4
Basic Nutrition Services for Newborn Infants

BASIC CARE FOR THE NEONATE

Exclusive breastfeeding is the preferred method of feeding normal infants throughout their first 4 to 6 months. Breastfeeding provides the infant with a clean supply of milk, in an amount that is responsive to the infant's needs, and in a manner that promotes optimal interaction between the mother and infant. Human milk provides all essential nutrients in a form that is easily digested and absorbed and in amounts that allow normal growth and development of full-term infants (assuming adequate exposure to sunlight). Moreover, human milk provides the infant with immunoglobulins and many other antiinfective substances, as well as anti-inflammatory substances, hormones, enzymes, and growth factors that appear to have important health-promoting effects. It also appears to minimize the risk of allergic reactions. Breastfeeding may benefit the mother by suppressing ovulation (thereby extending the period of postpartum infertility), hastening the return of the uterus to its prepregnant size (which reduces the risk of hemorrhage in the immediate postpartum period), and perhaps reducing the risk of certain health problems (such as osteoporosis and breast cancer) later in life.1

The approach to basic nutritional care of the neonate presented in this chapter is consistent with national health goals for the year 2000:

Increase to at least 75 percent the proportion of mothers who breastfeed their babies in the early postpartum period and to at least 50 percent the proportion who continue breastfeeding until their babies are 5 to 6 months old(p. 123).2



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Nutrition Services in Perinatal Care 4 Basic Nutrition Services for Newborn Infants BASIC CARE FOR THE NEONATE Exclusive breastfeeding is the preferred method of feeding normal infants throughout their first 4 to 6 months. Breastfeeding provides the infant with a clean supply of milk, in an amount that is responsive to the infant's needs, and in a manner that promotes optimal interaction between the mother and infant. Human milk provides all essential nutrients in a form that is easily digested and absorbed and in amounts that allow normal growth and development of full-term infants (assuming adequate exposure to sunlight). Moreover, human milk provides the infant with immunoglobulins and many other antiinfective substances, as well as anti-inflammatory substances, hormones, enzymes, and growth factors that appear to have important health-promoting effects. It also appears to minimize the risk of allergic reactions. Breastfeeding may benefit the mother by suppressing ovulation (thereby extending the period of postpartum infertility), hastening the return of the uterus to its prepregnant size (which reduces the risk of hemorrhage in the immediate postpartum period), and perhaps reducing the risk of certain health problems (such as osteoporosis and breast cancer) later in life.1 The approach to basic nutritional care of the neonate presented in this chapter is consistent with national health goals for the year 2000: Increase to at least 75 percent the proportion of mothers who breastfeed their babies in the early postpartum period and to at least 50 percent the proportion who continue breastfeeding until their babies are 5 to 6 months old(p. 123).2

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Nutrition Services in Perinatal Care Breastfeeding rates in 1988 were very much lower than this at discharge from the birth site: 54% for white mothers, 32% for low-income mothers, 25% for black mothers, and 51% for Hispanic mothers.2 Rates for migrant Hispanic mothers appear to be lower than those for nonmigrants.3 When breastfeeding is not desired or not possible, modern infant formulas are an acceptable alternative if they are prepared and fed properly. The committee strongly endorses breastfeeding. It also believes that each woman should be able to make an informed decision about which feeding method will be most acceptable for her situation and to receive nutrition services appropriate to that choice. For example, the woman who decides to feed her baby formula may need to be taught how to reconstitute it. The committee supports a patient-centered plan of care to promote appropriate infant feeding. Planning for the Support of the Breastfeeding Woman Nutritional care of the breastfed infant mainly involves breastfeeding support for the mother. Most women make decisions about how to feed their infant before or during pregnancy.4,5 A small randomized study demonstrated that prenatal breastfeeding education was associated with higher rates of breastfeeding by low-income African-American women than by their counterparts in a control group.6 Thus, information to support the decision to breastfeed should be provided preconceptionally and prenatally, and methods to convey the information need to consider outside influences on decision making.7 Women may benefit from practical information about how to breastfeed offered during prenatal visits or classes as well as in the immediate postpartum period. The logical times for health care providers to provide direct assistance to and support for the breastfeeding mother are when she first initiates feedings and when her milk ''comes in.'' Advice and support are also needed for mothers who encounter difficulties or have concerns in the following weeks or months. Hospitals should implement standard practices that facilitate the initiation of breastfeeding (such as those described by Strembel and colleagues,8 Winikoff and others,9 and the World Health Organization)10 , and primary care providers need to offer additional services after discharge. (See also Spisak and Gross.11) During their hospitalization, women who deliver vaginally usually have only a short period to acquire breastfeeding skills and to ask questions. In 1990, the mean duration of hospitalization for these women, including time spent in labor, was 2.4 days (E. Graves, National Center for Health Statistics, personal communication, 1991); many women are discharged

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Nutrition Services in Perinatal Care within 24 to 36 hours after delivery. Fatigue or discomfort during the hospital stay may temporarily interfere with the mother's learning. Mothers whose infants are delivered by cesarean section have longer hospital stays (mean = 4.6 days) and thus more opportunity for interactions. However, such women require extra assistance and support from skilled nursing staff to manage the discomforts and other barriers to breastfeeding that result from this major surgery, including the likelihood of greater separation from the newborn infant while in the hospital. 12–14 Breastfeeding women who return to work or school are usually confronted with barriers to breastfeeding. Health care providers can assist them (1) by helping with practical details such as how to pump and store milk and (2) by providing information to the worksite about the advantages of supporting breastfeeding and about helpful short-term strategies, such as alterations in work schedules and a private place for expressing milk.15,16 To make breastfeeding a more realistic option for women after they leave the hospital or birth center will require greater community acceptance of and tangible support for breastfeeding as the preferred method of feeding babies. To provide women with adequate support for breastfeeding involves activities of many types: For both health care providers and the general population, raising the level of awareness of breastfeeding as an infant feeding option—this could be carried out as a part of both women's health and school-based health education. Education and training for health care personnel in policies, procedures, and skills that promote and support breastfeeding. Educational activities for parents (such as prenatal and early postpartum classes, demonstrations, and videotapes) about the benefits and techniques of breastfeeding. The discontinuation of hospital practices (such as distributing infant formula gift packages) that tend to undermine breastfeeding. Early and direct assistance with breastfeeding upon its initiation in the hospital and as needed during the hospital stay. Skilled nursing care to assist women with breastfeeding following a cesarean delivery. Instructions for contacting the physician in the event of breastfeeding or infant health problems and encouragement to do so. For example, early symptoms of mastitis, decisions concerning prescription medications for the mother, and concerns about the adequacy of the infant's intake should be directed to the physician as soon as possible. Specific information before discharge about sources of support for the process of breastfeeding. Such sources include La Leche League,

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Nutrition Services in Perinatal Care Mothers of Twins, other mother-to-mother support groups, a telephone hot line for breastfeeding women, or the hospital's lactation consultant. Support for and additional information about breastfeeding provided in the woman's home within a few days after discharge. Support for and additional information about breastfeeding at the first neonatal health visit (within 2 weeks after birth)17 and at the routine postpartum visit, with anticipatory guidance to prevent premature cessation of breastfeeding.18 Assistance with strategies for continuing to breastfeed upon returning to work or school. Home Visits and Other Early Follow-up The home visit deserves special consideration and discussion because it is not a part of routine care in the United States. In Western Europe, home visits (usually by specially trained nurses) are widely used in postnatal care: seven of nine countries always provided at least one postnatal home visit in 1982.19 In the United States, the value of home visits for a variety of purposes is receiving increasing ecognition.20–30 Home visits offer unique opportunities for care providers to observe infant feeding and care practices, the mother's coping skills, and the resources available to the mother; they also allow follow-up of many other aspects of maternal and infant health. Such observations enable the home visitor to tailor the assistance and educational strategies to the mother's and infant's special needs. Suitably trained home visitors can quickly identify ways to advise the mother on planning simple but nutritious meals and snacks, avoiding or managing infant feeding problems, and resolving other concerns. This may be especially valuable for mothers of twins, low-income women, adolescents, women with limited education or intelligence, and women with a history of problems with child rearing. The home visit is also an opportunity to provide direct assistance with techniques for the manual expression of milk and, if desired, for the use of a breast pump. Although too few studies have been conducted to allow an adequate evaluation of the cost-effectiveness of postpartum home visits, the U.S. General Accounting Office concluded that "home visiting is a promising strategy for delivering or improving access to early intervention services that can help at-risk families become healthier and more self-sufficient" (p. 2).29 A telephone contact can serve as only a partial substitute for a home visit because it does not allow for direct observation or intervention, or for the modeling of desirable behaviors. A home or office visit with a physician, midwife, or nurse-practitioner within approximately 2 weeks of delivery is highly desirable for both

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Nutrition Services in Perinatal Care medical follow-up of the neonate and the support of either breastfeeding or appropriate formula feeding. Early discharge (<48 hours after delivery) calls for earlier follow-up.17 DELIVERY OF BASIC NUTRITION SERVICES FOR INFANTS Availability of the following nutrition services is basic to the preparation of parents for infant care, to the care of all normal infants, and to the care of previously ill or disabled infants who have been discharged to routine care. (See also Chapter 3 for information about services in support of breastfeeding.) Offer or organize structured programs to provide information about infant feeding choices to pregnant women and their partners and to support breastfeeding efforts in the hospital and following discharge. Provide support for and assistance to breastfeeding mothers as described in the preceding section "Planning for the Support of the Breastfeeding Woman." This may include special support for mothers of twins or triplets and for those who plan to continue breastfeeding after returning to work or school. Evaluate and manage the nutritional care of the infant. Screen for nutrition-related problems such as phenylketonuria, over-or underfeeding, inappropriate feedings or nutrient supplements, and abnormal patterns of growth. Measure, monitor, and assess infant growth. Provide instructions for the safe preparation of infant formula, feeding instructions, and anticipatory guidance for the primary caregiver and others as appropriate. Address feeding practices to prevent the development of tooth decay in infants. Determine the need to adjust feeding strategies, formula (if used), and vitamin-mineral supplements. Adjust recommendations to treat food -and nutrition-related problems of the infant, such as overnutrition, undernutrition, anemia, and allergies. Consult with specialists concerning complex nutritional challenges (see Chapter 5) and make referrals as necessary. Provide for the continuity of nutritional care; this includes referral to and communications with outpatient and home health services and parental support groups, as well as referral to local agencies with food and nutrition programs (see Chart 3-2) when appropriate.

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Nutrition Services in Perinatal Care Provide organized in-service nutrition education for the health care team about normal nutrition throughout the first years of life. Personnel The health care team may include physicians (pediatricians or family practitioners with special interest in the care of the newborn), midwives, nurse-practitioners, nurses (hospital based or in the physician's office), and sometimes a dietitian or a social worker, or both. These team members need experience in providing for the nutritional needs of lactating mothers (see Chapter 3) and in the feeding of newborn infants. They also need to be familiar with sources of assistance in the community, their eligibility requirements, and strategies for helping parents gain access to these sources. It is essential that all members of the team convey consistent, accurate messages to the mother about infant growth, nutrition, and feeding techniques. Nurses are expected to be able to provide support and technical assistance in the art of breastfeeding and to help find solutions to common problems that might otherwise obstruct successful breastfeeding. The nurse, nurse-practitioner, midwife, and physician are the caregivers who are primarily responsible for teaching the mother about the care of her infant. Ancillary personnel in the community extend the reach and effectiveness of the facility-based health care team. For example, if the Expanded Food and Nutrition Education Program (EFNEP) is available locally, a nutrition teaching aide can help low-income families stretch their food dollars and make more healthful food choices during lactation; a visiting nurse can provide breastfeeding support and assist the mother in the safe handling of her expressed milk or of formula; and a community health worker may help link the mother with needed resources. WIC staff can offer helpful information on food choices during lactation and on breastfeeding management for those women who are enrolled in the program. Knowledge Base and Clinical Skills Health care providers who are responsible for the nutritional care of normal infants and of breastfeeding mothers are expected to have a firm knowledge base concerning the following topics and the education and experience needed to develop the skills covered in this section.

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Nutrition Services in Perinatal Care Knowledge and Understanding Similarities and differences in the composition of human milk and infant formulas. Factors that facilitate or hinder successful breastfeeding. Methods for overcoming barriers to breastfeeding, both at home and after the mother returns to work or school. Practical information about breastfeeding techniques, such as positioning the baby. Conditions that require the physician's attention, including early signs of mastitis, dehydration of the infant, abnormally slow infant growth, or unadvised discontinuation of a prescription medicine. Nutrient requirements of normal infants at each stage of development and appropriate ways to provide those nutrients. Neuromuscular development related to the appropriate times for the introduction of solid foods and the emergence of self-feeding. Safety precautions for formula preparation. Assessment Skills Obtain a current feeding history. Identify barriers to the continuation of breastfeeding. Identify the mother's strengths and the resources available to her—to serve as a basis for a constructive plan of care. Accurately measure the infant and monitor his or her weight and length. Detect abnormal growth and developmental patterns. Determine the need for adjustments in the feeding program. Identify the need for referral for special nutritional care for the infant. Health Maintenance Skills Provide nutrition education and counseling that is appropriate for the feeding method chosen. This may include information regarding the management of successful breastfeeding, hygienic measures for the safe handling and feeding of formula and supplementary foods, the appropriate use of infant formula, the indications for and safe use of nutrient supplements, the supplementation of breastfeeding or formula with other foods or fluids, the prevention of baby bottle-mouth syndrome, or any combination of these.

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Nutrition Services in Perinatal Care Provide support and technical assistance in the art of breastfeeding and in coping with other aspects of infant feeding. Communicate in a second language or make effective use of an interpreter or translator to communicate with non-English-speaking families. Intervention Skills Use problem-solving techniques to support breastfeeding women who may otherwise wean their babies prematurely. Manage the nutritional care of infants with health problems who have been discharged to routine care. Assist the caregiver to solve real or perceived feeding problems. Facilitate the parents' use of available community services and agencies that provide resources to support maternal and child nutrition. Management of the Organization and Delivery of Nutritional Care Assist in training home visitors (including peer counselors) to support breastfeeding and to provide guidance on other aspects of infant feeding. Develop strategies for achieving consistency of care by various health team members and for triggering appropriate follow-up when there is a change in providers. Incorporate new knowledge into nutritional care plans and educational programs. SUMMARY Because exclusive breastfeeding is the recommended feeding method for infants for the first 4 to 6 months, basic nutritional care for the neonate needs increased attention to support for breastfeeding, preferably beginning before conception. Emphasis should be placed on appropriate anticipatory guidance both pre-and postnatally, direct support in the hospital, and a variety of forms of assistance with breastfeeding management after discharge. Early home visits offer a promising strategy for supporting continued breastfeeding.

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Nutrition Services in Perinatal Care REFERENCES 1. Institute of Medicine. 1991. Nutrition During Lactation. Report of the Subcommittee on Nutrition During Lactation, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. National Academy Press, Washington, D.C. 2. Department of Health and Human Services. 1990. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Public Health Service, Office of the Assistant Secretary for Health, Washington, D.C. 3. O'Malley, B., A.C. Brown, M. Tate, A.A. Hertzler, and M.H. Rojas. 1991. Infant feeding practices of migrant farm laborers in northern Colorado. J. Am. Diet. Assoc. 91:1084–1087. 4. Hally, M.R., J. Bond, J. Crawley, B. Gregson, P. Philips, and I. Russell. 1984. Factors influencing the feeding of first-born infants. Acta. Paediatr. Scand. 73:33–39. 5. Sarett, H.P., K.R. Bain, and J.C. O'Leary. 1983. Decisions on breast-feeding or formula feeding and trends in infant-feeding practices. Am. J. Dis. Child 137:719–725. 6. Kistin, N., D. Benton, S. Rao, and M. Sullivan. 1990. Breastfeeding rates among black urban low-income women: effect of prenatal education. Pediatrics 86:741–746. 7. Baranowski, T., D.E. Bee, D.K. Rassin, C.J. Richardson, J.P. Brown, N. Guenther, and P.R. Nader. 1983. Social support, social influence, ethnicity and the breastfeeding decision. Soc. Sci. Med. 17:1599–1611. 8. Strembel, S., S. Sass, G. Cole, and J. Hartner. 1991. Breast-feeding policies and routines among Arizona hospitals and nursery staff: results and implications of a descriptive study. J. Am. Diet. Assoc. 91:923–925. 9. Winikoff, B., D. Myers, V.H. Laukaran, and R. Stone. 1987. Overcoming obstacles to breast-feeding in a large municipal hospital: applications of lessons learned. Pediatrics 80:423–433. 10. World Health Organization. 1989. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. A Joint WHO/UNICEF Statement. World Health Organization, Geneva. 11. Spisak, S., and S.S. Gross. 1991. Second Followup Report: The Surgeon General's Workshop on Breastfeeding and Human Lactation. National Center for Education in Maternal and Child Health, Washington, D.C. 12. Frantz, K.B., and B.A. Kalmen. 1979. Breastfeeding works for cesareans, too. RN 42(12):39–47. 13. Lawrence, R.A. 1989. Breastfeeding. A Guide for the Medical Profession, 3rd ed. C.V. Mosby, St. Louis. 14. Nurses Association of the American College of Obstetricians and Gynecologists. 1991. Facilitating Breastfeeding. NAACOG, Washington, D.C. 15. Barber-Madden, R., M.A. Petschek, and J. Pakter. 1987. Breastfeeding and the working mother: barriers and intervention strategies. J. Public Health Pol. 8:531–541. 16. Petschek, M.A., and R. Barber-Madden. 1985. Promoting prenatal care and breastfeeding in the workplace. Occ. Health Nurs. 33:86–89. 17. American Academy of Pediatrics/American College of Obstetricians and Gynecologists. 1992. Guidelines for Perinatal Care, 3rd ed. American Academy of Pediatrics, Elk Grove, Ill. 18. Ferris, A.M., L.T. McCabe, L.H. Allen, and G.H. Pelto. 1987. Biological and sociocultural determinants of successful lactation among women in eastern Connecticut. J. Am. Diet. Assoc. 87:316–321. 19. Miller, C.A. 1988. Prenatal care outreach: an international perspective. Pp. 210–228 in S. Brown, ed. Prenatal Care: Reaching Mothers, Reaching Infants. National Academy Press, Washington, D.C. 20. Aaronson, M. 1989. The case manager-home visitor. Child Welfare 68:339–346.

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Nutrition Services in Perinatal Care 21. Chapman, J., E. Siegel, and A. Cross. 1990. Home visitors and child health: analysis of selected programs. Pediatrics 85:1059–1068. 22. Combs-Orme, T., J. Reis, and L.D. Ward. 1985. Effectiveness of home visits by public health nurses in maternal and child health: an empirical review. Public Health Rep. 100:490–499. 23. Heins, H.C., N.W. Nance, and J.E. Ferguson. 1987. Social support in improving perinatal outcome: the Resource Mothers Program. Obstet. Gynecol. 70:263–266. 24. Klerman, L.V. 1990. Home visiting during pregnancy. Pp. 593–602 in I.R. Merkatz and J.E. Thompson, eds. New Perspectives on Prenatal Care. Elsevier, New York. 25. Larson, C.P. 1980. Efficacy of prenatal and postpartum home visits on child health and development. Pediatrics 66:191–197. 26. National Commission to Prevent Infant Mortality. 1989. Home Visiting: Opening Doors for America's Pregnant Women and Children. National Commission to Prevent Infant Mortality, Washington, D.C. 27. Olds, D., C. Henderson, R. Tatelbaum, and R. Chamberlin. 1986. Improving the delivery of prenatal care and outcomes of pregnancy: a randomized trial of nurse home visitation. Pediatrics 77:16–28. 28. Olds, D.L., and H. Kitzman. 1990. Can home visitation improve the health of women and children at environmental risk? Pediatrics 86:108–116. 29. Powell, D.R. 1990. Home visiting in the early years: policy and program design decisions. Young Children 45:65–73. 30. General Accounting Office. 1990. Home Visiting: A Promising Early Intervention Strategy for At-Risk Families. GAO Publ. No. HRD-90-83. General Accounting Office, Washington, D.C.