Infant feeding
Dr. Lara Abbas
Counseling in PHC
Counseling in IMCI includes:
1. Feeding recommendation.
2. Counseling about feeding problems.
3. Advice the mother when to return to health center (HC).
4. Advice the mother about her own health.
1. Feeding Recommendation: Grouping of
children in feeding recommendation
1.
2.
3.
4.
5.
Age 0-6 months
Age 6-8 months
Age 9-11 months
Age 12 months up to 5 years
Persistent diarrhea.
Recommendation for age group up to 6
months
Note: breastfeeding should start as soon as possible following deliver,
same goes for cesarean section, as soon as the mother has recovered
and is able to[1]. The secretion of anesthetic into breastmilk is in small
amounts considered clinically insignificant.
• Breastfeed as often as the child wants, day and night, at least 8 times
in 24 hours (~ every 3 hours at least)
• Do not give other foods or fluids.
• Do not use bottles or teats.
• Note: Exclusive breast feeding means the child not take anything
other than breast milk with exception of vitamins and drugs.
Note: how to tell if the child has had enough?
• The swallowing of the baby can be heard and this can let you know if they’re
actually feeding.
• The neonate can get tired quickly (?) and also has a small stomach the amount of
time needed for sufficient breast feeding is not clear in the first month [Dr. Lara].
• The baby develops a range of cues to communicate their needs, e.g., showing
clear signs of anticipation of feeding. At the beginning of the feed when the baby
is hungry, they’re not interested in socializing, and as they feel less hungry, the
pace of feeding slows, and they may pause for a few moments (they should not
be interrupted), and start feeding again when they’re ready. The baby might give
cues to when they are ready to change sides [Dr. Lara: change the breasts as the
breast being used may be empty]. They also give cues that they’ve finished
feeding; take it slowly [Dr. Lara: wait 1 or 2 minutes], and check if they’re sure
they’re finished [attempt to give them a nipple to see if they’ll suckle on it], but
don’t force them to feed [watch the video on the last slide for more info].
Amount and frequency of complementary
feeding according to the age
1: 6-8 months: 1-2 teaspoons, twice a day
2: 9-11 months: 1/4 cup, 5 small meals a day
3: 12m-5 years: 1 cup, 5 small meals a day
Note:
• 1 cup = 250ml.
• The feeding should not be before breast feeding.
• A child has small stomach so they will not eat enough to last for many
hours
Recommendations for age 6 months up to 8
months
1. Breastfeed as often as the child wants.
2. Give adequate serving of iron rich foods
• Dried beans
• Minced meat
• Egg
• Boneless fish
• Chicken or chicken liver
• Vegetables and fruit; potato , carrot, apple
These food must be cooked and mashed to make them soft and easy for swallow (Dr. Lara:
Soft enough to be able to be eaten through a milk bottle??)(Make sure foods are soft
enough “to mash with the tongue on the roof of the mouth or are large enough that
small pieces don’t break off when sucked or chewed, e.g., strips of meat)
Recommendations for age 9 months to 11
months
Sirilak = meal
1. Breastfeed as often as the child wants.
2. Iron rich food;
• Increase the amount and variety of foods
• Food doesn’t need to be smooth as in the past months
• Give small pieces of food they can hold (banana, bread, cooked
carrots)
• Give safe water to drink from a cup regularly
Recommendations for age 12 months up to 5 years
• Give at least 5 adequate nutritious family meals* per day (note: the baby can eat the same food as the rest
of the family. They can take the flavoring, e.g., salt and sweets, the rest of the family has in their food.
Before this age, foods prepared for a child should not be flavored by things like salt or seasoning.
• Give food before breast milk
• Yogurt, Cheese, bread, egg
• Note: dairy products are not given before 1 year, as they’re made from animal milk, usually cow milk; a child will only be
able to drink cow’s milk and dairy-based products starting at twelve months old. A younger child’s (<12 months) digestive
system is not ready to digest cow’s milk (it’s hard for them to digest)[1].
• Fresh fruit juice.
• Tomato juice.
• Note: tomato and fresh fruit juice are regurgitated in infants <12 months old and hence not given???
Note: There is no age at which breastmilk is considered to become nutritionally insignificant for a child.
Breastfeeding can be continued past 12 months for as long as the baby and mother like (but should be
reduced??)
Note: honey should not be given to infants <12 months because it may cause botulism.
Note: The child is sitting and
eating on its own. Their
utensils are separate from the
parent (to prevent
transmission of H. pylori?)
Picture 1: Active
feeding of the child
Video
Active feeding
• Active feeding means the mother or other care fiver should sit with
the child and encourage the child to eat and the child should have a
separate dish and his own spoon with appropriate size
• Adequate serving means the child does not want any more food after
active feeding
Feeding recommendation for a child who has
persistent diarrhea
• If still breastfeeding, giver more frequent, longer
breastfeeds, day and night.
• If taking something other than milk:
• Replace with increased breastfeed OR
• Replace with fermented milk products, such as yoghurt (if more
than one year)
• Replace half of the milk with nutrient-rich semisolid food
• For other foods, follow feeding recommendations for the
child’s age.
Assess the child’s feeding
Ask questions about the child’s usual feeding and feeding during the illness. Compares
the mother’s answers to the feeding recommendations.
Ask:
• Do you breastfeed your child?
• How many times during the day
• Do you also breastfeed during the night
• Does the child take any other food or fluids (note: even if the child is younger than 6
months, as mothers may not know better and be giving the child other foods or fluids)?
•
•
•
•
What food or fluids?
How many times per day?
What do you use to feed the child? How large are the servings?
Does the child receives his own serving? Who feeds the child and how?
Note: How to know if breastfeeding is adequate
for a mother coming for counseling?
• Who feeds the child and how (active feeding; does the child eat on their own? Are they attended
by a caregiver or are they alone? Do they have their own dish and spoon)
• The most accurate measure of breastfeeding adequacy is the infant's rate of weight gain,
documented by serial measurements
• Infants usually lose weight in the first days of life, and infants who are successfully breastfeeding should
return to birth weight by 10 days of age (Dr. Lara: infants lose weight in the first 10 days??).
• During the first 4 months, weight gain is about 750 gm/month, totaling to 3 kg (weight gain of 25-30 g/day)
• During the second 4 months, weight gain is about 500 gm/month, totaling to 2 kg
• During the third 4 months, weight gain is about 250 gm/month, totaling to 1 kg
• In total, 6 kg are gained in the first year.
• Ask about defecation and urination. Even in a hot, dry environment, the baby can acquire
adequate water through frequent breastfeeding. You can tell if the baby is provided with
sufficient water by observing their urine. If the baby is passing yellowish urine at least six times a
day it means they have adequate water supply, and this is an indicator of sufficient milk supply[1].
The frequency of defecation can vary; they may pass stools as frequently as every feeding.
Breastfed infants can pass loose stools normally.
Which of the following is not correct
regarding active feeding of the child?
A. The mother or care giver should sit with the child during
feeding
B. The child should complete his food at the same time that
the family complete
C. The mother or care giver should encourage the child to eat
D. The child should have a separate dish during feeding
Counsel the mother about feeding problems
Feeding problems include
1. Breastfeeding difficulty.
2. Use of bottle feeding.
Note: ask
• How many bottles do they use?
• How are the bottles sterilized? (e.g., boiling)
• What’s the position?
• How much milk is given (how many ounces [‫?)]رەقەم‬
• Depends on weight
• 1 ounce = 30 cc = 20 kcal
• An infant needs 100cal/kg/day, divide that by 8 (or the no. of feeding sessions) to get the amount needed for each
session.
3. Lack of active feeding.
4. Not feeding well during illness.
5. Insufficient milk.
6. Not breast feeding exclusively because the mother works outside the home (note: milk can be expressed manually and stored for
later feeding in these situations)
7. Improper intake of food.
Causes of insufficient milk supply
• More than half of breastfeeding women believe their milk supply is insufficient
• In fact, less than 5% of women can’t make enough milk to exclusively feed their infants for 6
months
Causes of insufficient milk supply:
• Lack of sufficient stimulation
• Infrequent feeds
• Formula supplementation
• Note: The amount of breast milk you produce may be affected when the mother starts giving your baby
formula. The baby may also stop breastfeeding or breastfeed less after getting used to the bottle; sucking
from a conventional bottle teat that doesn’t require a vacuum to be created is less effort for a baby than
sucking from mum’s nipple, as the milk flows more freely and gravity lends a hand
• Not emptying breast fully
• Note: changing breasts too quickly?
• Rarely, medications, illness, stress, etc.
Note: medications and breast feeding
• Some medications are contraindicated in breastfeeding, and knowing the medications the mother
is on is important. Examples include ciprofloxacin, tetracycline, etc.
• Knowing the half life of the medications is important to know when they can breastfeed. The halflife will determine when the contraindicated medication has left the bloodstream and, by
extension, the milk
• For drugs with a short half-life, such as zolpidem, the risk of side effects can be reduced by
breastfeeding at times when the drug concentration in the mother’s milk is at its lowest level.
This can be achieved by taking the drug immediately after breastfeeding, or immediately before
the infant’s longest sleep period.
• If the woman is recommended to avoid breastfeeding while exposed to a drug, an estimation can
be made of the time interval required before the drug is cleared from the milk or is present only
in insignificant concentrations, so that breastfeeding can be resumed as quickly as possible. After
a period equal to five times the half-life, for practical purposes all of the drug will have been
eliminated from mother’s plasma, and thereby also from her milk. For example, a woman who
uses sumatriptan (with a half-life of approximately 1 – 1.5 hours) against migraine will be able to
breastfeed after 5 – 8 hours.
• If the half life is long, milk expression and storage can be done.
Advice on how to overcome the
breastfeeding problem
• Advise the mother to breastfeed as often and for as long as the infant wants, day
and night
• If not well attached or not suckling effectively, teach correct positioning and
attachment (note: Make the mother breastfeed in front of you to assess position
and attachment)
• Note: Ankyloglossia (commonly known as tongue tie) is a congenital oral anomaly that may
decrease the mobility of the tongue tip and is caused by an unusually short, thick lingual
frenulum. In some, it can restrict the tongue’s movements, making it harder to breastfeed.
• If breastfeeding less than 8 times in 24 hours, advise to increase frequency of
feeding
• If receiving other foods or drinks, counsel mother on exclusive breastfeeding, and
the importance of stopping other foods or drinks
• If thrush, treat and teach the mother to treat for thrush at home
• Follow-up in 2 days
Storing and using expressed breastmilk
Temperature
Duration
Room temperature
Up to 8 hours
Fridge
Up to 6 days
Ice box freezes (-18 °C)
3-6 months
Note: at room temperature, formula can only last 2 hours.
Note: expressed breastmilk
can be given using a teaspoon
or cup. This is to avoid using a
teat [Dr. Lara]
After 2 days follow up
• Ask about any feeding problems found on the initial visit and reassess
feeding
• Counsel the caregiver about any new or continuing feeding problems.
• If you counsel the caregiver to make significant changes in feeding, ask her
to bring the young infant back again after 5 days.
• If the young infant has POOR GROWTH (low weight for age or has poor
weight gain), ask the caregiver to return again after 5 days to measure the
young infant’s weight gain.
• Note: For follow up of growth issues: if younger than 2 weeks, in 2 days, and if older
than 2 weeks, in 7 days [Dr. Lara].
• Continue follow-up until the weight gain is satisfactory.
• If the young infant has lost weight, refer
Advice
Fluid and food:
• Advice the mother to increase fluid and food during illness.
For any sick child:
• Breastfeed more frequently and for longer at each feed.
• Give small frequent meals during illness.
• Add extra meal to the child feeding until complete cure of the child.
For child with diarrhea:
• Increase fluid, for example, give soup, rice water, yogurt drinks or clean
water.
• Giving extra fluid can be lifesaving. Give fluid according to plan A or plan B.
• Continue feeding until diarrhea stopped.
Counsel the mother about her own health
• If the mother is sick, provide care for her, or refer her for help.
• If she has a breast problem, provide care for her, or refer her for
help.
• Advice her to eat well to keep up her own strength and health.
• Check the mother’s immunization status and give her TT if
needed.
• Make sure she has access to
• Family planning (contraception)
• Counseling about STDs
Video