TOPIC 5: Breastfeeding and Formula Feeding in Infants – Understand, evaluate, and manage issues with both breastfeeding and formula feeding in infants
OFFICIAL ABP TOPIC:
Understand, evaluate, and manage issues with both breastfeeding and formula feeding in infants
BACKGROUND
The AAP recommends exclusive breastfeeding for the first 6 months of life, but only 25% of U.S. infants are exclusively breastfed through 6 months. The pediatrician plays an important role in encouraging breastfeeding and helping parents overcome common barriers to breastfeeding. Furthermore, if a family chooses to use formula, pediatricians should be aware of common problems associated with formula feeding.
EVALUATION OF BREASTFEEDING ISSUES
Inadequate milk intake is the most common reason for early termination of breastfeeding. It may be due to insufficient milk production, failure of milk extraction by the infant, or both. A comprehensive history and physical exam should include:
- Feeding history: Infants should typically be breastfeeding at least 8 times a day in the first month of life and seem content after feeding.
- Assessing hydration status and monitoring for signs of dehydration; infants with adequate intake usually urinate at least 6-8 times a day.
- Tracking weight and growth; weight loss >10% or failure to regain birth weight by 2 weeks may indicate inadequate milk intake.
- Examining the infant’s mouth for anatomic issues like ankyloglossia or cleft palate, or infection such as candidiasis.
- Examining the mother’s nipples and breasts for injury, infection, or other abnormalities if breastfeeding is not going well.
- Directly observing breastfeeding technique and latch.
MANAGEMENT OF COMMON BREASTFEEDING ISSUES
INADEQUATE MILK INTAKE
- Optimize breastfeeding technique to achieve proper latch through observation and education by pediatricians, lactation consultants, or educational videos.
- Consider supplementation with expressed breast milk or formula if medically necessary, using alternative feeding methods to bottle-feeding when possible.
- Address any breastfeeding issues such as nipple or breast pain (see below).
NIPPLE PAIN
- Normal nipple sensitivity typically resolves by one week postpartum; severe pain or pain after the first week likely indicates nipple injury.
- Nipple injury is usually due to an improper latch, and improving breastfeeding technique will help prevent further injury.
- Traumatized nipples can be treated with topical bacitracin or mupirocin.
- Apply cool or warm compresses as needed.
- Avoid excessive moisture or irritating cleansers.
- If the mother is unable to tolerate breastfeeding, consider hand expressing or pumping temporarily until nipple injury heals and latch improves.
ANKYLOGLOSSIA
- Most infants with ankyloglossia (tongue tie) can breastfeed without difficulty.
- Consider frenotomy for infants with ankyloglossia who are unable to latch well or having difficulty breastfeeding despite lactation support.
ENGORGEMENT
- Manually express or pump a small amount of milk to soften the areola before feeds.
- Between feeds, use cool compresses and analgesics.
BLOCKED DUCTS
- Promote drainage with frequent feeding in different positions, gentle massage, and supportive bras.
CANDIDIASIS
- For candidal infection of the nipples, treat the mother with topical miconazole or clotrimazole.
- Also, treat the infant with oral nystatin if thrush is present.
OTHER ISSUES
- Bloody nipple discharge in the first days postpartum is common and generally resolves. Beyond one week, evaluate for other causes such as cracked nipples or mastitis.
- Milk overproduction may cause the infant to have difficulty feeding and paradoxical poor weight gain. Manage with upright nursing positions, one-sided block feedings, and cold compresses.
- Dysphoric milk ejection reflex is an uncommon condition of temporary negative emotions with milk let-down. Support and reassurance are therapeutic.
- Neonatal jaundice: Distinguish between breastfeeding failure jaundice caused by inadequate milk intake and benign breast milk jaundice, which typically resolves on its own within the first few months of life. If milk intake is inadequate, optimize breastfeeding and monitor bilirubin levels and weight as needed.
FORMULA FEEDING ISSUES
ANTICIPATORY GUIDANCE FOR FORMULA FEEDING
Providing guidance and education to families can help prevent common issues associated with formula feeding:
- Most U.S. formulas contain iron, and iron-fortified formulas are recommended to prevent anemia.
- Read instructions carefully to prepare powdered formula correctly with the right ratio of water to formula.
- Avoid bottle propping, which can increase the risk of choking, ear infections, and cavities.
- Avoid putting babies to bed with a bottle, which can cause tooth decay.
- Do not use illegally imported formulas, homemade formula, or toddler formula for infants.
CHOOSING A FORMULA FOR INFANTS AT HIGH RISK FOR ALLERGY
An infant is at high risk for allergic disease if there is at least one first-degree relative with a documented allergic condition (atopic dermatitis, asthma, allergic rhinitis, or food allergy). There is a lack of consistent evidence that using hydrolyzed formulas reduces the risk of allergic disease in high-risk infants compared to cow’s milk formulas. Breastfeeding remains the optimal choice, regardless of atopic risk. When breastfeeding is not possible, use this approach to select formula for high-risk infants:
- Use a cow’s milk formula.
- If there are symptoms of possible allergy, change to an extensively hydrolyzed formula.
- If symptoms persist, change to an amino acid-based formula.
- If symptoms persist, reevaluate the diagnosis.
ALLERGIC PROCTOCOLITIS
Allergic proctocolitis is a common cause of rectal bleeding in infants in the first few months of life.
- Diagnosis:
- Mucus-streaked and bloody stools.
- Otherwise well-appearing.
- Commonly triggered by cow’s milk or soy proteins in breast milk or formula.
- Additional testing (e.g., stool tests, blood tests, endoscopy) is rarely needed unless there are atypical features or inadequate response to treatment.
- Management:
- Switch to an extensively hydrolyzed formula (or eliminate triggering food proteins from the maternal diet if breastfeeding).
- Expect resolution by 1 year in most cases.
- Reintroduce cow’s milk to the infant’s diet at 12 months old (or earlier in small quantities). For high-risk infants, an allergist may guide reintroduction.
- Avoid soy formulas due to high co-reactivity rates with cow’s milk.
REFERENCES
https://www.uptodate.com/contents/breastfeeding-parental-education-and-support
https://www.uptodate.com/contents/introducing-formula-to-infants-at-risk-for-allergic-disease
https://www.uptodate.com/contents/common-problems-of-breastfeeding-and-weaning
https://www.uptodate.com/contents/food-protein-induced-allergic-proctocolitis-of-infancy