66 Mount Lucas Road, Princeton, NJ 08540-2733, USA
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Mark B. Levin, M.D., F.A.A.P.
John M. Cotton, M.D., F.A.A.P.
Timothy J. Patrick-Miller, M.D., F.A.A.P.
Louis J. Tesoro, M.D., F.A.A.P.
Helen M. Rose, M.D., F.A.A.P
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Choosing Feedings, Formula Types, Formula Use, Sleeping Patterns, Bowel Movements, Fussiness, Colic, Burping, Gastroesophageal Reflux, Engorgement
We want your infant feeding experience to be successful and enjoyable. The following information is aimed toward achieving that goal. Please feel free to contact us with any questions.
Choosing feedings: Formulas manufactured today are higher in quality than ever before. Their balance of fat, carbohydrate, protein, vitamins and minerals is similar to breast milk. Formula feedings are sometimes preferred by parents who work out of the home or by those who want to supplement nursing so that a father can participate in feedings. For those who prefer to bottle feed because of personal preference or adoption or because illness or prior surgery makes breast-feeding impossible, formula is a nourishing and wholesome substitute. What is most important in making a selection from the various methods of feeding is that the parents are comfortable with their choice. Choosing one type of feeding over another because of pressure from media, friends or relatives will only add stress to an adaptation period that already requires emotional and physical fortitude. If you would like any advice regarding feedings, consult with us.
Types of Formula : Formulas can be divided into three main categories, those manufactured from cow milk, those from soy beans and those that are hydrolyzed or predigested. When there is no family history of allergy or sensitivity to cow milk products, pediatricians usually recommend cow milk-based formulas. These formulas were developed first and have the full complement of amino acids necessary for growth and development. For those infants who cannot tolerate cow milk formula, soy bean formulas offer a completely satisfactory substitute. For the few babies who can tolerate neither cow milk-based nor soy bean-based formulas, specialized formulas are available. The proteins in these more expensive formulas have been broken down into smaller non-allergenic components to enhance tolerance. Like cow milk- and soy-based formulas, these hydrolyzed formulas are very nutritious.
It is a commonly held belief that medicinal iron causes constipation or abdominal pains. Infant formulas contain iron in an ionic form that usually does not cause digestive problems. (In studies in which infants were fed unlabeled formulas, parents were unable to tell whether their baby was receiving iron fortified or low iron formulas.) Since infants who do not receive iron supplementation will outgrow their birth endowment of iron by four to six months of age, and since iron is known to be an important nutrient for optimal mental development as well as for blood production, infants should be fed only iron fortified formula.
Each type of formula is available in three forms. Ready to feed formulas are used directly from the can to a bottle without any preparation other than that described below. The concentrate form is mixed with equal parts of water to arrive at the proper dilution prior to being fed to the infant. The powdered form, which needs no refrigeration until mixed, requires mixing with additional water. All three forms are similar in caloric and nutritional content. Fat emulsifiers are added to the ready to feed and concentrate forms to keep fat in suspension during storage. Also, forms that require added water will differ in content from ready to feed because of the minerals in your water. These differences are usually inconsequential to the baby. Only rarely will a baby have any type of intolerance to a different form of the same formula. If you use a form that requires the addition of water you may either use tap water, provided it is lead-free (houses built after the mid to later 1960s are likely to have lead-free water) or bottled water. You need not sterilize the water or bottles unless you have your own well. Most bottled waters contain no fluoride. Fluoride supplementation is recommended for infants after six months of age. A parent may choose to use a fluoridated water source to mix concentrate or powdered formula or obtain a prescription for fluoride drops from us. An infant does not usually need extra water between feedings. However, your pediatrician may recommend water if your infant has firm bowel movements or the weather is particularly warm.
Formula Use : Once formula is mixed it should be refrigerated until used. It can be left out for up to one and one-half hours before re-refrigerating. If it is out too long, discard it, especially in warmer weather. If there is any formula left from one feeding, it may be refrigerated and reused only for the next feeding. Most babies have little difficulty in taking formula at room temperature or even chilled directly from the refrigerator. If your infant prefers formula warmed, leave it at room temperature for twenty minutes or place the bottle upright in a saucepan of warm water for ten to twenty minutes. Invert the bottle to make sure it is evenly mixed and that there are no hot spots. Shake out a few drops onto the underside of your wrist to test the temperature. We recommend that you never microwave infant formula. Either the bottle could explode or the formula may heat in a spotty fashion and scald the baby's mouth. There are several different types of bottles and nipples available. Despite claims by each manufacturer that their product is best for your infant, the choice should depend on which one the baby seems to like the best. For many babies, it will not matter. It is normal during the first forty-eight hours of life for babies not to eat much, often less than one-half ounce per feeding. Despite this, they often spit up because of mucus that has accumulated in the respiratory and gastrointestinal tracts during gestation. By one week of age, a baby will take two to four ounces per feeding every three to four hours with less regurgitation.
To feed the infant, cradle the baby close to you in a semi-upright position with his or her head in the crook of your elbow. Stroking the central portion of the lower lip with the nipple will often cause the baby to move forward and take the nipple. The more securely the infant's lips are closed around the nipple, the less air the baby will take in. Hold the bottle on a slant so the nipple will be filled with formula throughout the feeding. Avoid the temptation to prop up a bottle and leave your baby during a feeding, even if you have a million things to do or have not slept in a long time. The risk of the infant choking is too great. Some researchers feel this practice might also predispose an infant to ear infections.
Feeding time is an ideal opportunity to bond with your infant. It is a wonderful chance to look into your baby's eyes and try to figure out what is going through his or her brain. It is easy to sense that (s)he is thinking. His or her eyes are open staring at you intently. But what is (s)he thinking? This is one of the fascinating mysteries of life. After many feedings and being up at night, some parents will be tempted to daydream during feeding time. These parents miss the wondrous feeling of communicating with their infant and the opportunity to let their baby learn from them. Talk to your baby. Sing to your baby, even if you do not have a melodic voice! The sensory stimulation will enhance the baby's development. Your enjoyment will rival the baby's benefit!
Sleeping Patterns: Some babies feed often during the day and sleep all night. Most infants, however, will get up once or twice at night for feedings. Occasiona!ly, infants will want to eat through the night and sleep through the day. Given that this style is not much fun for the parents, if your baby displays this pattern, you may want to encourage your baby to try to eat no less than every four hours during the day. Hopefully the baby will be satisfied with your efforts and will sleep more at night. In the case of this reverse pattern, even without intervention, babies will often begin to sleep more at night and eat more often during the day at about two weeks of age, with completion of the change usually by one to three months of age. You can expect your baby to take two to three ounces per pound of body weight per day, divided by the number of feedings the infant wants to take - - usually six to eight. Fill the bottle with about one-half ounce more than the baby usually takes. That way, if the baby wants more, it is there without your having to prepare it. If not, little is wasted. In any case, the baby should be the one who decides when the feeding is over. Trying to encourage a baby to take more in the hope that you will have to offer fewer feedings or that the infant will sleep longer at night may result either in an overweight infant or one with abdominal pains and vomiting.
Bowel Movements: Once the baby passes all the meconium (the sticky greenish-black stool that accumulates in the baby's intestine before birth) by about the third day of life, the baby's bowel movements will vary in color (yellow to green to brown). consistency (watery to soft to formed) and frequency. The frequency, color and consistency are of little importance as long as the baby is eating, sleeping, gaining weight and acting content. Call us if you see any blood in the stool, if the baby is crying frequently or if the baby seems constipated.
Fussiness: If your baby passes gas but seems happy, you need not worry about it. On the other hand, fussing most of the time might indicate a formula problem, a mechanical problem related to swallowing air without burping well, gastroesophageal reflux or constipation. Some infants may have trouble digesting a particular formula because of allergy to the protein in the formula or intolerance to another component, usually the carbohydrate. Symptoms that might indicate intolerance or allergy to a particular formula include fussiness, gas, failure to feed, mucus and/or blood in the stool, loose or watery stool, vomiting, rashes, pallor, respiratory congestion and wheezing. Should any of these signs develop, you should contact us to discuss the symptoms and what to do about them. Changing from one brand of formula in a category to another brand in the same category is unlikely to alleviate any symptoms. If we suspect a problem related to digestion of the baby's formula, we will likely suggest an alternate category of formula in addition to measures intended to comfort the baby. We usually do not choose the more expensive hypoallergenic formulas first because many cow milk intolerant infants will do fine on soy bean-based formula. A night's sleep is worth a lot. But if the same comfort can be accomplished with a less expensive formula, it seems reasonable to try that first. Talk with us about which formula is best for your infant. Children who are intolerant or allergic to a particular component of a formula can usually safely consume foods made from those ingredients by one to three years old after their gastrointestinal tract matures.
Parents sometimes experience difficulty comforting their infant despite the fact that their infant is well nourished and has no medical condition. We call this type of infant "colicky". The term colic means that an infant suffers periods of crying and discomfort for any of several different reasons. In the absence of illness, an infant can be colicky by swallowing air and not burping well, by being allergic or intolerant to a particular component of infant formula, by having gastroesophageal reflux or by having a fussy temperament. Only rarely is any internal anomaly related to this behavior. Being a responsible parent who is unable to quiet or console a colicky baby can be very frustrating. It is not unusual for parents of colicky babies to become angry and depressed. A conversation with us, sometimes supplemented with an examination, can usually pinpoint the cause. We have found that colic drops (simethicone) are only marginally useful. Herbal remedies (chamomile tea, gripe water, etc.) are not helpful if dilute and are potentially dangerous if concentrated.
A reclining position may cause the baby to swallow excessive amounts of air from a nipple that flows too quickly or too slowly. This results in colicky behavior. Trying a different brand or size of nipple and feeding the infant in a more upright or seated posture will usually resolve the problem. Burping a baby can sometimes be challenging. Some babies do everything in their power to retain swallowed air despite their parents' best efforts! But knowing and taking advantage of an infant's anatomy can aid a parent's effort in thwarting this gas retention. The top (fundus) of the stomach lays to the upper left side of the baby's abdomen. The esophageal opening of the stomach, however, is nearer to the center of the abdomen, slightly lower and toward the back. When it is time for a burp, cradle the baby face up with the baby's head toward the left, and slightly tip the infant so that the baby's left shoulder is lower than the buttocks. Pat the baby gently with your underneath hand for a few seconds, thereby floating the air bubble from the fundus up toward the esophageal opening. After a few pats, bring the baby forward to a seated position or put the baby up against your shoulder (with a spit diaper in place to avoid smelling like digested milk!) and pat the baby's back. With this maneuver, more often than not, you will be rewarded with a burp, be it wet or dry, thus avoiding the eventuality of gas stopping at every bend in the baby's gastrointestinal tract and causing hours of colicky pain and lost sleep.
We expect it is Nature's intent that when food is swallowed it should stay in the stomach until the first phase of digestion is completed, then pass in an orderly, comfortable fashion through the lower stomach opening (the pylorus) into the small intestine for further processing. Sometimes the stomach contents, complete with the acid from the stomach, passes up the esophagus, or food pipe, instead, causing pain. We refer to this as gastroesophageal reflux (GER), or, more commonly, heartburn. Having experienced this, most of us can empathize with infants who have this condition. The constant crying of an infant with gastroesophageal reflux can be mistaken for colic. If the usual remedies for colic fail, or symptoms last beyond the first three to four months, GER must be considered. Modes of therapy for GER include dietary changes (some forms of formula intolerance can cause GER), feedings thickened with infant cereals, anti-reflux positioning (elevating the head of the infant's bed about thirty degrees and placing the infant to sleep on his or her abdomen), an antacid and medications that stimulate gastric motility. If GER is a suspected problem, consult us for individualized care.
Finally. there is the fussy baby, the infant who fusses for no apparent reason. Some babies just need to be held more than others. Spontaneously discovered parental behaviors, such as walking the floors or rocking the infant, are timed-honored, successful, short term techniques. Strap-on infant carriers are useful to free your arms while carrying your baby. Some parents use a baby swing or cradle to soothe their infant. These do no harm to a baby's spine and are acceptable for brief periods of time until about four months of age. A warm bath can often settle a fussy baby. Some babies just need to be left alone to fuss for a period of time before they settle down. Sometimes it is difficult to figure out which baby is which. Here again is an area where we can assist. A frank discussion of infants' needs and parenting styles can often lead to a satisfactory resolution.
Engorgement: As a result of the hormonal changes you are undergoing after delivery, your breasts may produce milk and become engorged, especially on postpartum days four through six. The recommended approach to dealing with engorgement includes:
• applying ice to the breasts;
• wearing a supportive brassiere, if you like, but not binding your breasts;
• maintaining normal fluid intake (decreasing fluids may lead to dehydration and will not decrease your engorgement);
• laying on your back to avoid pressure on the breasts;
• taking pain relievers (acetaminophen or ibuprofen are often recommended), if needed;
• calling your obstetrician if you notice your breasts becoming red, shiny or painful in a particular spot or if you develop fever, as this may indicate infection;.
• if you are severely engorged, briefly pumping may be of benefit. We can advise you regarding a pump.
As with other issues, call us about questions regarding infant feeding. We can help you decide what is best for you and your baby.
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