#14: Infant Nutrition: Digestible Pearls with Dr. Joan Meek, MD 

December 9, 2020 | By Justin Berk

Summary

Tie on your bib and get ready for some serious knowledge food about infant nutrition with Dr. Joan Meek! We discuss normal newborn feeding and voiding patterns, the benefits of breastfeeding, and how to counsel families about their options for supplementation. Dr. Meek also tells us about some of the origins of and existing structures driving disparities in breastfeeding. And don’t miss our feeding frenzy rapid-fire questions at the end. You’ll leave this episode like an infant who just finished eating–burping yet satisfied! 

Credits

• Writer and Producer: Edward Corty, MPH
• Infographic: Edward Corty, MPH
• Cover Art: Chris Chiu, MD
• Hosts: Justin Berk, MD and Chris Chiu, MD
• Editor: Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Joan Meek, MD

Time Stamps

• Picks of the Week 8:20
• Newborn Weight & Breastfeeding 10:23
• Newborn Feeding Red Flags 16:30
• Supplementing 20:00
• Benefits of Breastfeeding 22:30
• Disparities in breastfeeding 26:40
• Iron and Vitamin D for Newborns 35:35
• Types of Formula (Hydrolyzed and Soy) 39:20
• Formula Mixing 44:55
• Starting solids in infancy 48:08
• Feeding frenzy rapid fire questions (IDA, water, baby-led weaning, vegan toddlers) 56:13
• Take-Home points 1:01:00

Infant Nutrition Pearls

1. Breastfeeding yields numerous benefits for mom (e.g. decreased risk of diabetes, HTN, breast and ovarian cancer) and baby (e.g. decreased risk of severe diarrhea, otitis media, obesity, lower respiratory tract infections).
2. Some families will make an informed choice to use formula feeding; this decision should not be stigmatized. Instead, build trust through communication and support.
3. Breastfeeding disparities are rooted in systemic racism including the reverberations from wet nursing and continued inadequate access to nutritional support.
4. Try using demonstrations and the teach back method for mixing formula properly. 
5. When making formula with powder, emphasize the importance of putting the water in first, then adding the formula, in order to maintain the proper concentration.
6. Drinking regular cow’s milk before one year of age can cause iron-deficiency anemia.

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Newborn Nutrition

• Try to start the nutrition conversation prenatally! 
• The first visit is important, AAP recommends within 2-3 days of hospital discharge and within 5th day of life 
• Some mild jaundice is expected but not necessarily concerning
• Most babies will lose 8-10% of their initial birth weight–it’s good to emphasize this to the family so they know what to expect
• Sometimes after C-section, mother and baby can be separated which delays feeding past the desired first hour of life
• Immediately postpartum, the newborn should feed every 2-3 hours or approximately 8-12 times every 24 hours
• Also assess stooling and voiding of baby–we should expect 6-8 voids per day and fewer voids can be a concern for dehydration or not receiving enough calories
• Meconium will transition to green, seedy stools when calories are being adequately added
• Greater than 10% weight loss that is not turning around could be concerning, that baby may need supplementation of some sort. If mom has enough milk, expressing and feeding with a syringe or bottle works. If mom does not have enough milk, formula is next best choice

Some benefits of breastfeeding

(McInerny, TK et al.)

• We should not stigmatize parents who have made an informed decision to formula do feeding or combined feeding! We should partner with the family and support them where they are.

Disparities in breastfeeding

• Breastfeeding rates are lower for Black infants compared with White and Hispanic/Latinx infants (CDC)

Historical context: the legacy of slavery

• Enslaved Black women were systematically dehumanized through wet nursing. They were forced to breastfeed the children of slave owners while their own children were fed by cow or goat milk, leaving them susceptible to infection and illness. 
• Research shows that breastfeeding remains a topic viewed with negative attitudes among many Black women  (Johnson et al)

Inequity in access

• Availability of breastfeeding support services may be limited based on where you live 
• The Affordable Care Act said that breast pumps and consultation should be covered by insurance
  • People of color are at a higher risk of being uninsured than White people (KFF)
  • Medicaid is run by states and does not always cover breastfeeding services such as lactation counseling and breast pumps (KFF)

Strategies to oppose disparities

• Diversification of the workforce, from physicians to nurses, to lactation consultants, etc. 
• Multi-level responses are needed for multi-level issues 
• Some non-profit organizations are doing fantastic work to reach out to Black mothers in particular such as Reaching Our Sisters Everywhere (ROSE)

Feeding Supplementation

Formula Types

• Cow’s milk formula (e.g. Enfamil Infant, Similac Advance, Gerber Good Start)
  • Altered to have similar contents to breast milk
  • Most infants will use this type of formula if they are using formula
• Hydrolyzed formula (e.g. Nutramigen, Alimentum, Pregestimil)
  • Useful for babies with allergies to cow’s milk formula (milk protein allergy)
  • Hydrolyzed formula breaks down these proteins 
  • This formula smells and tastes horrible (expert opinion)
• Soy formula (e.g. Enfamil Prosobee, Similac Isomil, Gerber Good Start Soy)
  • Normally do not contain lactose
  • These are useful for babies with classic galactosemia
• “Sensitive” formulas (e.g. Enfamil Gentlease, Similac Sensitive, Good Start Gentle)
  • Certainly more expensive and the product of high amounts of marketing
  • Mostly small differences between standard formulas and these formulas (expert opinion)
  • Try to partner with the patient and work to achieve their goals being cognizant of the high price for very little difference for the infant

Making formula

• Concentrate
  • Mixed 1:1 with water
• Powder
  • Use the scoop that comes with the can
  • Add 2 oz of water first and then add 1 scoop of powder to that water 
  • Economic issues–families try to stretch powder with too much water leading to inadequate calories in for baby
  • Language barriers–labels can be confusing
  • Use the teach back method!

Iron

• Breast fed, healthy term babies with delayed cord clamping should receive iron supplementation at about 4 months
• Once solids are started, baby can get enough iron from iron-rich foods like pureed pork, poultry, eggs, lentils, or beans.
• Formula fed babies do not need extra iron supplementation
• The premature population is different and needs a more individually tailored approach

Vitamin D

• Should be supplemented in exclusively human milk fed infant or those getting less than 1L (34 Oz) of vitamin D fortified formula
  • Usually if the family is doing partial supplementation of breastfeeding they should still get vitamin D supplementation to be safe
• Start at hospital discharge and keep reinforcing this at each visit
• Dose is 400 IU/day

Initiating Solids

• Babies need extra protein, iron, and zinc starting at 6 months
• Consider adding one new food at a time in case of an intolerance
• Just because they turn away peas once doesn’t mean they won’t ever like them–give peas a chance!
• Simply grabbing for food doesn’t necessarily mean baby is ready for solids

Some signs they are ready include:

• Sitting with minimal support
• Strong head and neck control
• Turning the head away when they are done feeding
• Moving a bolus of pureed substance in the mouth and swallowing without choking

Feeding Frenzy! (Extra Pearls)

• Avoid regular cow’s milk before one year of age because it is a poor source of iron and can even cause iron deficiency anemia! (small amounts of cheese or yogurt are okay) (Ziegler, 2011)
• Water is okay for infants after 6 months, and it is a great habit to drink from a cup after one year.
• It is possible to provide proper nutrition for an infant with a vegetarian diet (or ovo vegetarian) diet; for a strict vegan diet, consider counseling with a dietician (and watch out for B12 deficiency)

Other Stuff

Citations.

1. Ziegler EE. Consumption of cow’s milk as a cause of iron deficiency in infants and toddlers. Nutr Rev. 2011 Nov;69 Suppl 1:S37-42. doi: 10.1111/j.1753-4887.2011.00431.x. PMID: 22043881.
2. American Academy of Pediatrics. Breastfeeding the Newborn. In: McInerny TK, Adam HM, Campbell DE, DeWitt TG, Foy JM, Kamat DM, eds. American Academy of Pediatrics Textbook of Pediatric Care. American Academy of Pediatrics; 2017. 
3. Breastfeeding Among U.S. Children Born 2010–2017, CDC National Immunization Survey. 
4. Johnson A, Kirk R, Rosenblum KL, Muzik M. Enhancing breastfeeding rates among African American women: a systematic review of current psychosocial interventions. Breastfeed Med. 2015;10(1):45-62. doi:10.1089/bfm.2014.0023

Links

1. When Breath Becomes Air by Paul Kalanithi
2. Bending the Arc (Netflix)
3. Avatar the Last Airbender (Netflix) 
4. Egg cream as seen on the West Wing (the pick is egg cream, not the show)
5. AAP Physician Breastfeeding Education

Goal

Listeners will learn the basic nutritional needs of an infant and improve their skills in counseling families throughout infancy. 

Learning objectives

After listening to this episode listeners will…  

1. Explain the basic nutritional needs of an infant.
2. Identify the most important time points to assess adequacy of infant nutrition.
3. Describe the major benefits of breastfeeding for the mother and baby.
4. Recognize historical and existing structures driving breastfeeding disparities.
5. Describe strategies to combat health disparities in infant nutrition.
6. Identify the major types of infant formulas and their respective uses.
7. Recognize the major signs that an infant is ready to eat solid foods.

Disclosures

Dr Meek reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Corty EW, Meek JY, Chie C, Berk J. “#14 Digestible Pearls on Infant Nutrition with Joan Meek, MD.” The Cribsiders: Pediatric Podcast. https:/www.thecribsiders.com/14. December 9, 2020.