AAP Breastfeeding Guideline

 

AAP Breastfeeding Guideline

• The AAP recommends exclusive breastfeeding for the first 6 months.
• The AAP supports continued breastfeeding along with appropriate complementary foods introduced at about 6 months, as long as mutually desired, for 2 years or beyond.

Benefits of Breastfeeding

• For mothers: bonding, depression, hemorrhage, weight management, reduces breast/ovarian cancer risk, financial benefits.
• For infants: bonding, growth, digestion, immunity, brain development.

Risks of Unnecessary Formula Supplementation

• Decreased breast milk supply: Formula may suppress the mother's milk production.
• Overfeeding, spitting up, excess weight gain: Formula can lead to these issues if not used appropriately.

Formula Supplementation

• Consider formula supplementation if the newborn is experiencing significant weight loss:
  • Low maternal breast milk volume
  • Increased caloric and nutrient needs due to prematurity, congenital heart disease, etc.
• Exclusive formula feeding is indicated for:
  • Certain medical conditions requiring soy formula, like galactosemia
  • Adoption
  • Mother's fully informed decision to solely formula feed

Assessing Feeding Adequacy in Newborns

• Objective: Assess feeding adequacy during the newborn visit.
• Factors to consider:
  • Weight trend since birth
  • Number of feedings per day
  • Hunger and satiety cues
  • Number of stools and wet diapers per day
  • Color and consistency of stools

Normal Weight Loss in Newborns

• Nadir: Typical weight loss of 7-10% in the first few days.
• Weight regain: Birth weight regained by 10-14 days old.
• Subsequent weight gain: Gain 15-30 grams (0.5-1 ounce) per day after regaining birth weight.

Reasons for Newborn Weight Loss

• Diuresis: Newborns excrete excess extracellular fluid to maintain hydration and electrolyte balance.
• Colostrum: Early breast milk is low in water and high in protein, contributing to weight loss.
• Mature breast milk: Fully comes in around 48-72 hours after delivery, later for C-sections due to stress.

Excess Weight Loss in Newborns

• Definition: Loss of more than 10% of birth weight.
• Consequences: Can lead to hypoglycemia, dehydration, hypothermia, jaundice, and lethargy.
• Impact: Can lead to feeding difficulty and further weight loss, creating a downward spiral.

Feeding Frequency and Cues

• Frequency: Newborns should feed 8-12 times per day (every 2-3 hours).
• Duration: 10-15 minutes per breast.
• Wake for feedings: Wake the baby on their own for most feedings.
• Hunger cues: rooting, lip smacking, sucking on hands, crying (late sign).
• Satiety cues: stopping sucking, closing mouth, pulling away, turning head away, falling asleep.

Stools and Wet Diapers

• Normal: 6+ wet diapers and 3+ stools per day.
• Transitional stools: Expected by 3-5 days old, yellow and seedy, indicating bilirubin excretion.

Managing Excess Weight Loss in Breastfed Infants

• Continue breastfeeding: Encourage continued breastfeeding.
• Temporary formula supplementation: Supplement with formula to address weight loss.
• Donor breast milk: Consider donor breast milk from a bank, but it can be challenging to obtain outpatient.
• Lactation consultant: Seek guidance from a certified lactation consultant.
• Weight monitoring: Check weight every 2-3 days until weight loss stops and daily weight gain of 0.5-1 ounce resumes.

Managing Excess Weight Loss in Formula-Fed Infants

• Assess formula preparation: Ensure correct formula preparation to avoid dilution:
  • Ready-to-feed: Do not add water.
  • Concentrate: Add equal parts water and concentrate.
  • Powder: Add 1 level scoop of powder to 2 ounces of water.
• Assess intake volume:
  • Approximately 1 ounce per week of life per feeding for the first four weeks
  • At least 24 ounces per day by the end of the first month
  • Aim for 100 kcal/kg/day (1 ounce of formula = 20 kcal)
• Assess formula access: Consider store brands, which are safe and nutritious; if eligible, sign up for WIC.

Postpartum Depression Screening and Management

• Screening: Administer a validated postpartum depression screening tool at all well visits through 6 months of age.
• Validated screening tools:
  • Edinburgh Postpartum Depression Scale
  • Patient Health Questionnaire-9 (PHQ-9)
• Referral for treatment: Refer mothers who screen positive for treatment.

Social Determinants of Health

• Definition: Social and economic factors that influence health.
• AAP resources: The AAP offers resources for providers.
• Assessment: Ask about:
  • Medical insurance
  • Food security
  • Safe and stable housing
  • Mother's employment
  • Childcare
  • Mother's social support system
  • Domestic violence

Safe Sleep Recommendations

• Key message: Reduce infant deaths from unsafe sleep environments.
• Room sharing: Room sharing for the first 6 months of life.
• Separate sleep surface: No co-sleeping; infant should sleep on a separate surface within the parents' room.
• Sleep surface:
  • Flat surface (not inclined)
  • Firm surface
• Bedding: Avoid soft objects, loose bedding, bumpers.
• Sleep position: Back to sleep, tummy to play.
• Overheating: Avoid overheating the infant.
• Other recommendations:
  • Breastfeeding
  • Vaccination
  • Avoid smoking, alcohol, and drugs
  • Consider a pacifier
  • Commercial cardiorespiratory monitors do not reduce risk of SIDS

Circumcision Care

• Purpose: Elective procedure for most newborns, reducing the risk of urinary tract infections (UTIs) in infancy and penile cancer, HIV, and other sexually transmitted infections (STIs) later in life.
• Postoperative care:
  • Petroleum gauze dressing for 4 hours post-op
  • Petroleum jelly application with each diaper change for 7-10 days until healed
  • Gentle foreskin retraction with each diaper change when healed to prevent adhesions
  • Sponge baths only until healed
• Signs of infection: Sores, yellow crust, purulent discharge, poor healing, and/or fever

Normal Newborn Skin Changes

• Peeling skin: Normal for the first 4-6 weeks; self-resolves; not itchy or painful.
• Erythema toxicum neonatorum: Normal for the first few weeks; self-resolves; not itchy or painful; appears as flea bites on hair-bearing skin surfaces; papules contain eosinophil-rich infiltrate.
• Cradle cap (infant seborrheic dermatitis): Normal between 2 weeks and 12 months of age; self-resolves; not itchy or painful; erythematous papules and scaliness on any skin surface with oil glands; due to the interaction of overactive oil glands and Malessezia furfur* yeast on the skin.

Developmental Dysplasia of the Hip (DDH)

• Definition: Congenital malformation where the femoral head subluxates out of the acetabulum.
• Spectrum of severity: Mild cases may go undetected and not become symptomatic until adulthood.
• Risk factors: Family history, female sex, breech presentation in the third trimester, incorrect swaddling (legs extended).
• Consequences of late detection/treatment: Limp, limb length discrepancy, limited hip abduction, premature osteoarthritis.

Examining for DDH

• Visual assessment: Observe for asymmetric abduction, asymmetric skin folds, asymmetric prominence of the trochanter, and limb length discrepancy.
• Galeazzi sign: Femur on the side with DDH appears shorter, but the femur is not actually shorter.
• Barlow maneuver: Attempts to dislocate the hip.
• Ortolani maneuver: Attempts to relocate the hip.
• Manuever timing: Should not remain positive beyond 6 weeks of age; order imaging if still positive; perform maneuvers at all well visits until the infant is walking.

Diagnosing and Treating DDH

• Imaging: Hip ultrasound between 6 weeks and 4 months of age; Hip X-ray (AP and frog leg views) between 4-6 months of age.
• Referral: If risk factors or positive/inconclusive exam by 6 weeks, refer to Pediatric Orthopedics.
• Treatment:
  • Hip abduction brace
  • Surgical correction for failed brace

Fevers in Infants Under 60 Days Old

• Definition: Rectal temperature ≥ 100.4˚F (≥ 38˚C).
• Rectal temperature: Recommended for infants under 60 days old due to better accuracy.
• Medical emergency: Fever is considered an emergency in infants < 60 days old.
• Reason: Need to rule out serious bacterial infections, such as UTIs, bacteremia, and meningitis.
• Parent guidance: Counsel families to call immediately if their infant develops a fever and to avoid giving Tylenol or fever-reducing medications until a medical assessment is performed.

Car Safety Seat Recommendations

• Importance: Vehicle crashes are a leading cause of death and disability in children.
• AAP recommendation: Use a rear-facing car safety seat until at least 2 years old.
• Rear-facing safety: Protects the cervical spine by absorbing the force of a collision.
• Forward-facing risks: The head is thrown forward, which poses risks to infants and toddlers with large, heavy heads and weak neck muscles.