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Feeding of Newborns and Infants
A normal newborn has active rooting and sucking reflexes (see Three Common Reflexes of Newborns) and can start feeding right away, so doctors recommend placing the newborn at the mother's breast immediately after birth. If this is not done, feedings are begun at least within 4 hours after birth.
Most babies swallow air along with the milk. Babies usually cannot burp on their own, so a parent needs to help. Babies should be held upright, leaning against the parent's chest, with their head against the parent's shoulder, while the parent pats them gently on their back. The combination of patting and pressure against the shoulder usually leads to an audible burp, often accompanied by spitting up of a small amount of milk.
Breast milk is the ideal food for newborns. Although babies may be fed breast milk or formula, doctors recommend exclusive breastfeeding for at least the first 6 months and introducing appropriate solid foods between 6 months to 1 year (see page Feeding of Newborns and Infants : Starting Solid Foods). After children reach 1 year of age, breastfeeding can continue for as long as both the child and mother desire. However, after age 1 year, breastfeeding should complement a full diet of solid foods and other fluids.
Sometimes breastfeeding is not possible (for example, if the mother is taking certain drugs—see page Taking drugs while breastfeeding), and many healthy babies have been raised on formula (see page Feeding of Newborns and Infants : Bottle-Feeding).
Breastfeeding is good for the mother and the baby. Besides providing the baby with the necessary nutrients in the most easily digestible and absorbable form, breast milk contains antibodies and white blood cells that protect the baby against infection.
The first milk the mother produces is a thin yellow fluid called colostrum. Colostrum is particularly rich in calories, protein, white blood cells, and antibodies.
The breast milk that is produced after colostrum helps maintain the correct pH of the stool and the proper balance of normal intestinal bacteria, thus protecting the baby against bacterial diarrhea. Because of the protective qualities of breast milk, many types of infections occur less often in babies who are breastfed rather than formula-fed. Breastfeeding also seems to protect against the development of certain chronic problems, such as allergies, diabetes, obesity, and Crohn disease.
Breastfeeding offers many advantages to the mother as well. For example, it helps her to bond and feel close to her baby in a way that bottle-feeding cannot. Mothers who breastfeed have a quicker recovery time after delivery and have some long-term health benefits, such as decreased risk of obesity, osteoporosis, ovarian cancer, and some breast cancers. About 60% of mothers in the United States breastfeed their babies, and this proportion is steadily increasing.
If the mother follows a healthy, varied diet, normal-term infants who are breastfed do not need vitamin or mineral supplements, except for vitamin D and sometimes fluoride. Infants who are fed only breast milk are at risk of vitamin D deficiency after 2 months of age, particularly if they are premature or dark-skinned or have limited exposure to sunlight (for example, infants who live in northern climates). These infants are given vitamin D supplements beginning at 2 months of age. After 6 months of age, breastfed infants in homes where the water does not have adequate fluoride (supplemental or natural) should be given fluoride drops. Parents can obtain information about the fluoride content of their water from a local dentist or health department.
Positioning a Baby to Breastfeed
To begin breastfeeding, the mother settles into a comfortable, relaxed position, either seated or lying almost flat. The mother should be able to comfortably turn from one side to the other to offer each breast. The baby faces the mother. The mother supports her breast with her thumb and index finger on top and other fingers below and brushes her nipple against the middle of the baby's lower lip, which stimulates the baby's mouth to open (the rooting reflex) and grasp the breast. As the mother eases the nipple and areola into the baby's mouth, she makes sure the nipple is centered, which helps keep the nipple from becoming sore. Before removing the baby from the breast, the mother breaks the suction by inserting her finger into the baby's mouth and gently pressing the baby's chin down. Sore nipples result from poor positioning and are easier to prevent than to cure.
Initially, the baby tends to feed for several minutes at each breast. The resulting reflex (let-down reflex) in the mother triggers milk production. The production of milk depends on sufficient suckling time, so feeding times should be long enough for milk production to be fully established. During the first few weeks, the baby should be encouraged to nurse on both breasts with each feeding. However, some babies fall asleep while feeding at the first breast. Burping the infant and switching to the other breast helps keep the infant awake. The breast used last should be used first for the next feeding.
For a first baby, full milk production is usually established in 72 to 96 hours. Less time is needed for subsequent babies. No more than 6 hours should elapse between feeding sessions during the first few days in order to stimulate breast milk production. Feeding should be on demand (the baby's, that is) rather than by the clock. Similarly, the length of each breastfeeding session should be adjusted to meet the baby's needs. Babies nurse 8 to 12 times in a 24-hour period, but this guideline varies widely.
Mothers who work may breastfeed while at home and have the baby drink pumped breast milk from a bottle during the hours they are away. Pumped breast milk should be immediately refrigerated if it is to be used within 2 days and should be immediately frozen if it is to be used after 2 days. Refrigerated milk that is not used within 4 days should be thrown away because the risk of contamination by bacteria is high. Frozen milk should be thawed by placing it in warm water. Breast milk should not be heated in a microwave.
The main complication caused by breastfeeding is underfeeding. Because mothers cannot tell exactly how much milk a baby takes, mothers should take the baby to the doctor 3 to 5 days after delivery so that the doctor can find out how breastfeeding is going, weigh the baby, and answer any questions. A doctor may need to see the baby earlier if the baby was discharged within 24 hours or is not feeding well, or if the parents have a particular concern.
Doctors use frequency of feeding, number of urine and stool diapers, and weight gain to tell whether milk production is adequate. Parents can get a rough idea of whether their baby is getting enough milk by counting diapers. By 5 days of age, wetting fewer than 6 diapers a day and/or having fewer than 4 bowel movements a day may mean the baby is not getting enough milk. Babies who are hungry and feed every hour or two but who do not gain weight appropriately for their age and size are probably not getting enough milk. Babies who do not get enough milk may become dehydrated and develop hyperbilirubinemia (see page Jaundice in Newborns). Babies who are small or premature or who have a mother who is ill or had a delivery that was difficult or required surgery are at risk of underfeeding.
Common complications caused by breastfeeding include breast engorgement, sore nipples, plugged milk ducts, mastitis, and anxiety.
Breast engorgement is painful overfilling of the breasts with milk. Engorgement occurs during the early stages of milk production (lactation). For ways to relieve symptoms, see page Breast engorgement.
For sore nipples, the infant's position during breastfeeding should be checked. Sometimes the infant draws in a lip and sucks it, which irritates the nipple. For ways to prevent and relieve sore nipples, see page Breastfeeding.
Plugged milk ducts occur when the breasts do not get completely drained of milk on a regular basis. They cause mildly tender lumps that can be felt in the breasts of lactating women. Continued breastfeeding is the best way to unplug the duct. Although it may be painful to nurse on the affected side, frequent breastfeeding is necessary to completely empty the breast. Warm compresses and massage of the affected area before breastfeeding may help. Women may also vary their breastfeeding positions because different areas of the breast empty better depending on the infant's position at the breast. A good nursing bra is helpful because regular bras with underwires or constricting straps can compress milk ducts.
Mastitis (see page Breast Infection) is a breast infection that can occur in women who are breastfeeding, particularly if there is engorgement or a plugged milk duct. Bacteria can enter the breast through cracked or damaged nipples and cause an infection. The infected area is tender, warm, and red, and the woman may have fever, chills, and flu-like aching. Women whose symptoms are severe or do not go away in 12 to 24 hours are given antibiotics that are safe for breastfeeding infants. If pain is significant, women may take acetaminophen for relief. Women should continue breastfeeding during treatment.
Anxiety, frustration, and feelings of inadequacy may result from a mother's lack of experience with breastfeeding, difficulties holding the infant and getting the infant to latch on and suck, fatigue, difficulty telling whether the infant is getting enough milk, and other physical changes that occur after giving birth. These factors and emotions are the most common reasons mothers stop breastfeeding. Mothers can consult with their pediatrician or a lactation specialist to discuss their feelings and possibly prevent stopping breastfeeding early.
Mothers who are breastfeeding should avoid taking drugs if possible. When drug therapy is necessary, mothers should avoid certain drugs and take only those that are known to be safe (see Taking Drugs While Breastfeeding).
When to stop breastfeeding (wean the infant) depends on the needs and desires of both mother and baby. The most desirable feeding combination is to breastfeed exclusively for at least 6 months, breastfeed along with solid foods until age 12 months, and then continue to breastfeed for as long as mother and child wish. Gradual weaning over weeks or months is easier for both the baby and mother than stopping suddenly.
Mothers initially replace one to three breastfeeding sessions a day with a bottle or cup of water or diluted fruit juice (water or fruit juice should not be used when weaning infants younger than 6 months old), expressed breast milk, formula, or whole milk if the baby is older than 12 months. Learning to drink from a cup is an important developmental milestone, and weaning to a cup can be completed by age 10 months. Babies who are weaned to a sippy cup instead of a bottle do not go through a second weaning process from bottle to cup.
Some feedings, particularly those at mealtimes, should be replaced with solid food. Mothers gradually replace more and more breastfeedings, although many infants continue one or two breastfeedings daily until the age of 18 to 24 months or longer. When breastfeeding continues longer, the child should also be eating solid foods and drinking from a cup.
In the hospital, newborns are usually fed shortly after delivery, then ideally on demand thereafter. During the first week after birth, babies take ½ ounce to 2 ounces at a time, gradually increasing to 3 or 4 ounces about 6 to 8 times a day by the second week. Parents should not urge newborns to finish every bottle but, rather, allow them to take as much as they want whenever they are hungry. As infants grow, they drink larger amounts, consuming up to 6 to 8 ounces at a time by the third or fourth month.
The proper position for babies who are bottle-feeding is semi-reclining or sitting up. Babies should not bottle-feed lying flat on their back because milk may flow into the nose or the eustachian tubes. Older infants who are able to hold their own bottle should not be put to sleep holding the bottle because the continuous exposure to milk or juice can damage their teeth and lead to cavities.
Commercial baby formulas are available as ready-to-feed sterile bottles, cans of concentrated formula that must be diluted with water, and powder. Formulas contain a proper balance of nutrients, calories, and vitamins and are available both with and without an iron supplement. All formula-fed babies should be given iron-fortified formula to prevent iron deficiency anemia.
Parents who use concentrated formula or powders must carefully follow the directions for preparation. Concentrated and powdered formulas should be prepared with water that has fluoride in it. Formulas are usually made from cow's milk, but other special formulas are available for infants who cannot tolerate cow's milk. If infants cannot tolerate standard formula, the pediatrician may recommend switching to a soy-based formula or a hydrolyzed formula. If infants cannot tolerate a hydrolyzed formula, they may be switched to an amino acid formula. There are no long-term health differences in infants fed either standard or special formula. Plain cow's milk, however, is not an appropriate food during the first year of life.
To minimize the infant's exposure to microorganisms, formula must be fed from a sterile container. Disposable plastic liners eliminate the need to sterilize bottles. Nipples for the bottles should be sterilized in the dishwasher or in a pot of boiling water for 5 minutes. Parents should warm formula feedings to body temperature. Filled bottles (or formula containers, if disposable liners are used) are placed in a warm water bath and allowed to come to body temperature. Babies may be seriously burned if formula is too hot, so parents need to shake the bottle gently to even out the temperature and then check the temperature by placing a few drops on the sensitive skin inside their wrist. Formula at body temperature should feel neither warm nor cold to the touch. Microwave ovens may dangerously overheat formula and are not recommended for warming formula or baby food.
The size of the nipple opening is important. In general, formula should drip slowly out of a bottle held upside down. Larger, older infants want larger volumes of liquid and can tolerate a larger nipple opening.
The time to start solid food depends on the infant's needs and readiness. Generally, infants need solids when they are large enough to need a more concentrated source of calories than breast milk or formula. This need is recognized when an infant takes a full bottle and is satisfied but then is hungry again in 2 or 3 hours or is consuming more than 40 ounces of formula per day. This typically occurs by the age of 6 months. Many infants take solids after a breastfeeding or bottle-feeding, which both satisfies their need to suck and quickly relieves their hunger. Infants younger than 4 months of age do not need solid food for nutrition, cannot easily swallow solid food, and should not be force-fed with a spoon or by mixing baby food with formula in a bottle. The introduction of solid food before 4 months of age may cause food allergies and celiac disease.
Infants develop food allergies or intolerance easier than older children or adults. If many different foods are given in a brief period, it is difficult to tell which one may have been responsible for a reaction. Because of this difficulty, parents should introduce new foods one at a time, no more than one new food a week. Once it is clear a food is tolerated, another one may be introduced.
Single-grain cereals (such as iron-fortified rice cereal) are begun first, followed by fruits and vegetables. Pureed meats, which are a good source of protein, iron, and zinc, should be introduced later, after about 7 months. Many infants initially reject meat.
The food should be offered on a spoon so that the infant learns the new feeding technique. By age 6 to 9 months, infants are able to grasp food and bring it to their mouth, and they should be encouraged to help feed themselves. Pureed home foods are less expensive than commercial baby foods and offer adequate nutrition. However, commercial preparations of carrots, beets, turnips, collard greens, and spinach are preferred for infants who are under age 1 year because they are screened for nitrates. High nitrate levels, which can cause methemoglobinemia (a disorder that affects the blood's ability to carry oxygen) in young children, are found in vegetables that are grown using water supplies contaminated by fertilizer.
Although infants enjoy sweet foods, sugar is not an essential nutrient and should be given only in small quantities, if at all. Sweetened dessert baby foods have no benefit for babies. Juice is a poor source of nutrition, contributes to cavities, and should be limited to 4 to 6 ounces a day or avoided altogether.
Foods to avoid include
Eggs and peanuts (until age 1 year) because infants may become allergic to these foods
Honey (until age 1 year) because it may contain the spores of Clostridium botulinum, which are harmless to older children and adults but can cause botulism in infants
Foods that can easily cause choking or be inhaled (until age 2 or 3 years), including nuts, hard candies, soybeans, popcorn, hot dogs, meat (unless it is pureed), and grapes (unless they are cut into very small pieces)
At or after age 1 year, children can begin drinking whole cow's milk. At age 2 years, children can switch to reduced-fat milk because their diet essentially resembles that of the rest of the family. Parents should limit milk intake to 16 to 24 ounces a day in young children. Children who drink too much milk may not get enough nutrients from other important foods and may develop iron deficiency.
By about age 1 year, the growth rate usually slows. Children require less food and may refuse it at some meals. To determine how much their child is eating, parents should review how much their child has eaten over the course of a week rather than at a single meal or during a day. Underfeeding of solid food is only a concern when children do not meet expected weight percentiles at a steady rate (see Figure: Weight and Length Charts for Infants).
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