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Dietary management of young infants who are not adequately breast-fed
I. INTRODUCTION
It is now universally recognized that breast-feeding is by far the best method of nourishing and protecting a young infant. Occasionally, however, difficulties are experienced. This paper suggests guidelines for health workers in the dietary management of infants aged 0 - 6 months who are not breast-fed or who are not being adequately breast-fed. The document particularly addresses this problem within the context of homes where hygienic and economic conditions make formula-feeding hazardous. This paper also suggests ways of preserving lactation during temporary suspension of breast-feeding, and when mothers are employed outside the home. Several appendices are included to provide specific instructions to health workers on the selection and preparation of appropriate milk formulas and staple-based alternatives, as well as helpful auxiliary information. The suggestions are not exhaustive. Further information on the management of lactation can be found in literature referred to in section V.
Infants who are not breast-fed need close monitoring as frequently as possible, preferably by weekly or fortnightly checks.
II. METHODS FOR THE MANAGEMENT OF LACTATION FAILURE IN ORDER OF PRIORITY
A. Re-establishment of lactation
B. Breast-feeding by surrogate
C. Feeding non-human milk or a milk product
D. Feeding a cereal/other staple gruel augmented by milk protein
or other sources of protein
A. Re-establishment of Lactation
In cases where the mother is present and the baby willing to suckle, every effort should be made to establish lactation or to re-establish lactation when it has temporarily ceased. The two following conditions must be fulfilled for this to be successful.
1. The baby must suckle frequently.
a. Put the baby to each breast for about five minutes at least every two or three hours, even if there is a negligible amount of milk.
b. Supplemental feeding (for details see annexes 1 and 2) will be necessary until the mother's milk supply is established. Diluted (50:50) milk should be given after nursing, so that the baby is frequently hungry and hence suckles strongly. This practice should not continue beyond one week. The diluted milk should be given by spoon or appropriate traditional utensil. Otherwise, there is a danger that the baby may develop a preference for a rubber teat through which he can obtain milk more easily than from the breast.
c. Apart from the daily bath no special care for cleaning the nipples is necessary. Soap or alcohol should be avoided as they cause dryness and cracking of the nipples. If the nipples are sore, advises short but frequent suckling periods and apply a thin coating of lanolin, vaseline, or any food oil to the nipples. These products are harmless and do not have to be removed before nursing.
2. The mother must be relaxed and confident that she will produce milk.
In support of this:
a. Establish a sympathetic relationship with the mother (and if necessary, relatives); convey confidence that relactation probably will be successful. Frequent supportive contacts are necessary to overcome doubts.
b. Discover and discuss with the mother the causes of her lactational failure. The most common causes are:i. premature and unnecessary supplemental feeding;
ii. worried, misinformed, tired, or embarrassed mother;
iii. the use of oral contraceptive pills with high oestrogen content.c. If necessary, explain to her the benefits of breast-feeding or appropriate alternatives.
d. Where necessary, use drugs to encourage the "letdown" reflex, e.g.:i. Oxytocin spray, which acts directly on the muscles squeezing the milk into the milk ducts, e.g., Syntocinon nasal spray- one spray (4 units) into one or both nostrils 2 - 3 minutes before nursing.
ii. Chlorpromazine, which stimulates milk production and is also effective in reducing excessive anxiety or tension, e.g., Thorazine or Largactil 10 - 25 mg tablets 2 or 3 times per day for 3 - 10 days, or 25 mg suppository 1 or 2 times per day for 3 - 10 days. If necessary, increase the dose to 50 mg or more (but not exceeding 200 mg/day) after 1 - 2. days until the mother is calm and lactation is initiated. Then reduce the dosage gradually.e. Advise the mother to eat a good quantity of the most nourishing diet the family can afford. The cost of lactation is 500 - 600 kcal per day, or one-third to one quarter more than she normally eats.
f. Treat maternal infections promptly, but continue putting the baby to both breasts.
g. Where traditional harmless methods of inducing or stimulating lactation exist (rituals, foods considered to stimulate milk production, gentle massage, herb infusions, drinking 1 or 2 cups of any liquid after nursing, etc.), allow the mother to use these, provided they are culturally acceptable to her.
If all efforts to establish lactation or secure a surrogate breast-feeder (see section 11 B) fail, the mother will have to feed a formula (annexes 1 and 2). However, if she has any milk at all, she should continue to give the breast for a few minutes before each feeding because (a) this will boost the nutritional value of the infant's diet; (b) it will provide some protection from infections; (c)) it will encourage bonding between mother and child; and (d) the breast-milk may increase if the mother becomes more relaxed.
B. Breast-feeding by Surrogate (Relative or "Wet Nurse")
If the real mother is dead, absent, or unable to breast-feed, every effort should be made to find a relative or family friend who is willing to nurse the baby. Ideally, such a woman should have a genuine affection for the child or a kinship obligation to care for it, be healthy, and be a proven successful lactator. Cultural implications may be associated with surrogate breast-feeding and should be taken into consideration (e.g., the child may have certain "obligations" to the "mother" or acquire the same status as her own children). The capability for breast-feeding may be reestablished in a woman who has had a previous pregnancy by the same procedures as described in section 11 A for the re-establishment of lactation.
Real milk, as opposed to colostrum, should appear after three to five days, but adequate amounts of milk may not be available for three or four weeks. Encouragement and monitoring of such women should, therefore, continue at least for this period. The most important stimulus is frequent suckling by the baby. A woman who is confident that she can lactate will re-establish her milk supply more quickly than a woman who is anxious and doubtful.
The surrogate mother may not produce enough milk.
Therefore, the infant's weight gain should be monitored carefully as early supplementary feeding may be indicated.
C. Feeding Non-human Milk or a Milk Product
If breast-feeding is impossible or very inadequate, the baby has to be fed non-human milk by bottle, special feeding vessel, or spoon. Some source of milk is critical for the first three to four months and, up to six months, some source of animal protein should be fed as frequently as possible. Artifical feeding is a hazardous procedure in poor homes because of the dangers of contamination and over-dilution of the feed. Advice on the choice of milk products, the quantities to be used, and the method of preparation and feeding must be adapted to the economic and hygienic conditions in the home. Specific guidelines for doing this are given in annexes 1, 2, and 3. Formula preparation should be demonstrated and checked ;in the home, if possible) and the child's progress be very closely monitored. The mother herself should be taught how to check the child's weight and report immediately the occurrence of diarrhoea and any deterioration in health. In addition to stressing hygiene, it is wise to instruct the mother on the home management of diarrhoea, with emphasis on early oral rehydration. The mother should also be encouraged to feed the baby herself to promote "bonding." From the age of three months, an increasing proportion of the milk formula may be replaced by mixes of foods as described in annex 3.
D. Feeding a Cereal or Other Staple Gruel Augmented by Milk Protein or Other Sources of Protein
It is very difficult to raise an infant on a non-milk diet in the first three months, and yet in many areas milk other than human milk is not available, or is expensive. The aim must be to feed as good a diet as possible and take all precautions against infection.
When milk is not available, the diet must be based on a local staple. Unsupplemented gruels made from these staples are, however, likely to have (a) low energy-density and high bulk, (b) low protein quality and quantity, and (c) low content of vitamin A and ascorbic acid. Gruels made from legume flours have a higher protein content but can cause considerable abdominal distension.
To make an adequate infant gruel (multimix), the following four components are needed.
1. Basic staple. It should preferably be made from a cereal flour, but if this is not available, from a starchy root, tuber, or plantain. (Note that these, and in particular cassava and sago, are low in all nutrients other than carbohydrates.)
2. Protein-rich supplement. This should be preferably a milk or milk product; otherwise, in order of preference, another animal food product; a mixture of animal or vegetable protein foods; pulses or oil-seeds.
3. Energy supplement. Oil, butter, or sugar will serve.
4. Mineral and vitamin supplement This can be obtained either from fruit juice or boiled, mashed green leaves, low in fibre. Alternatively, multi-vitamin and mineral drops may be fed separately (annex 4).
Some recipes for gruels providing adequate energy and protein are given in annex 3. Although some of these have been used in the treatment of malnourished infants, there are few data on their use in the earliest weeks of life. All the gruels would be improved by including a higher proportion of milk or other animal protein foods, or a mixture of animal and vegetable protein foods. It is up to the local worker to devise the best possible gruel using available resources.
Gruels in these recipes are thick and must be fed by spoon. Feedings should be given at least every four hours, and fresh gruel must be prepared two to three times a day. Consequently, the mother needs plenty of encouragement. In order to monitor progress and minimize the effects of common infections, the infant should be seen and weighed frequently, preferably in his home. Again, the mother should know how to follow her child's progress herself.
The concept of an adequate food combination, preferably as a complement to breast milk (or, if necessary, an alternative milk source) is illustrated below. Some foods that are included among each category in the illustration are provided in annex 3.
III. MAINTENANCE OF LACTATION IN THE TEMPORARY ABSENCE OF SUCKLING
If for any reason the infant is unable to suckle, e.g., during a short illness or separation from the mother, lactation can still be maintained with proper management.
The mother's milk should be expressed five or six times a day; manual expression is preferable, though a suitable breast-milk pump can be used. Overfilling and distension of the breast should be avoided at all costs; when it occurs the milk should be expressed as soon as possible. In some cases a substitute baby may help relieve the mother temporarily and thus maintain lactation. With hygienic precautions, the expressed milk can be given to the baby from an appropriate vessel.
The encouragement and support of the mother in this period is extremely important. To assist in this, her milk should be fed to her child, thus giving her a feeling of contributing to its maintenance or recovery. In the absence of efficient suckling, the volume of breast-milk secreted may diminish despite manual expression. Re-establishment of lactation according to the guidelines given in section 11 A may be necessary.
IV. MANAGEMENT OF LACTATION IN THE WORKING MOTHER
Mothers who must work away from the home during the lactation period often have special logistical problems, and as a result frequently wean early. This should be avoided if at all possible. The health worker should explain the advantages of giving the infant as much breast-milk as possible. This may include taking the infant to the work environment when nursery provisions exist nearby. Where legal provisions exist, such as post-natal leave or breast-feeding breaks, the mother should be made familiar with these.
The mother should be advised to breast-feed often during the night. This is conveniently done when the baby sleeps with her. She should breast-feed the baby just before leaving and just after returning from work, and if possible during a lunch break. The mother should be helped to work out the best way to avoid breast engorgement, either by manual expression or breast pump. Dribbling also can be avoided by use of absorbent pads while she is at work.
Supplementary feedings, when necessary, should be prepared and fed by someone who understands the importance of hygiene. They should not be given near the time when the mother returns from work. Otherwise the baby may not be sufficiently hungry to empty the mother's engorged breasts.
V. FURTHER READING
Cameron, M., and Y. Hofvander, Manual on Feeding Infants and Young Children (PAG, UN 2nd ed., New York, 1976).
de Ville de Goyet, C., J. Seaman and U. Geijer, The Management of Nutritional Emergencies in Large Populations (WHO, Geneva, 1978)
FAO/WHO, "Handbook on Human Nutritional Requirements," (WHO Monogr. 61, Geneva; FAO Nutr. Studies 28, Rome, 1974).
Ghosh, S., "The Feeding and Care of Infants and Young Children" 2nd ea., Voluntary Health Association of India, New Delhi.
Helsing, E., and F. King, Lactation in Practice- How to Help Mothers to Breast-Feed. Manual for health workers (to be published 1981, Oxford University Press, London).
Jelliffe, D.B., Child Nutrition in Developing Countries, (USAID, Washington,1969).
Jelliffe, D.B., and E.F.P. Jelliffe, Human Milk in the Modern World (Oxford University Press,1978)
King, M., F. King, and S. Martodipoero, Primary Health Care (Oxford University Press,1978).
King, M.H., F.M. King, D. Morley, H.J.L. Burgess, and A.P. Burgess, Nutrition For Developing Countries (Oxford University Press, 1972).
Morley, D., Pediatric Priorities in the Developing World (Butter worth, London,1974).
WHO, "Treatment and Prevention of Dehydration in Diarrhoeal Diseases- A Guide for Use at the Primary Level" (WHO, Geneva,1976).
WHO, "Nutrition in Preventive Medicine" (WHO Monogr. 62, Geneva, 1976).
WHO, "A Growth Chart for International Use in Maternal and Child Health Care" (WHO, Geneva,1978).
WHO, "Health Aspects of Food and Nutrition" (3rd ed., WHO Regional Office, Manila, 1972).
ANNEX 1. METHODS FOR FEEDING MILK FORMULAS
It is during the preparation of the formula that the dangers of over-dilution and contamination occur. Therefore, a practical demonstration, first by the health worker and then by the mother, is most important. This should take place in the home. It is in fact extremely difficult to make a hygienic feeding under many home conditions. No method should be advised until it has been tested in a "typical" home using the resources available to the mother.
1.1 Feeding Utensils
The following should be taken into account when recommending choice of feeding utensil:
- Teaspoon: carries least risk of contamination.
- Cup: recommended as soon as infant can drink (4 - 5 months old).
- Special feeding utensil: vessels with a lip or spout can be recommended if they can be properly cleaned. This includes some traditional utensils.
- Bottle: easily contaminated. Should be glass ;not plastic), upright variety and wide-mouthed (to facilitate keeping clean) and clearly marked in millilitres or fluid ounces.
- Teat: easily contaminated. Should be of good quality to withstand boiling. The hole in the teat should allow a steady flow of drops when the bottle is held upside down. If possible, the mother should have several teats and should discard those that are old or cracked.
1.2 Methods for Cleaning Utensils
Recommend the cheapest and most practical method, recognizing that in many circumstances the supply of water may be limited.
1.2.1 Wash all utensils immediately after use in cold water with soap or detergent using a bottle brush, if possible. Scrub teat with salt to remove milk curds. Rinse well.
1.2.2 Sterilize by boiling. Place utensils, including teats, in a pot one-third full of water. Cover. Boil for 5 - 10 minutes. Leave covered until used. If it is not practical to boil after each feeding, boil at least 1 or 2 times a day. Having 2 or 3 bottles and teats cuts down number of boilings.
1.2.3 If regular sterilization is impossible, follow 1.2.1 but use hot water, and rinse in potable water or salt water. Keep utensils covered. Try to persuade the mother to boil each bottle and teat at least once a day.
1.3 Feeding the Formula
- Preferably, the mother or surrogate mother should feed the baby holding him closely to foster the development of their relationship.
- Much patience is needed for spoon-feeding, as the young baby's tongue movements cause milk to drool. Spoons with a longer than normal spout are much better and are traditionally used in some areas.
- A cup can be used from the age of 4 - 5 months.
- When bottle-feeding, make sure the bottle is held so that only milk, and not air, is sucked through the test.
- A baby should not be left alone with a bottle. He can easily choke and he needs the human contact.
- The food can be fed at tepid or at room temperature.
- Feeding should be given "on demand." For the first month or so, the baby may indicate his need for food every 2 - 3 hours. Later, babies are usually statisfied by roughly four-hourly feedings that can be arranged to the mother's convenience. If food is needed during the night, it should be prepared late the previous evening and be kept cool and covered. If not used, it should be discarded in the morning unless refrigerated.
- A few spoonfuls of water, boiled and given by spoon, are needed by formula-fed babies because of the heavy solute load of cow's milk. This should be given after each feeding. Extra water must be given when the weather is very hot, or if the baby has diarrhoea or jaundice.
- Artificially fed babies usually swallow some air and need to be "winded" after feeding by holding the baby upright against the shoulder for a few minutes.
- Each feeding should be given to the child soon after preparation. Unused formula should be covered and kept for no more than 1 or 2 hours before being consumed (unless refrigerated).
