOD
– Commonly called as weaning food or supplementary food
based on cereal/pulses, millets, nuts and edible oil seeds
processed to low moisture content and so fragmented to
permit dilution with water ,milk or other suitable medium
• COMPLETE CEREALS OR MIK –CEREAL BASED
COMPLEMENTARY FOOD

– These foods are based on milk, cereal, millets, nuts and

edible oil seeds processed to low moisture content and so

fragmented as to permit dilution with water

• PULPY WEANING FOODS
– These are high quality pulp of selected single or combination of
fruit and vegetable pulps packed in suitable containers.
– These are not available in India

• FOLOW ON /FOLLOW-UP FORMULAS

– Is a food intended for use as a liquid part of the weaning diet for
the infant from the 6th month onwards till 2 years of age
• Follow – on formulas should continue to provide about 40% of
the infants energy intake, with about 500 ml to be consumed
every day
– PROTIEN
• Protein used is of good quality. From sources such as
milk, eggs and fish
– CALCIUM
• Follow on formulas should contain at least 90 mg of
calcium per 100 kcal (50-140mg/100 kcal)
• FAT
– Fat content of follow –on formula should be higher than
3.3gm /100kcal and it should provide at least 35% of total
energy in the formula

– Linoleic acid content should be between 300 mg and

1200mg /100kcal
 THANK YOU

"If ever I get a chance, I should love to be reborn just to have the
ecstasy of being re-fed by the kindly mother." — W. Oscar