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4

Feeding normal infants

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Contents

Objectives

When you have completed this unit you should be able to:

Introduction to infant feeding

4-1 What are the nutritional needs of a normal infant?

Like the adult, the infant needs the following nutrients to grow and develop normally:

  1. Water
  2. Carbohydrates such as lactose (milk sugar) and glucose
  3. Proteins (made up of amino acids)
  4. Fats
  5. Vitamins
  6. Minerals (such as sodium, potassium, chloride, calcium, magnesium, phosphate)
  7. Trace elements (such as iron)

The carbohydrates, proteins and fats provide the infant with 440 kilojoules per kg per day (105 kilocalories/kg/day) needed to grow normally.

4-2 What milk can be given to a normal infant?

  1. Breast milk. Human breast milk meets all the nutritional needs of a healthy term infant.
  2. Formula feeds. These feeds are made from cow’s milk or soya bean and are modified to have similar constituents to breast milk.

Infants and mothers benefit most from exclusive breastfeeding. This means giving the infant only breastmilk with no extra formula, water, juices or solids. Prescribed medicines or supplements can be given.

Whenever possible mothers should exclusively breastfeed their infants.

The benefits of breastfeeding

4-3 What are the benefits of breastfeeding?

Breastfeeding provides many benefits to both the infant and mother, especially if it is exclusive breastfeeding. The main benefits are:

  1. Benefits to the infant:
    • Breast milk is the perfect feed for term infants as it provides all the nutrients in the correct amount and proportion for normal growth and development until the age of 6 months. Thereafter breast milk should still provide a lot of the protein in the infant’s diet until 2 years of age.
    • Breast milk is easily digested and absorbed.
    Note
    The protein in breast milk (lactalbumin) does not form a curd and, therefore, is easily digested. Most fatty acids in breast milk are unsaturated and, therefore, easily absorbed. The main sugar in breast milk is lactose.
    • Breast milk is clean and warm, and avoids the dangers of a contaminated water supply, inadequately sterilised bottles and teats, and lack of refrigeration facilities.
    • Breast milk avoids the danger of diluted or concentrated formula.
    • Breast milk contains many anti-infective factors, such as antibodies, living cells (lymphocytes and macrophages) and complement. Breast milk also encourages the growth of beneficial bacteria in the infant’s bowel. These properties of breast milk help to prevent gastroenteritis, the major cause of infant deaths in many poor communities.
    • Breast milk decreases the risk of allergy in the infant, especially if there is a strong family history of allergy.
    • Breastfeeding decreases the incidence of gastroenteritis and therefore lowers the infant mortality rate in poor communities.
  2. Benefits to the mother:
    • Breastfeeding is much cheaper than buying formula feeds.
    • Breast milk is instantly available at all times. No sterilising of bottles and teats, and preparation of formula is needed.
    • It is emotionally satisfying for the mother to successfully breastfeed her infant and this helps to form a strong bond between mother and infant.
    • Breastfeeding helps the involution of the uterus and reduces the amount of bleeding during the puerperium.
    • Breastfeeding helps the mother to lose excessive weight gained during pregnancy. Pregnancy, not breastfeeding, alters the shape of a woman’s breasts.
    • Exclusive breastfeeding reduces the risk of the mother falling pregnant again.
    • Breastfeeding may reduce the risk of breast cancer.

Breastfeeding saves money and ensures an adequate, safe supply of food. It therefore decreases the incidence of malnutrition.

Prolonged breastfeeding is one of the most successful ways of reducing infant mortality in poor communities.

4-4 Why do some mothers not breastfeed successfully?

Breastfeeding is not always easy as some mothers and infants have to learn the ‘natural art of breastfeeding’.

Some mothers do not breastfeed or fail to breastfeed successfully because:

  1. They do not know the advantages of breastfeeding.
  2. They believe that they do not have enough milk because they do not understand that infants need frequent, small feeds for the first few days. It takes a number of days before the supply of milk increases.
  3. They think that their milk is too thin, or their breasts too large or too small.
  4. They develop cracked nipples or engorged breasts due to an incorrect method of feeding.
  5. They want to return to work and do not realise that many working mothers can continue to breastfeed successfully.
  6. They are afraid of breastfeeding.
  7. They have flat or inverted nipples which are often managed incorrectly.
  8. Traditional beliefs may result in unsuccessful breastfeeding, e.g. incorrect beliefs that colostrum is not good for the infant, intercourse spoils the milk, and delayed feeding causes the milk to become sour in the breast.
  9. Poor sleeping or excessive crying by the infant is blamed on the inadequate quality or supply of the breast milk.

Some HIV-positive mothers may elect not to breastfeed once they have been counselled.

Promoting breastfeeding

4-5 How can breastfeeding be promoted?

Exclusive breastfeeding should be promoted as the normal, natural method of feeding an infant. This can be achieved by:

  1. Encouraging a positive attitude towards breastfeeding in the home during childhood and adolescence by seeing other infants being breastfed.
  2. Teaching the advantages of breastfeeding in schools.
  3. Promoting breastfeeding in the media (radio, TV, books).
  4. Teaching the advantages and method of breastfeeding in all antenatal clinics.
  5. Starting breastfeeding groups run by mothers who have themselves breastfed.
  6. Encouraging breastfeeding in hospitals and clinics.
  7. Discouraging bottle feeding in hospital by using cups instead by women who formula feed.
  8. Teaching mothers how to express their milk.

Further information on breastfeeding can be obtained from a local breastfeeding support group or local branches of the Breastfeeding Association of South Africa and La Leche League.

Breast is best.

4-6 How can breastfeeding be encouraged in hospitals and clinics?

Staff should be trained in the many advantages that breastfeeding has for the mother and infant, they should feel comfortable and not embarrassed when speaking to patients about breastfeeding, and they must have the knowledge and skills to teach mothers how to breastfeed. Breastfeeding must be promoted during all visits to antenatal clinics.

Infants should be placed on the mother’s abdomen immediately after birth and put to the breast when ready to start breastfeeding. Rooming-in must be encouraged, giving mothers unlimited access to her infant to demand feed. Mothers must be helped individually with kindness and patience.

4-7 What is the value of a local breastfeeding support group?

Often the best person to advise and help a breastfeeding mother is someone who has herself breastfed an infant. A number of mothers who have breastfed and are interested in helping others to breastfeed can form a local support group. With help and training by knowledgeable midwives and doctors they can provide a very helpful service.

Teaching mothers to breastfeed

4-8 What preparation does a mother need for breastfeeding?

The decision to breastfeed should ideally be taken before her infant is born. If she is undecided at delivery, she should be encouraged to breastfeed.

No preparation of breasts and nipples before delivery is necessary.

A good, supportive bra should be worn. Breast size or shape and nipple size are no indication of a woman’s ability to breastfeed.

Routine breast and nipple preparation during pregnancy is not needed.

4-9 How can you treat flat or inverted nipples?

If a woman’s nipples appear flat or inverted during pregnancy, she may need additional help with breastfeeding. Hoffman’s exercises and nipple shields are not helpful and are no longer recommended.

Many flat or inverted nipples will correct once breastfeeding starts. The infant is the best treatment for flat or inverted nipples.

4-10 Should the infant be put to the breast immediately after delivery?

Yes. The mother should breastfeed her infant as soon as possible after delivery as the infant’s sucking drive is usually strongest in the first hour or two after birth. Early suckling promotes bonding between the mother and infant. It also stimulates milk production and encourages successful breastfeeding. The small amount of colostrum satisfies the infant and is very rich in antibodies. It is very important not to give formula feeds on the first day as this may interfere with the establishment of breastfeeding.

Practising kangaroo mother care (skin-to-skin care) is a very powerful way of promoting successful breastfeeding, especially exclusive breastfeeding. Most mothers can be given their infant within minutes of birth, before the placenta is delivered. When placed on the mothers abdomen the infant will start looking for the nipple.

Note
If a patient cannot breastfeed her infant soon after delivery because she has had a Caesarean section under general anaesthesia, then she should express some colostrum before the Caesarean section. This can be used for the first few feeds. With an epidural or spinal anaesthetic, the infant can be given to the mother immediately after the surgery.

The infant should not be put to the breast immediately after delivery if:

  1. Polyhydramnios was present. A nasogastric tube must be passed first to exclude an oesophageal atresia.
  2. The infant had low Apgar scores and required resuscitation.
  3. Severe maternal distress or illness is present.
  4. The mother has decided not to breastfeed.
  5. The infant is to be adopted.

Some stable preterm infants with an assessed gestational age of less than 35 weeks can be given to the mother for skin-to-skin care after delivery even if they are too immature to breastfeed.

4-11 Why are clear feeds not necessary?

It is not necessary to give clear feeds of sterile water or dextrose water to an infant before starting breast or formula feeds on day 1. A breastfed infant does not need additional clear feeds. If the mother chooses to breastfeed, no bottle feeds should be given to the infant as a teat can confuse the infant and cause it to reject the nipple.

Routine clear feeds are not needed on day 1.

Note
Unlike a bottle-fed infant that sucks the milk out of the teat, a breastfed infant holds the nipple against the hard palate and compresses the milk ducts under the areola with the gums. This is called suckling.

4-12 What is the best position to hold an infant while feeding?

The correct position of the infant while feeding is important. The mother should be warm, relaxed and comfortable. Usually she sits up and holds her infant across her body in front of her. The infant is held in one arm, and should lie on its side with its mouth facing the nipple. The breast being offered to the infant is held in the other hand.

Mothers should be encouraged to try different feeding positions in order to find which is most comfortable. Some mothers prefer to lie down while they feed. Other mothers prefer to tuck the infant under an arm like a rugby ball.

4-13 How should an infant latch at the breast?

One of the commonest mistakes made when breastfeeding is that the infant is not held and latched correctly to the breast. Sucking or chewing on the nipple due to incorrect latching causes the mother pain and damages the nipple.

To latch the infant to the breast correctly the mother should hold the infant in a comfortable position facing her. With a hand holding her breast she should tickle the infant’s mouth with her nipple and wait for the infant to open its mouth (this is called ‘rooting’). The mother should then pull the infant towards the breast so that the infant takes the nipple and as much of the pigmented areola into the mouth as possible. She should feel no pain when the infant starts to suckle. If she feels pain she should gently remove the infant from the breast and latch the infant correctly. Make sure that the infant’s nose is not covered by the breast.

When the infant is correctly latched more areola will be visible above than below the infant’s mouth, the infants lower lip will be turned out and the infant’s nose will touch the breast.

The infant must take the whole nipple and most of the areola into the mouth when latching to the mother’s breast.

4-14 Should infants be demand fed?

Yes. Whenever possible infants should be demand fed. This means that the infant is put to the breast whenever hungry. A normal breastfed infant will usually feed every 2 to 3 hours during the day for the first few weeks. Demand feeding helps to encourage a good milk supply and prevent engorged breasts. Demand feeding is easy in hospital if mothers room-in and use skin-to-skin care.

4-15 What is the let-down reflex?

When an infant is put to the breast, the pituitary gland in the mother’s brain responds by producing the hormones prolactin and oxytocin. Prolactin stimulates the breast to secrete milk while oxytocin produces the ‘let-down reflex’. This reflex produces a tingling feeling in the breast, and results in milk being pumped into the infant’s mouth by the contraction of muscle cells that surround the milk ducts in the areola. At the same time, oxytocin causes the uterus to contract. Milk may leak from the other nipple. The release of oxytocin helps the uterus to involute but may produce abdominal pain during feeding for the first few days after birth. Reassure the mother that abdominal pain with feeding is normal. Tension, anxiety and a lack of sleep may inhibit the let-down reflex.

4-16 How do you manage leaking breasts?

Milk leaking from the breasts is common in the first few weeks of feeding. Leaking of the opposite breast during feeding is normal and can be stopped by pressing on that nipple. Cotton handkerchiefs or pads can be used for leaking between feeds. They should be changed frequently as dampness may cause sore nipples.

4-17 Can a mother’s milk be too strong or too weak?

No, but the appearance of breast milk varies. There are 3 different types of breast milk:

  1. Colostrum. This is a milky fluid produced in small quantities for the first few days after birth. However, it contains a lot of protein and provides all the infant’s nutritional needs. After 3 to 5 days the milk supply suddenly increases (‘comes in’) and the breasts feel full. This is due to the production of mature milk, which consists of foremilk and hind milk.
  2. Foremilk. This is produced at the start of each feed. It appears very ‘weak’ and ‘thin’ as it consists mainly of water with little fat. On a hot day a thirsty infant will take frequent, small feeds of foremilk.
  3. Hindmilk. This is only produced towards the end of a feed. It looks thick and rich, and contains a lot of fat. A hungry infant will empty the breast to obtain the hind milk.

It is best to empty one breast first before putting the infant to the opposite breast. This ensures that the infant gets the rich hind milk. However, on some days the infant may wish to feed on both breasts while on other days may want to feed on one breast only. Start each feed on alternate breasts.

4-18 Do all mothers produce enough breast milk?

All healthy mothers can produce enough milk for their infant if breastfeeding is managed correctly. Unfortunately many mothers stop breastfeeding during the first 5 days because they are incorrectly advised that they ‘do not have enough milk’ or because the infant is losing weight. Milk supply is normally poorest in the late afternoon and early evening.

A mother is probably not producing enough milk if her breasts do not feel full before a feed, especially in the mornings after day 5.

4-19 How can you improve a mother’s milk supply?

  1. Reassurance, support and encouragement that she will be able to breastfeed. Also ensure that she is getting enough sleep and is not under too much stress, as anxiety is a major cause of poor milk production. Anxiety also inhibits the let-down reflex. Many mothers are more relaxed in their own homes.
  2. Make sure that she is latching the infant correctly to the breast and that the infant is sucking correctly. Pain during feeding suggests that the infant is not latching correctly.
  3. Put the infant to the breast frequently during the day until a good milk supply is established. If the infant is not demand feeding 2 to 3 hourly, it should be woken for feeds. The best stimulus to milk production is the infant sucking frequently and for prolonged periods.
  4. The mother should rest for a while in the afternoon and drink adequate fluids.
  5. Stop any formula or water feeds.

Reassurance, support and encouragement are important for successful breastfeeding.

Note
If the milk supply has not improved after 5 days and the infant has not started to gain weight despite the above steps, the mother can be given metoclopramide (Maxolon) 10 mg 8 hourly for a week to stimulate the secretion of prolactin. The dose should then be gradually reduced and stopped over a further week. Prolonged use of these drugs may be dangerous for the mother and infant.

4-20 How do you know that an infant is getting enough breast milk?

The infant is probably latching well and getting enough milk if:

  1. The mother’s breasts feel full before feeds and empty after a feed.
  2. The infant is content at the end of a feed and falls asleep.
  3. The infant loses less than 10% of its birth weight.
  4. The infant starts gaining weight by day 5.
  5. The infant has 5 or more wet nappies a day after day 5.

Weight gain is best determined over a few days. Many mothers stop breastfeeding simply because their infant cries a lot and they think that the infant is not getting enough milk.

Note
If you are worried that an infant is not getting enough milk, then the infant can be test weighed before and after a feed. After day 5, most term infants will gain about 25 g per day.

Infants that gain weight normally are getting enough feed.

4-21 Should infants be routinely test weighed?

No, there is no need to test weigh most infants. The amount of milk an infant takes varies widely between feeds. A small feed, which is common in the afternoon or when the mother is tired, may cause maternal anxiety.

4-22 What is the appearance of the stools of a breastfed infant?

The stools of a breastfed infant may be yellow or green, and may be loose or firm. The infant may have several stools a day or only pass stool every few days. The stools should not smell offensive. The number of stools a day does not indicate whether the infant is getting adequate feeds.

Managing breastfeeding problems

4-23 What should you do if an infant refuses the breast?

Some infants may reject the breast and refuse to latch on the nipple. Common causes are a sore mouth due to thrush, the infant being ill or upset, or the milk flow being too fast. These problems should be looked for and treated. As infants get older they spend less time feeding. As long as the infant is gaining weight the mother should be reassured.

Do not hold the infant’s head too tightly or push the face towards the breast as the infant will turn towards your hand instead of the nipple. It helps to squeeze a little breast milk onto the nipple before latching the infant.

4-24 What causes the infant to choke while feeding?

Sometimes the mother may have too much milk and the milk may flow too fast causing the infant to choke or gag when feeding. As a result the infant may refuse to feed and become restless. It may help for the mother to lie back at the start of the feed with the infant across her chest so that the milk has to flow uphill against gravity. The mother may have to express a bit to soften the areola before starting the feed. Only offer one breast per feed and only when the infant appears hungry and the milk supply will settle with time.

4-25 How should you manage swollen or painful breasts?

A normal, full breast feels tense and heavy, but is not painful and is relieved by feeding. Breasts that are swollen, tender, hard, lumpy and painful are caused by either engorgement or mastitis. Both engorgement and mastitis result from an obstruction in milk flow.

  1. Engorged breasts:
    • Usually both breasts are swollen, hard and painful but the mother does not feel ill. The milk does not flow freely. Engorged breasts usually occur between days 3 and 5 when the mother’s milk suddenly ‘comes in’. Engorged breast are common if the infant does not feed correctly, if the mother does not room-in and if the mother does not demand feed.
    • Treatment consists of encouraging the infant to suckle frequently. The infant should be fed on the most painful breast first. Placing ice onto the breasts between feeds will help to reduce the swelling and a warm shower relieves the discomfort, while a mild analgesic like paracetamol (Panado) is helpful. Often the infant is not able to latch correctly if the breast is engorged as the nipples become flattened by the swelling. If some milk is first expressed from the breast to soften the areola, the infant will usually latch well. Breast engorgement is prevented by frequent feeds.
    • Sometimes only a segment of one breast is painful due to a blocked milk duct. Changing the infant’s position during the feed and gently massaging the breast towards the nipple usually clears the obstruction.
  2. Mastitis (milk fever):
    • Mastitis is an inflammation of the breast due to blocked milk ducts and seepage of milk into the surrounding tissues. It causes a swollen, painful, red area of one breast. The mother feels ill and may have a temperature.
    • Treat with rest, warm compresses and a mild analgesic. It is most important that the infant continues to suckle frequently on the affected breast as this will help the milk to flow. Altering the feeding position often helps to drain the affected area. The breast milk is not dangerous for the infant. If the signs and symptoms do not improve within 24 hours an antibiotic (flucloxacillin 250 mg 6 hourly) is prescribed for 10 days. If a fluctuant mass develops then a breast abscess has formed. This should be surgically drained. Because of the pain of a breast abscess, feeding may have to be stopped on that breast for a few days. Usually feeding can start again once the oozing from the abscess has stopped. Breastfeeding from the other breast must continue.

4-26 How do you prevent painful nipples?

It is most important that the infant is correctly latched at the breast so that the nipple is not chewed. Remember that infants breastfeed and do not nipple feed. Nipples should not be painful, even in the first few days, if the infant is correctly latched to the breast. Make sure that the infant has all of the nipple and most of the areola in the mouth when feeding. When removing the infant from the breast, the mother should insert her little finger into the corner of the infant’s mouth to break the suction.

Instead of protecting the nipples with lanolin cream, petroleum jelly (Vaseline) or masse cream, it is suggested that a little colostrum or hind milk be left to dry on the nipples after each feed. The milk has anti-infective properties and the fat protects the nipples. Do not use alcohol on the nipples. Avoid vigorous washing or soap on the nipples.

Correct latching of the infant at the breast will help to prevent painful nipples.

4-27 How should you treat painful nipples?

Cracked nipples are very painful and should be prevented by correctly latching the infant to the breast and avoiding engorged breasts. Treat cracked nipples with breast milk spread onto the nipple between feeds. Usually with correct latching to the breast the mother will feel no pain and the crack will heal within a day. However, should the cracked nipple be too sore to continue feeding, express the affected breast. Feed the infant on the other breast and after the feed give the expressed breast milk by cup.

4-28 Do breastfed infants need complementary feeds?

Most breastfed infants do not need complementary (additional) feeds of formula. Complementary feeds decrease the time the infant spends on the breast and, thereby, reduce the production of breast milk. Bottle feeds may confuse the infant. Only if an infant continues to lose weight and the mother has inadequate lactation should complementary feeds be used. The mother should be encouraged to express her breasts to increase milk production. Some mothers will give complementary feeds if they have to leave their infant for more than a few hours. However, expressing milk into a sterile container for the missed feed would be preferable.

Expressed breast milk can be safely stored up to 6 hours in a cool place or for 48 hours in a fridge. Breast milk can be safely frozen and stored for 2 weeks in a fridge freezer or 6 months in a deep freeze. Frozen milk should be thawed slowly by placing the container in warm (not hot) water. Expressed breast milk should be given by cup.

4-29 Can working mothers continue to breastfeed?

Yes. Mothers can continue to breastfeed for many months while working. Breastfeeds can be given in the morning and again when she returns home. Feeding over the weekend should not be a problem. Breast milk can be expressed at work and this can be stored and then given to the infant during the following day. Alternatively, formula can be given while the mother is away at work and then breastfeeds given when she is home. Ideally it should be possible to take the infant to work or place the infant in a creche at or near the place of work.

4-30 Do drugs cross into the breast milk?

Almost all drugs that the mother takes by mouth will cross into the breast milk but only in very small quantities that will not affect the infant. Breastfeeding mothers should only take medication that is necessary. There is no evidence that antituberculous drugs or antiviral drugs that cross in the breast milk are dangerous to the infant.

Note
Thyroxine, antithyroid preparations, Warfarin, antidepressants, anticonvulsants, mild analgesics and most antibiotics can safely be given to a lactating mother. Tetracycline and cytotoxics should not be used if the patient is breastfeeding. Avoid breastfeeding for 24 hours after radioactive iodine is given to treat thyrotoxicosis.

Formula-feeding newborn infants

4-31 When should an infant be formula fed?

  1. If the mother has decided that she definitely does not want to breastfeed, then the infant should be fed formula. If possible the formula feed should be given by cup rather than by bottle.
  2. If a mother is unable to breastfeed because she is separated from her infant, she should express her milk, manually or with a breast pump, for the infant. Only if this is not practical should the infant be formula fed.
  3. If the mother has an inadequate milk supply despite advice and support, and if the infant is not gaining weight by 7 days, then complementary feeds should be started to ensure normal growth. However, the mother should be encouraged to continue to express her breast milk to increase her milk production.
  4. If the mother is very ill.
  5. If an HIV-infected mother decides to exclusively formula feed.
Note
Maternal tuberculosis is not a contraindication to breastfeeding unless the mother is very ill. The infant should be given prophylactic treatment for 3 months whether breast or formula fed.

4-32 What formula should be used for a term infant?

A number of starter formula feeds are available for term infants (e.g. NAN 1, S26 1, SMA 1). They are very similar and, therefore, the milk available at the local clinic or the cheapest milk should be bought. Unaltered cow’s milk, evaporated milk and skimmed milk are not suitable for infants under 6 months of age. Milk creamers must never be used to feed infants. Follow-up formulas are used from 6 months (e.g. NAN 2, S26 2, Lactogen 2).

Formula-fed infants should be fed on demand. If fed according to a schedule, most infants will need to be fed 5 times a day, at 06:00, 10:00, 14:00, 18:00 and 22:00. Most term infants will take about 100 ml per feed after the first week.

4-33 How is formula made up?

Usually a level scoop of milk powder (scraped level with a knife and not packed down) is added to every 25 ml of water in a cup or feeding bottle (read the instructions on the tin). The water should have been boiled beforehand and allowed to cool. Mix the formula well before feeding the infant. The bottle and teat must have been cleaned and sterilised by boiling or standing in a disinfecting agent (Milton or half diluted Jik). A feeding cup can be cleaned with soap and water.

One of the great dangers of formula feeds is to make the mixture too strong or too weak. If too much milk powder is added, the infant may receive too much salt and protein which can be dangerous. If too little milk powder is added, the infant may become malnourished. Another danger is gastroenteritis caused by infected water or dirty bottles and teats. These and other problems of formula feeds can be avoided by breastfeeding.

Many of the dangers of infection when using bottles and teats can be avoided if cup feeds are used instead.

Formula-fed infants may be offered a few clear feeds daily if the weather is very hot. Bottle-fed infants must be held while feeding. The bottle should never be propped.

4-34 What are the advantages of cup feeding over bottle feeding?

If an infant cannot be breastfed it is better to cup feed than to bottle feed. The greatest advantage of cup feeding is that a cup can be easily cleaned with soap and water. A cup also dries easily, especially if placed in the sun which helps to sterilise the cup. This is most important when clean or boiling water is not available for washing bottles. A cup feed usually takes less time than a bottle feed. It is also easier to wean a preterm infant from tube feeds onto cup feeds than onto bottle feeds. Infants drink the milk out of the cup. The milk should not be poured into the infant’s mouth. Any small plastic cup or dish can be used to feed an infant. Breast milk can be expressed directly into the cup before a feed. Mothers who do not breastfeed should be shown how to cup feed correctly before they are discharged home after delivery.

In some infants bottle feeding may cause problems with breastfeeding as the mechanism of sucking from a bottle is different from feeding at a breast. This is often called ‘nipple confusion’.

The ideal feeding cup for formula can be used for measuring the correct amount of water, mixing in the powder, storing and finally giving the feed. It should also be easy to clean. Keep the cup away from flies and dust.

Note
An excellent feeding cup can be brought from SINAPI. It allows the volume of water to be measured, power added and mixed, and the milk stored and given to the infant. Contact sales@sinapi.co.za or 021 887 5260 / 086 617 3296.

Cup feeding has many advantages over bottle feeding.

4-35 Are iron and vitamin supplements needed?

A normal term infant born to a healthy mother on a good, mixed diet and regularly exposed to sunlight does not need supplements in the first 6 months of life. Additional iron and vitamin supplements may, however, be of benefit in poor communities when iron drops 0.3 ml (or syrup 5 ml) and multivitamin drops 0.3 ml (or syrup 5 ml) can be given daily. Supplements given to well term infants are not harmful. Remember that all preterm infants need supplements.

Note
Vitamin D deficiency in unsupplemented breastfed infants is not uncommon during winter, especially in dark-skinned infants, in countries far from the tropics. In some areas with very little fluoride in the drinking water, supplementary fluoride drops can be given to reduce the risk of dental caries.

4-36 When should solids be introduced?

Normally breast milk or formula feeds will meet all the infant’s nutritional needs until 6 months of age. Thereafter milk alone is not enough and solids are usually introduced. If possible, an infant should be exclusively breastfed for 6 months. Even if the mother can only breastfeed for a few weeks or months, this will be of benefit to both her and her infant. Introducing solids reduces the anti-infectious properties of breast milk.

Some mothers continue to partially breastfeed up to 2 years. It is best to continue breastfeeding after solids have been introduced. This practice is particularly important in poor communities as breast milk provides the infant with a good source of protein. Weaning should be done over a few weeks by dropping one feed per week. In practice solids are often introduced early, especially with formula feeding.

Whenever possible infants should be exclusively breastfed for 6 months.

4-37 How should lactation be suppressed if indicated?

Cold or warm compressors help relive the discomfort. Breast binding is no longer used. Oral pyridoxine 200 mg three times a day for 5 days may help. Only express a little milk if the engorgement is very uncomfortable. Fluid intake should not be reduced. Paracetamol (Panado) can be taken for pain.

Bromocriptine (Parlodel) is not safe and should not be used. Oestrogen is contra-indicated as it increases the risk of deep-vein thrombosis.

Note
Cold cabbage leaves or ice packs will help to relieve the discomfort of engorgement if placed on the breast.

The baby friendly initiative

4-38 What is a baby friendly hospital?

The idea of a ‘Baby Friendly Hospital’ was introduced by the World Health Organisation to promote the advantages of breastfeeding. UNICEF is the agency which assesses and registers hospitals as baby friendly. To become registered as a Baby Friendly Hospital all the ‘Ten steps to successful breastfeeding’ have to be implemented. Clinics should also be baby friendly.

4-39 What are the ten steps to successful breastfeeding?

  1. Have a written breastfeeding policy that is frequently communicated to all the health-care staff.
  2. Train all the health-care staff in the skills needed to implement successful breast­feeding.
  3. Inform all pregnant women about the benefits of breastfeeding.
  4. Help mothers to start breastfeeding within 30 minutes of delivery.
  5. Show mothers how to breastfeed and teach them how to maintain lactation even if they are separated from their infants.
  6. Do not give newborn infants formula or water feeds unless this is indicated for medical reasons.
  7. Allow mothers and their infants to remain together all the time from delivery to discharge.
  8. Encourage demand feeding.
  9. Discourage the use of dummies, teats and nipple shields.
  10. Promote the formation of breastfeeding support groups and refer mothers to these groups on discharge from hospital or clinic.

Feeding the HIV-exposed infant

4-40 How should HIV-positive women feed their infants?

The decision to exclusively breastfeed or exclusively formula feed should be made by all HIV-infected women well before they deliver. The choice should be made after the mother has been carefully counselled about the advantages and disadvantages as well as the risk of HIV transmission of each feeding method. It is most important that HIV-infected mothers do not give mixed breastfeeds (breast milk as well of formula or solid feeds) as this carries the highest risk of HIV transmission from mother to infant. Most HIV positive mothers on antiretroviral treatment can exclusively breastfeed safely for 6 months if the infant is receiving prophylactic antiretrovirals.

Mixed breastfeeding carries the highest risk of HIV transmission.

4-41 When is it best to formula feed HIV-exposed infants?

The World Health Organisation recommends that HIV-positive women exclusively formula feed their infants only if all of the following criteria can be met:

  1. It should be acceptable to her family and friends. There are social and cultural barriers to formula feeding in many poor communities. In some communities women may be afraid to formula feed and not breastfeed.
  2. It should be feasible to formula feed. The mother must have the knowledge and skills to make up formula correctly.
  3. It must be affordable to formula feed. Formula is expensive. Free formula may be provided in some areas.
  4. It should be sustainable. Formula must be available. Mothers often live far from shops in rural areas.
  5. It should be safe. Clean water must be available. The mother should be able to prepare feeds hygienically and be able to clean the bottles, teats and cups. Access to primary health care is particularly important if infants are formula fed.

If any of these criteria cannot be met, it would be better for women to exclusively breastfeed as the risk of HIV transmission in breast milk is probably less than the dangers of formula feeding. Women who decide to formula feed must be taught how to prepare and give formula correctly. A cup rather than a bottle should be used as cups are easier to clean.

Women should exclusively breastfeed unless the risk of HIV transmission in breast milk is greater than the dangers of formula feeding.

Note
WHO uses the acronym AFASS for acceptable, feasible, affordable, sustainable and safe.

4-42 Is the danger of HIV infection with breastfeeding not unacceptably high?

No. In poor, underserved rural or peri-urban communities the risk of not breastfeeding (gastroenteritis and malnutrition) is often greater than the risk of HIV transmission via breastfeeding. With exclusive breastfeeding for 6 months the risk of HIV transmission through breast milk is less than 5%. If the mother is receiving antiretroviral treatment the risk is almost nil. Therefore, in many poor communities, exclusive breastfeeding is the safest option.

Case study 1

A woman who bottle fed her first infant, delivers at term and wants to breastfeed this infant. However, she is concerned as she has small breasts and flat nipples. She asks the staff what are the benefits of breastfeeding.

1. Should she try to breastfeed this infant if she formula fed her first child?

Yes, many mothers are able to breastfeed successfully even if they did not breastfeed their previous children. The use of prolonged skin-to-skin care helps to promote breast­feeding. She needs to be shown how to hold and latch her infant correctly. She also needs a lot of support and encouragement. It is important to keep the mother and her infant together if possible.

2. Why are some women unable to breastfeed successfully?

The commonest cause of failure to breastfeed successfully is that mothers are not supported and managed correctly and not fully informed about the advantages and method of breastfeeding.

3. Can women with small breasts feed their infants?

Yes. The size of a woman’s breasts is determined by the amount of fat and not glandular tissue and, therefore, does not influence her ability to breastfeed.

4. How should flat nipples be treated?

No treatment is needed during pregnancy. However, it is important to identify women with flat or inverted nipples so that extra help can be given to get the infant to latch correctly at the breast.

5. What are some of the benefits of breastfeeding?

6. When should women decide whether to breastfeed or not?

This decision should be made during pregnancy and preferably before the infant is born.

Case study 2

A mother has breastfed her infant for 3 days. The infant’s birth weight was 3200 g but he now weighs only 3000 g. When she squeezes her nipple, her milk appears very watery.

1. Is the infant’s weight loss normal?

Yes. Normal infants can lose up to 10% of their birth weight, which would be 320 g for this infant. The weight loss of 200 g will not cause the infant any harm.

2. When should an infant start gaining weight after birth?

Most infants start gaining weight between 3 days and 5 days after birth when breast­feeding is established and the mother’s milk supply increases.

3. Should the mother give complementary feeds of formula?

These are not needed. Complementary feeds will decrease the time the infant spends sucking at the breast and this will reduce the mother’s milk supply.

4. How can this mother increase her milk supply?

She should put the infant to the breast frequently to stimulate her milk supply. She can also be encouraged to express her milk after feeds. Usually there is no need for a mother to take drugs to increase her milk supply.

5. Why does her milk appear too weak?

Foremilk looks ‘too weak’. This is normal and contrasts with the hind milk which is much richer with more fat.

6. If the weather is hot should clear feeds be given?

There is no need to give clear feeds to breastfed infants.

Case study 3

A mother who has breastfed her infant for 5 days develops painful, cracked nipples after her breasts became engorged. She feeds her infant every 5 hours and is taking flucloxacillin for an infected Caesarean section wound.

1. How can cracked nipples be prevented?

With prevention of breast engorgement and careful attention to latching the infant correctly, cracked nipples should not occur.

2. How can breast engorgement cause painful nipples?

If the infant is unable to latch correctly due to swelling of the areola and breast, the nipple can be damaged by the infant sucking incorrectly.

3. Why is it advisable for mothers to demand feed rather than schedule feed?

Demand feeding whenever the infant is hungry helps prevent engorged breasts which can lead to cracked nipples.

4. How should you treat cracked nipples?

By showing the mother how to latch correctly. Breast milk helps the nipple to heal.

5. Should the mother continue breast­feeding as she is taking an antibiotic? Give reasons for your answer.

Yes, she should continue breastfeeding. Like most other antibiotics, flucloxacillin will cross into the breast milk in small quantities only. This should not be dangerous to the infant.

6. How can she continue to breastfeed if she plans to return to work?

She can still breastfeed in the morning before going to work and again when she gets home. She can also breastfeed throughout the weekend and express her breast milk at work to be stored and fed by cup during the next day. Alternatively, the infant can be formula fed while she is at work. Ideally she should be able to take the infant to work with her.

Case study 4

After counselling an HIV-positive woman decides to formula feed her infant. She is discharged from the clinic 6 hours after delivery without any clear instructions.

1. What milk formula should she buy?

She can buy any term formula. There is no need to buy the more expensive formulas. Fresh cows milk, evaporated milk or skimmed milk are not suitable for small infants.

2. How is formula made up?

Most formulas are made up by adding one level scoop of milk powder to every 25 ml of water. The water should first be boiled and allowed to cool. The formula must be mixed well. Making the formula too strong or too weak is dangerous.

3. What is the best way to formula feed an infant?

It is better to give formula by cup than by bottle as cups are easier to clean. This is particularly important in poor communities where gastroenteritis is common.

4. How should bottles and teats be cleaned?

The bottle and teat must be cleaned and sterilised by boiling or standing in a disinfect­ing agent (Milton or half diluted Jik). Teats should be scrubbed both inside and outside with a brush.

5. When should solids be started?

It is preferable to only introduce solids at 6 months. However, solids are often started earlier in formula-fed infants.

6. Should iron and vitamin supplements be given to healthy, term infants?

These are not routinely needed in term infants.

Video

Breast engorgement

Video by the Global Health Media Project made available under a Creative Commons Attribution-NonCommercial-NoDerivatives License