3. Infant Feeding

Infant Feeding

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

The World Health Organization (WHO) recommends that "All mothers should have access to skilled support to initiate and sustain exclusive breast-feeding for 6 months and ensure the timely introduction of adequate and safe complementary foods with continued breast-feeding up to two years or beyond."[1]

Infants require milk in their diet for the first 12 months. It forms the bulk of their calories until weaning is introduced at 6 months. The most recent national survey shows a breast-feeding initiation rate in the UK of 76% in 2005.[2] The rates for the four countries of the UK were 78% in England, 70% in Scotland, 67% in Wales and 63% in Northern Ireland. It showed a significant increase in the number of mothers who start off breast-feeding between 2000 and 2005. This has been the trend since 1990. The highest incidence of breast-feeding was found among:

  • Mothers with managerial and professional occupations.
  • Those with the highest educational levels.
  • Those aged 30 or over.
  • First time mothers.

These patterns are seen in all countries, and are consistent with previous surveys.

Breast milk is free and available without preparation. There is no need to buy a steriliser, bottles or formula milk.

Breast-feeding in public can be socially taboo. There is an initiative from UNICEF/WHO to (amongst other targets) increase public awareness and encourage certain environments to be more welcoming to breast-feeding mothers, eg surgery waiting rooms, restaurants.[3]

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Child

  • Immunity/infection protection: infants who are breast-fed have been reported to have lower rates of otitis media and lower respiratory tract infections.[4] Also, fewer episodes of gastroenteritis.
  • It protects against constipation: bottle-fed babies have more problems with constipation, than their breast-fed counterparts.[5]
  • Atopy: exclusive breast-feeding for 4 months has been shown to reduce the risk of asthma and eczema at the age of 4 years.[6][7] 3 months or more of partial breast-feeding seems to offer some protection. The effects tend to be stronger in children without a family history of allergy.
  • Sudden infant death syndrome (SIDS): outcomes from studies of variable quality have shown breast-feeding to be protective against SIDS.[8] Analysis showed that bottle-fed infants are twice as likely to die from SIDS.
  • IQ: studies have shown that breast-feeding for longer than 4 months has a positive effect on the child's mental development at 24 months of age.[9] Parental intelligence also appears to influence cognitive development.
  • Obesity: in a population of low-income children, breast-feeding was associated with a reduced risk of obesity at age 4 years.[10] This effect was seen only among white children, whose mothers did not smoke in pregnancy and only when breast-feeding continued for at least 16 weeks without formula, or at least 26 weeks with formula.

Mother

  • Breast cancer: the longer women breast-feed, the more protected they are against breast cancer.[11] The lack of (or short lifetime duration of) breast-feeding, typical with women in developed countries, makes a significant contribution to the high incidence of breast cancer in these countries.
  • Contraception: the Lactation Amenorrhoea method has been shown to be 98% effective[12] if:
    • Child is up to 6 months old
    • Mother is amenorrhoeic
    • Child is exclusively breast-fed

Vitamin D[13]

  • Breast milk is low in vitamin D. Vitamin D supplements are recommended for all pregnant women, breast-feeding women and breast-fed babies. All breast-fed babies should receive vitamin drops (Abidec® or Dalivit®).
  • The advice is particularly important for those mothers at high risk of vitamin D deficiency (including those who have limited skin exposure to sunlight, or who are of South Asian, African, Caribbean or Middle Eastern descent, or who are obese) and their babies.

Transmission of human immunodeficiency virus (HIV)

  • The rate of mother-to-child transmission of HIV (in the absence of preventative interventions) is about 15-25% among HIV-infected women who do not breast-feed and 25-45% among HIV-infected women who do.[14][15]
  • The risk of transmission can be greatly reduced by:
    • Antiretroviral treatment (for the mother and the infant).
    • Delivery by Caesarean section.
    • Avoiding breast-feeding.
    When used in combination, these interventions can reduce the risk of mother-to-child HIV transmission to below 2%.[16]
  • The risk of transmission of HIV from an infected mother to her infant (through breast-feeding) is greater if she becomes infected during the breast-feeding period, compared with mothers who were already infected. Therefore, it is important that uninfected women (who are considered at risk of exposure to HIV) should be offered appropriate advice and support to help reduce their risk of becoming HIV-infected while breast-feeding.[17]

If a woman will be moving to somewhere where safe infant formula milk feeding is unavailable, breast-feeding may be the safer option.

Hepatitis B and hepatitis C

  • If there is appropriate immunoprophylaxis, including hepatitis B immune globulin and hepatitis B vaccine, breast-feeding babies from chronic hepatitis B virus (HBV) carrier mothers poses no additional risk for the transmission of HBV.[18]
  • Breast-feeding does not seem to influence the rate of vertical transmission of hepatitis C (approx 5%).[19]

Other Infections

  • Certain bacterial infections in the mother may be transmitted through breast milk, and temporarily stopping breast-feeding may be appropriate for a limited time: 24 hours for Neisseria gonorrhoeae, Haemophilus influenzae, group B streptococci and staphylococci and longer for others, for example Borrelia burgdorferi, Treponema pallidum, and Mycobacterium tuberculosis.
  • Most antituberculosis drugs appear to be safe for use with breast-feeding.[20]
  • In certain situations, prophylactic therapy may be advisable for the infant eg T. pallidum, M. tuberculosis and H. influenzae.[21]
  • Decisions about stopping breast milk because of infection should balance the potential risk with the huge benefits of breast milk.

Mastitis/abscess

  • Breast infections are usually caused by Staphylococcus aureus, which has entered through a cracked nipple. The infection takes place in the parenchymal (fatty) tissue of the breast and causes swelling which pushes on the milk ducts. This results in pain and swelling.
  • Treatment may include applying moist heat to the infected breast tissue for 15 to 20 minutes four times a day. Antibiotics can be given, egflucloxacillin 250 mg qds. Breast-feeding (or pumping to relieve breast engorgement) should continue while receiving treatment.

Cracked/ sore nipples

Nipple soreness is very common during the first weeks of breast-feeding. Some breast-feeding mothers describe nipple soreness as a pinching, itching, or burning sensation. It may be caused by:

  • Improper position of the baby; using different feeding positions may help to reduce soreness.[22]
  • Improper feeding techniques; nipple soreness may be caused by incomplete suction release at the end of baby's feeding. Gently inserting a finger into the side of the mouth to break the suction may help. It can also be caused by the baby chewing or biting on the nipples.
  • Improper nipple care; excessively dry (or excessively moist) skin can cause nipple soreness. Moisture can be caused by bras made of synthetic fabrics. Ointments containing lanolin may be helpful. Olive oil and expressed milk are also effective for soothing uncomfortable nipples.

Thrush and breast-feeding/ductal candidiasis

  • There is an increasing vogue to treat fungal infections of the breast. This is recognised by deep breast pain after breast-feeding, often in both breasts and associated with cracked nipples that won't heal.
  • Culture of the fungus is difficult - it is essentially a clinical diagnosis.
  • The nipple can be treated with miconazole cream after feeds (not licensed under 4 months). Oral fluconazole for the mother is not licensed; however, it does have a paediatric licence for higher doses than the baby would get by transmission through breast-feeding.

Note: commonly used dosing schedules and further information can be obtained from www.breastfeedingnetwork.co.uk

Breast engorgement

  • This is caused by congestion of the blood vessels in the breast. The breasts feel swollen, hard and painful. The nipples cannot protrude to allow the baby to 'latch on' and feeding becomes difficult.
  • Advise to nurse 8 times or more in 24 hours, for at least 15 minutes for each feed, to prevent engorgement. To relieve it, express milk manually or with a pump. Alternate warm showers followed by cold compresses help to relieve the discomfort.

Insufficient milk/hungry baby

  • Frequent feedings, adequate rest, good nutrition and adequate fluid intake can help maintain a good milk supply.
  • Checking weight and growth will determine whether the baby is taking enough milk.

Note: colostrum is nutrient-rich and babies do not need to eat much in the first hours and days of life.

Professional support for mothers has been shown to prolong the time they breast-feed their children.[23]

  • Keep baby skin-to-skin.
  • Watch for early feeding cues, eg turning the head and 'rooting'.
  • Offer feed within the first hour after birth.
  • Mums should sleep in the same room as the baby and be together as much as possible.
  • Don't limit the baby's time at the breast.
  • Let the baby finish the first breast, before offering the other.
  • Learn how to position the baby to 'latch on' well.
  • Well infants aged >34 weeks are usually able to co-ordinate sucking, swallowing and breathing. They can usually establish breast- or bottle-feeding.
  • Extremely preterm babies, or those expected to have a prolonged stay in neonatal intensive care, may require total parenteral nutrition.
  • Preterm human breast milk, compared with artificial formula milk, may not provide sufficient nutrition for preterm or low birthweight infants.[24]
  • However, human milk may have advantages in terms of decreased incidence of adverse gastrointestinal (necrotising enterocolitis) and neurodevelopmental outcomes:
    • There is little good quality research on this.[25]
    • Multinutrient fortifiers can be added to human milk.
    • Fortification with calcium and phosphate may improve bone mineral content. Protein and energy supplementation of human milk increases the rate of weight gain and head growth, at least in the short-term.[26][27]
  • Despite the benefits, the incidence and duration of breast-feeding preterm infants is less than that of full-term infants. The lower incidence is probably related to challenges that preterm infants and parents face, including establishing and maintaining a milk supply and changing from gavage (tube) feeding to breast-feeding.[28]

The most common reasons reported for ceasing milk expression are:

  • Low milk supply.
  • Returning to work.
  • Inability to pump as often as needed.

Mothers report that pumping is worth the effort.[29]

There have been case reports suggesting that children born to women with silicone breast implants may have an increased risk of rheumatic disease and/or oesophageal disorders. Subsequent analyses of outcomes among children born after a mother's implant surgery were not significantly higher than among children born before a mother's implant surgery.[30][31]

Mothers who have had surgery may have problems providing adequate milk, especially where babies are preterm.[32][33] Preoperative counselling and informed consent is necessary if the mother wishes to provide breast milk for her baby.

Infant formula is the only alternative to breast milk. It is available ready-made in cartons (expensive, but handy for days out or holidays) or as powder to be made up as directed.

Cow's milk is not suitable until a baby is a year old, because it contains too much salt and protein, but insufficient iron. Cow's milk infant formulas are the alternative to breast milk, and should be given until the baby is at least a year old. Follow-on milks can be given from six months old, but this isn't necessary.

  • Hydrolysed protein infant formulas can be prescribed if the baby has an allergy to cow's milk.
  • Soya-based infant formulas can also be used, but babies who are allergic to cow's milk may also be allergic to soya.
  • Goat's milk infant formulas are not suitable for babies, and are not approved for use in Europe.

When starting solid foods, mix a teaspoon of one of the following with your baby's usual milk (breast or formula):

  • Smooth vegetable purées, eg carrot, parsnip, potato.
  • Fruit purée, eg banana, cooked apple, pear or mango.
  • Cereal (not wheat-based), eg baby rice, sago, maize, cornmeal or millet.

This should be offered before or after one of the usual milk feeds, or in the middle of a feed, if that works better. If the food is hot, it should be stirred, cooled and tested before being offered. Most babies take time to learn how to take food from a spoon.

Avoid giving:

  • Salt: babies aged up to 6 months should have less than 1 g salt a day. From age 7 months to a year they should have a maximum of 1 g salt a day. Don't add salt to any food. Limit foods that are high in salt, eg cheese, bacon and sausages. Processed foods that aren't made specifically for babies (eg pasta sauces and breakfast cereals) can be high in salt.
  • Sugar: avoid adding sugar. Sugar could encourage a sweet tooth and lead to tooth decay when your baby's first teeth start to come through. Stewed sour fruit, eg rhubarb, can be sweetened with mashed banana, breast milk or formula milk.
  • Honey: this should not be given until the baby is one year old. Honey can (rarely) cause infant botulism.[34]

Until 2006 growth charts were based on children with mixed feeding patterns, predominantly bottle-fed; however evidence from various studies has suggested that exclusively breast-fed infants gained weight differently:[22]

  • The worry has been that misinterpretation of growth charts could lead to breast-fed babies being given unnecessary supplements of formula.
  • This has led the WHO to develop new charts, which the Department of Health has recommended be adopted for all children from the age of 2 weeks to 2 years.
  • Adopting these new charts means that fewer infants are defined as underweight, whereas the proportion who are overweight is increased.[35]
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Further reading & references

  1. Child and Adolescent Health and Development, Global Strategy for Infant and Young Child Feeding, World Health Organization, 2004
  2. Infant Feeding Survey 2005: Early Results, NHS, May 2006
  3. UNICEF; The Baby Friendly Initiative; Advice for both breast and bottle feeders and leaflets in many languages. Not just for 3rd world.
  4. Gulick EE, Johnson S; Infant health of mothers with multiple sclerosis. West J Nurs Res. 2004 Oct;26(6):632-49.
  5. Quinlan PT, Lockton S, Irwin J, et al; The relationship between stool hardness and stool composition in breast- and formula-fed infants. J Pediatr Gastroenterol Nutr. 1995 Jan;20(1):81-90.
  6. Kull I, Almqvist C, Lilja G, et al; Breast-feeding reduces the risk of asthma during the first 4 years of life. J Allergy Clin Immunol. 2004 Oct;114(4):755-60.
  7. Kull I, Bohme M, Wahlgren CF, et al; Breast-feeding reduces the risk for childhood eczema. J Allergy Clin Immunol. 2005 Sep;116(3):657-61.
  8. McVea KL, Turner PD, Peppler DK; The role of breastfeeding in sudden infant death syndrome. J Hum Lact. 2000 Feb;16(1):13-20.
  9. Gomez-Sanchiz M, Canete R, Rodero I, et al; Influence of breast-feeding and parental intelligence on cognitive development in the 24-month-old child. Clin Pediatr (Phila). 2004 Oct;43(8):753-61.
  10. Bogen DL, Hanusa BH, Whitaker RC; The effect of breast-feeding with and without formula use on the risk of obesity at 4 years of age. Obes Res. 2004 Sep;12(9):1527-35.
  11. No authors listed; Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet. 2002 Jul 20;360(9328):187-95.
  12. Kennedy KI, Visness CM; Contraceptive efficacy of lactational amenorrhoea. Lancet. 1992 Jan 25;339(8787):227-30.
  13. Maternal and child nutrition - Guidance for midwives, health visitors, pharmacists and other primary care services to improve the nutrition of pregnant and breastfeeding mothers and children in low income households; NICE Public Health Programme Guidance (March 2008)
  14. Thorne C, Newell ML; Prevention of mother-to-child transmission of HIV infection. Curr Opin Infect Dis. 2004 Jun;17(3):247-52.
  15. No authors listed; Rates of mother-to-child transmission of HIV-1 in Africa, America, and Europe: results from 13 perinatal studies. The Working Group on Mother-To-Child Transmission of HIV. J Acquir Immune Defic Syndr Hum Retrovirol. 1995 Apr 15;8(5):506-10.
  16. No authors listed; HIV-infected pregnant women and vertical transmission in Europe since 1986. European collaborative study. AIDS. 2001 Apr 13;15(6):761-70.
  17. HIV and infant feeding: Guidance from the UK Chief Medical Officer's Expert Advisory Group on AIDS, Dept of Health, September 2004
  18. Hill JB, Sheffield JS, Kim MJ, et al; Risk of hepatitis B transmission in breast-fed infants of chronic hepatitis B carriers. Obstet Gynecol. 2002 Jun;99(6):1049-52.
  19. Resti M; Mother-to-infant transmission of hepatitis C virus. Ital J Gastroenterol Hepatol. 1999 Aug-Sep;31(6):489-93.
  20. Tran JH, Montakantikul P; The safety of antituberculosis medications during breastfeeding. J Hum Lact. 1998 Dec;14(4):337-40.
  21. Lawrence RM, Lawrence RA; Breast milk and infection. Clin Perinatol. 2004 Sep;31(3):501-28.
  22. Hoddinott P, Tappin D, Wright C; Breast feeding. BMJ. 2008 Apr 19;336(7649):881-7.
  23. Britton C, McCormick FM, Renfrew MJ, et al; Support for breastfeeding mothers. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001141.
  24. Boyd CA, Quigley MA, Brocklehurst P; Donor breast milk versus infant formula for preterm infants: systematic review Arch Dis Child Fetal Neonatal Ed. 2007 May;92(3):F169-75. Epub 2006 Mar 23.
  25. McGuire W, Anthony MY; Formula milk versus preterm human milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2001;(3):CD002972.
  26. McGuire W, Henderson G, Fowlie PW. Feeding the preterm infant. BMJ, November 2004
  27. Premji SS, Fenton TR, Sauve RS; Higher versus lower protein intake in formula-fed low birth weight infants. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003959.
  28. Callen J, Pinelli J; A review of the literature examining the benefits and challenges, incidence and duration, and barriers to breastfeeding in preterm infants. Adv Neonatal Care. 2005 Apr;5(2):72-88; quiz 89-92.
  29. Sisk PM, Lovelady CA, Dillard RG, et al; Lactation counseling for mothers of very low birth weight infants: effect on maternal anxiety and infant intake of human milk. Pediatrics. 2006 Jan;117(1):e67-75.
  30. Kjoller K, Friis S, Signorello LB, et al; Health outcomes in offspring of Danish mothers with cosmetic breast implants. Ann Plast Surg. 2002 Mar;48(3):238-45.
  31. Signorello LB, Fryzek JP, Blot WJ, et al; Offspring health risk after cosmetic breast implantation in Sweden. Ann Plast Surg. 2001 Mar;46(3):279-86.
  32. Hill PD, Wilhelm PA, Aldag JC, et al; Breast augmentation & lactation outcome: a case report. MCN Am J Matern Child Nurs. 2004 Jul-Aug;29(4):238-42.
  33. Brown SL, Todd JF, Cope JU, et al; Breast implant surveillance reports to the U.S. Food and Drug Administration: maternal-child health problems. J Long Term Eff Med Implants. 2006;16(4):281-90.
  34. Cox N, Hinkle R; Infant botulism. Am Fam Physician. 2002 Apr 1;65(7):1388-92.
  35. Wright C, Lakshman R, Emmett P, et al; Implications of adopting the WHO 2006 Child Growth Standard in the UK: two prospective cohort studies. Arch Dis Child. 2007 Oct 1;.
Original Author: Dr Hayley Willacy Current Version:
Last Checked: 21/01/2011 Document ID: 2313  Version: 24 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.