Do Infants Need to Drink Water?
A Parent Asks
When should I introduce fluids other than breast milk or formula, particularly water, into my infant’s diet?
The Parent Coach Advises
New parents routinely seek the advice of medical professionals regarding newborn feeding. Infant feeding practices vary not only by the age of the infant, but also by region of the world. Cultural and religious practices also influence infant feeding practices. A literature review was conducted to provide the answer to this Parent Coach question.
The Guidelines
In regards to infant nutrition, breastfeeding and human milk are the “normative standards.”1 The American Academy of Pediatrics (AAP) recommends that mothers exclusively breastfeed for 6 months and then continue to breastfeed until 1 year, while introducing other complementary foods into a baby’s diet.1 Complementary feeding is defined as any solids or liquids other than breast milk or formula.2 Similarly, the World Health Organization (WHO) recommends exclusive breastfeeding for 6 months and breastfeeding until 2 years of age.3 The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) also advises exclusive breastfeeding for the first 6 months of life. Complementary feeding practices should not be introduced before 17 weeks of life per the ESPGHAN guidelines.2
Prelacteal Feedings
A prelacteal feed is defined as any liquid or semi-solid food given to an infant before breast milk, usually in the first few days of life, before the onset of lactation.4 Countries around the world practice various prelacteal feeding traditions. In Nepal, popular feeds include formula milk or cow’s milk.5 Mothers in Mansoura, Egypt often give glucose water to their newborns.6 In certain regions of Ethiopia, it is common to give mixtures of water, honey, bananas, and other herbs as a newborn’s first meal, especially in the home delivery setting.7
Commonly cited reasons for prelacteal feeding include cultural practice, mother or mother-in-law’s advice, the idea that prelacteal feeds will clear out meconium and prepare the gut, or the thought that babies need supplemental water to avoid dehydration in hot climates.5,6,8 A positive association exists between cesarean delivery and the use of formula as a prelacteal feed.9 This association may be related to a delay in breastfeeding initiation due to maternal surgery.4 A survey of health care workers by Akuse and Obinya showed that prelacteal feeds may be given due to perception of breast milk insufficiency (nurses) or an effort to prevent hypoglycemia and neonatal jaundice (physicians).10
Prelacteal feeding has been shown to negatively impact breastfeeding in multiple studies. The introduction of prelacteal feeds may interfere with suckling and has been shown to delay the onset of breastfeeding.11 In a retrospective study by Perez-Escamilla and colleagues, prelacteal feeds were found to be a risk factor for poor breastfeeding outcomes. Water prelacteal feeds were negatively associated with exclusive breastfeeding, and formula prelacteal feeds were negatively associated with exclusive breastfeeding and any breastfeeding.12 Infants who were fed traditional supplements of sugar water, camel thorn, and flix weed had reduced duration and frequency of breastfeeding when compared to controls in a study by Boskabadi and Bagheri.13
Protocols and policies are available to healthcare workers in regards to prelacteal feeds, addressing breastmilk insufficiency, infant dehydration, infant hypoglycemia, and neonatal hyperbilirubinemia. The Academy of Breastfeeding Medicine protocols provide guidance for the use of formula in healthy, term, breastfeeding infants. Examples of indications for formula feeds include hypoglycemia unresponsive to frequent breastfeeding, and clinical and laboratory evidence of dehydration.14,15 The American Academy of Pediatrics Hyperbilirubinemia clinical practice guidelines recommend “against routine supplementation of nondehydrated infants with water or dextrose water.” Studies have shown that water supplementation will not prevent hyperbilirubinemia or decrease serum bilirubin levels.16
A number of studies have been conducted to determine whether breastfed babies in hot climates might need supplemental water to prevent dehydration. Results from a study performed in Pakistan revealed that healthy breastfed newborns had no signs of dehydration in environments with temperatures as high as 40°C without additional water in their diets.17 Similar studies have shown no significant difference in urine output, serum osmolality, urine osmolality, weight change, or rectal temperature for infants in tropical climates who are exclusively breastfed vs those who are given supplemental water.18
The Harm of Prelacteal Feeding Practices
Supplemental water is a potential health hazard in newborns.19 Numerous publications document cases of hyponatremia and seizures in babies due to water intoxication.20,21 In a trial comparing newborns who were supplemented with 5% glucose water in the first 3 days of life to those who were exclusively breastfed, the exclusively breastfed group did not show any signs of hypoglycemia.22 Infants who received glucose water supplementation actually lost more weight and stayed in the hospital longer than those who did not receive glucose water.23 It is therefore advisable to discourage use of water or glucose water as a supplement to breastfeeding.
The use of honey as a prelacteal feed should also be discouraged. Honey should not be given to children younger than 1 year due to the risk of infantile botulism associated with honey ingestion.24 Clostridium difficile spores may be found in honey, and once ingested, these spores produce a neurotoxin. Infant botulism can present as poor feeding, hypotonia, and lethargy and may progress to paralysis and respiratory failure.24
Breastfeeding has been shown to provide immunity to infants via transfer of immunoglobulins in the breast milk.25 Breastfeeding has also been shown to reduce deaths from diarrhea and acute respiratory infection.26 A systematic review by Debes and colleagues assessed the impact of time to breastfeeding initiation on infant and neonatal mortality and morbidity. The data supported the protective effect of early breastfeeding initiation on death in the first 28 days of life.27 Additional concerns about prelacteal feeding are that such practices provide a route for exposure to infection by ingesting infectious pathogens.7
Timing of the Addition of Water in the Diet
Per AAP and WHO guidelines, exclusive breastfeeding without supplemental water is adequate for the first 6 months of life.1,3 After the 6-month mark, it is appropriate to give infants small amounts of water as they are learning to use a cup. The AAP recommends that juice, due to its high calorie and sugar content, should not be given until a child is 1 year old, and consumption should not exceed 4 to 6 oz per day. All beverages sweetened by added sugar, including juices and sodas, should be limited due to increased risk of diarrhea, malnutrition, and obesity.28 Babies should not drink juice out of a bottle or before bed, as this increases risk of tooth decay.29 For infants with functional constipation, it is reasonable to add a 100% fruit juice containing sorbitol, such as apple, pear, or prune juice, to the diet. The dose should be adjusted to induce 1 daily bowel movement, and it is reasonable to start around 2 oz per day for infants older than 4 months. Once it is time to start supplemental feeding at 6 months, high fiber multigrain cereals or pureed prunes can be added to help treat constipation.30
The Take-Home Message
Overall, prelacteal feeding is not supported by the literature. Although many places around the world practice prelacteal feeding due to cultural tradition and belief in its benefit, prelacteal feeding practices have the potential to cause more harm than good. Studies have shown that maternal education, antenatal counseling, and support from hospital staff decrease the practice of prelacteal feeding.9 Supplementation with water and glucose water should also be discouraged in infants younger than 6 months.
Alyse Elkins, is a medical student at the West Virginia University School of Medicine in Morgantown, West Virginia.
Emily K. Nease, MD, is an assistant professor of pediatrics at the West Virginia University School of Medicine in Morgantown, West Virginia.
Linda S. Nield, MD—Series Editor, is a professor of pediatrics and medical education at West Virginia University School of Medicine in Morgantown, West Virginia.
REFERENCES
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2. Agostoni C, Decsi T, Fewtrell M, et al; ESPGHAN Committee on Nutrition. Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2008;46(1):99-110.
3. Infant and young child feeding fact sheet: World Health Organization. http://www.who.int/mediacentre/factsheets/fs342/en/. Updated January 2016. Accessed July 25, 2016.
4. Boccolini CS, Pérez-Escamilla R, Giugliani ER, Boccolini P. Inequities in milk-based prelacteal feedings in Latin America and the Caribbean: the role of cesarean section delivery. J Hum Lact. 2015;31(1):89-98.
5. Khanal V, Lee AH, Karkee R, Binns CW. Prevalence and factors associated with prelacteal feeding in Western Nepal. Women Birth. 2016;29(1):12-17.
6. El-Gilany AH, Abdel-Hady DM. Newborn first feed and prelacteal feeds in Mansoura Egypt. Biomed Res Int. 2014;2014:258470.
7. Legesse M, Demena M, Mesfin F, Haile D. Prelacteal feeding practices and associated factors among mothers of children aged less than 24 months in Raya Kobo District, North Eastern Ethiopia: a cross sectional study. Int Breastfeed J. 2014;9(1):189.
8. National Research Council (US) Subcommittee on Nutrition and Diarrheal Diseases Control; National Research Council (US) Subcommittee on Diet, Physical Activity, and Pregnancy Outcome. Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases: Part II: Diet and Activity During Pregnancy and Lactation. Washington, DC: National Academies Press (US); 1992. http://www.ncbi.nlm.nih.gov/books/NBK234763/. Accessed July 25, 2016.
9. Raheem RA, Binns CW, Chih HJ, Sauer K. Determinants of the introduction of prelacteal feeds in the Maldives. Breastfeed Med. 2014;9(9):473-478.
10. Akuse RM, Obinya EA. Why healthcare workers give prelacteal feeds.
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11. World Health Organization. Evidence for the Ten Steps to Successful Breastfeeding. Geneva, Switzerland: World Health Organization;1998.
12. Pérez-Escamilla R, Segura-Millán S, Canahuati J, Allen H. Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras. J. Nutr. 1996;126(11):2765-2773.
13. Boskabadi H, Bagheri S. Comparison between Infants receiving traditional supplements (camel thorn, flix weed, sugar water) and exclusively breast fed infants. Avicenna J Phytomed. 2015;5(6):479-484.
14. Wight NE, Cordes R, Chantry CJ, et al; Academy of Breastfeeding Medicine Protocol Committee. Academy of Breastfeeding Medicine clinical protocol #3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. Breastfeeding Med. 2009;4(3):175-182.
15. Chantry CJ, Howard CR, Lawrence RA, Marinelli KA, Powers NG. Academy of Breastfeeding Medicine clinical protocol #5. Peripartum breastfeeding management for the healthy mother and infant at term. Breastfeeding Med. 2008;3(2):129-132.
16. American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114(1):297-318.
17. Ashraf RN, Jalil F, Aperia A, Lindblad BS. Additional water is not needed for healthy breast-fed babies in a hot climate. Acta Paediatr. 1993;82(12):1007-1011.
18. Sachdev HP, Krishna J, Puri RK, Satyanarayana L, Kumar S. Water supplementation in exclusively breastfed infants during summer in the tropics. Lancet. 1991;337(8747):929-933.
19. Williams HG. ‘And not a drop to drink’—why water is harmful for newborns. Breastfeed Rev. 2006;14(2):5-9.
20. Keating JP, Schears GJ, Dodge PR. Oral water intoxication in infants. An American epidemic. Am J Dis Child. 1991;145(9):985-990.
21. Hansen R. Hyponatremic seizure in a 6-month-old infant due to water intoxication [published online June 22, 2014]. J Paediatr Child Health. doi:10.1111/jpc.12646.
22. Martin-Calama J, Bunuel J, Valero MT, et al. The effect of feeding glucose water to breastfeeding newborns on weight, body temperature, blood glucose, and breastfeeding duration. J Hum Lact. 1997;13(3):209-213.
23. Glover J, Sandilands M. Supplementation of breastfeeding infants and weight loss in hospital. J Hum Lact. 1990;6(4):163-166.
24. Abdulla CO, Ayubi A, Zulfiquer F, Santhanam G, Ahmed MA, Deeb J. Infant botulism following honey ingestion. BMJ Case Rep. 2012;2012.
25. Oddy WH. Breastfeeding protects against illness and infection in infants and children: a review of the evidence. Breastfeed Rev. 2001;9(2):11-18.
26. Arifeen S, Black RE, Antelman G, Baqui A, Caulfield L, Becker S. Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums. Pediatrics. 2001;108(4):E67.
27. Debes AK, Kohli A, Walker N, Edmond K, Mullany LC. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health. 2013;13 suppl 3:S19.
28. American Academy of Pediatrics, Committee on Nutrition. The use and misuse of fruit juice in pediatrics. Pediatrics. 2001;107(5):1210-1213.
29. American Academy of Pediatrics. healthychildren.org. Available at https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Water-Juice.aspx. Updated February 2012. Accessed July 26, 2016.
30. Sood MR. Chronic functional constipation and fecal incontinence in infants and children: treatment. UptoDate. http://www.uptodate.com/contents/chronic-functional-constipation-and-fecal-incontinence-in-infants-and-children-treatment. Updated January 17, 2016. Accessed July 26, 2016.