Nutrition Infant

Nutrition for the Term Infant
Breast milk is universally recommended as the preferred source of infant nutrition, in part because of its superior nutrient and immunologic properties. Successful breast feeding requires nursing on demand, prevention of sore nipples and convenient access to medical advice. For mothers relying on bottle feeding, cow's-milk-based formula is the preferred choice. Because soy-based formulas are lactose-free, they may be tolerated by infants who are allergic to cow's-milk protein. Protein hydrolysate formulas should be used only in infants who cannot tolerate cow's-milk-based or soy-based formulas. Low-iron formulas and whole cow's milk should not be used during the first year. Breast-fed infants rarely require vitamin supplementation. Fluoride supplementation is no longer recommended for infants less than six months of age.

Benefits of Breast Feeding
Breast milk is universally recognized as the preferred source of infant nutrition, and the nutritional advantages of breast milk have been well documented. Colos-trum, the first milk produced after delivery, provides an initial dose of enzymes that promote gut maturation, facilitate digestion and stimulate passage of meco-nium. Colostrum is also high in protein, primarily because of high levels of im-munoglobulins and secretory IgA. The protein in human milk is ideal not only for absorption, but also for utilization, especially by the rapidly developing infant brain. Human milk also contains predominantly polyunsaturated fats with stable amounts of cholesterol, an important constituent of brain and nerve tissue.
Human milk also protects against infection by providing cellular immunity through macrophages and humoral factors, such as antibodies. Numerous studies have verified that breast-fed infants have a lower incidence of bacterial and viral illnesses than bottle-fed infants. This low incidence is of particular clinical significance in developing nations? Ongoing research suggests that breast feeding may provide immuno-logic protection against diabetes mellitus, cancer and lymphoma. Finally, breast feeding has been found to provide protection from allergic diseases, including eczema, asthma and allergic rhinitis. This protection is most likely the result of breast milk decreasing intestinal permeability to large, allergenic molecules.
Recognizing these as well as other advantages, the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP) have identified breast milk as the preferred source of infant nutrition. In addition, the U.S. Public Health Service (USPHS) has established a national goal that, by the turn of the century, 75 percent of new mothers will be breast-feeding at the time of hospital discharge. Despite an emphasis on breast feeding by both private and government organizations, only 54 percent of U.S. mothers initiate breast feeding, and fewer than half of these mothers continue nursing for at least six months. Clearly, all health care providers should actively promote breast feeding if the goal set by the USPHS is to be accomplished.
To successfully promote breast feeding, family physicians should consider the influence of marketing campaigns aimed at expectant and new mothers by the manufacturers of infant formulas. Historically, their dogged marketing efforts have included the distribution of free cases of infant formula to expectant mothers, as well as the inclusion of formula samples in commercial hospital discharge packs designed for breast-fed infants. Physicians must work proactively to weigh the risks and benefits of promotional materials and develop appropriate policies governing their distribution in their hospitals or academic institutions.

Counseling Strategies
Breast feeding should be initiated as soon after delivery as possible, and mothers should be encouraged to nurse on demand, usually eight to 10 times a day.

Signs of Successful Breast Feeding
Audible swallowing
Eight to 10 feedings per day
Six to eight wet diapers per day
Three to five bowel movements per day
Infant regains birth weight by two weeks of age

This strategy enables the milk supply to quickly become well established. Table 1 lists reassuring signs of successful breast feeding, which can be used to assess the infant's nutritional intake as well as to bolster the new mother's confidence in her breast-feeding success. Supplemental formula feedings should be discouraged in the early postpartum period, since they may result in a decreased milk supply or infant confusion between the artificial and maternal nipples?
The first weeks of nursing represent a pivotal time for success or failure of breast feeding. And with the trend toward increasingly abbreviated inpatient stays, nursing mothers will be relying more than ever before on their physicians and office staff to provide much of the breast-feeding counseling that previously took place in the hospital.
To be successful, nursing mothers must learn proper positioning of the infant. Since sore nipples can derail even the best intentions to breast feed, nursing mothers should learn techniques for preventing sore nipples, such as varying the nursing position and using the little finger to break the infant's suction before removing the infant from the breast. Should these efforts fail to prevent soreness, mothers should have quick access to effective treatment regimens.
The ability of the breast-feeding couple to weather difficulties and setbacks can be enhanced by close contact with a responsive physician and office staff. Early physician visits, home nursing visits and even telephone contacts can provide opportunities to offer support and guidance to nursing mothers? For example, a staff member might routinely call nursing mothers the day after hospital discharge. The physician's office environment can be structured to allow privacy and comfort for nursing mothers. Often this can be accomplished by simply making an examination room available.

Once nursing is well established, the physician should encourage the mother to continue nursing throughout the infant's first year of life. Physicians should avoid recommending unnecessary disruptions in breast feeding. Recent guidelines on the management of hyperbilirubinemia in the healthy term newborn, for example, discourage the interruption of breast feeding and, instead, provide the option of frequent breast feeding.
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