Formula Formula Feeding of Feeding of

InfantsInfants

Formula Formula Feeding of Feeding of

InfantsInfants

There is an agreement among healthcare professionals, infant food manufacturers and mothers that breastfeeding is the best choice for feeding infants during their first four to six months of life

There are several reasons There are several reasons why a mother may not why a mother may not breastfeed her baby:breastfeed her baby: 1. Medical or other health reasons

may prevent a mother from breastfeeding.

2. The baby with special requirements may not tolerate breast milk.

3. Some social or psychological reasons can make it more difficult to breastfeed exclusively.

The absolute The absolute contraindications to contraindications to

breast-feedingbreast-feeding

1. Hypergalactosaemia. 2. Phenylketonuria [PKU].3. Lactose intolerance.

Medical contraindications Medical contraindications to breast-feeding to breast-feeding

connected with motherconnected with mother1. Decompensated chronic diseases like

blood circulation insufficiency, kidney or liver problems, respiratory insufficiency of III grade, HIV-infection, etc.

2. Psychical disorders as epilepsy, schizophrenia, depressive phychosis, postpartum psychosis.

3. Taking certain medications (See tables 1, 2).

4.4. SubstSubstance-abuse (drugs, alcohol, marijuana, cocainecocaine, heroin, ets)(See table 3).

Table 1. Drugs that are Table 1. Drugs that are contraindicated during breast-feedingcontraindicated during breast-feeding

No. Drug Reported sign or symptom in infant

or effect on lactation

1. Bromocriptine Supresses lactation

2. Cocaine Cocaine intoxication

3.Cyclophos-phamide

Possible immune supression; unknown effect on growth or association with carcinogenesis; neutropenia

4. Cyclosporine

Possible immune supression; unknown effect on growth or association with carcinogenesis

5. Doxopubicin Possible immune supression; unknown unknown effect on growth or association with with carcinogenesis

6. Ergotamine Vomiting, diarrhea, convulsions (doseses used in migraine medication)

7. Lithium ⅓ to ½ therapeutic blood concentration in infants

8.Methotrexate

Possible immune supression; unknown effect on growth or association with carcinogenesis; neutropenia

9.Phencyclidine (PCP)

Potent hallucinogen

10.10. Phenindione Phenindione Anticoagulant; increased prothrombin and nd partial thromboplastin time in infant

Table 2. Table 2. Drugs that have caused Drugs that have caused significant effects on some nursing significant effects on some nursing

infants and should be given to infants and should be given to nursing mothers with cautionnursing mothers with caution

No. DrugReported sign or symptom in infant or

effect on lactation

1.Aspirin (salicylates)

Metabolic acidosis (dose related); may affect platelet function; hemorrhagic rashrash

2. Clemastine Drowsiness, irritability, refusal to feed,feed, high-pitched cry, neck stiffness

3.Phenolbarbitol

Sedation; infantile spasms after weaning weaning from milk containing phenolbarbitol, methemoglobinemia

4.4. PrimidonePrimidone Sedation; feeding problems

5.5. SulfasalazineSulfasalazine Bloody diarrhea

Table 3. Drugs of abuse that areare contraindicated

during breast-feedingdingNo. Drug

Reported sign or symptom in infant or effect on lactation

1.

Amphetamine

Irritability, poor sleep pattern

2.

Cocaine Cocaine intoxication

3.

Heroin Irritability, Heroin intoxication

4.

Nicotine (smoking)

Shock, vomiting, diarrhea, rapidid heart rate, restlessness; decreased milk production

55..

PhencyclidinPhencyclidinee

Potent hallucinogen

Other reasons why a Other reasons why a mother may not mother may not breastfeed her baby:breastfeed her baby:• Working outside the home makes it

more difficult to breastfeed exclusively, especially if there is no support at her workplace for her to either bring her baby or to express and store her milk.

• Choosing not to breastfeed for personal reasons, either from the birth of the baby or after breastfeeding for a short while, is a mother's prerogative.

Recommendations for Working Women:

• The mother who goes back to work can usually continue breast-feeding without problems. The milk supply adjusts itself to the demand. If the mother is working at least 8 hours a day, it is sometimes prudent to pump the breasts once during her work day in order to stay comfortable and maintain a good milk supply. Each woman is different in what is required to maintain a supply. Some women can work for a long time without pumping and without compromising the supply. Others have a supplya supply that is more responsive to decreased feeds.feeds. A woman will rarely “dry up” becayse she hasshe has returned to work.

• Working mothersWorking mothers, however, can easily breast-breast-feed part-time andfeed part-time and formula-feed part-time.

Breast pumps and storage of milk

• Hand expression is superior if the mother can learn the technique.

• Several pumps are available if the mother is unable to express by hand.

• It is good if the woman can borrow a pump from a friend before she decides which pump to purchase. Another alternative is to rent an electric pump.

• Milk should be stored in clean containers andand immediately refrigerated or frozen. – If refrigerated, it will stay good for 48 hours. – If frozen at 0°F, it wiil keep for months.

Recommendations for mother’s diet:

• To drink approximately 64 oz of fluids per day.

• The nursing mother requires an additional 500 calories and 20-30 g of protein a day.

• She has to take her prenatal vitamins with iron.

• The mother need not to avoid certain foods unless she observes consistent increased fussfussiness in the baby in association with the mother ingestion such foods.

Foods commonly Foods commonly incriminated:incriminated:

• Garlic• Onions• Cabbage• Chocolate• Great quantities of caffeine.Nursing mother may drink small amounts

of alcohol: a glass of sherry or wine may be beneficial in late afternoon if she is having let-down reflex problems.

Common problems encountered with brest-

feeding• Poor Let-Down (Milk ejection

reflex)• Poor Weight Gain• Mastitis• Cracked Nipples• Jaundice From Breast- Feeding

Artificial feedingArtificial feeding

• This is the feeding of infant when he gets cow’s or buffalo’s milk or formula from first days till 4th to 6th month of his life.

• Formula milks are humanized, i.e., they come very close to the composition of breast milk.

• However, they are more expensive, so cow’s or buffalo’s milk are quite often used.

Composition of cow’s milk versus breast milk.

(in 100 ml)

Human milkHuman milk Cow’s milkCow’s milk

Calories 67 67

Water 87 % 87 %

Carbohydrate 7.4 % 4.4 %

Lactose Lactose isomerisomer

β-lactose α-lactose

FatFat 3.5 %3.5 % 3.5 %3.5 %

Human milkHuman milk Cow’s milkCow’s milk

Protein 1.5 % 3.5 %

Lactalbumin:Casein ratio

60 : 40 20 : 80

SodiumSodium 15 mg60 mg

(4 times)

Phosphorus Phosphorus 15 mg90 mg

(6 times)

Calcium Calcium 30 mg120 mg (4 times)

Iron Iron 0.5 mg 0.1 mg

Other advantages of breast milk versus cow’s

milk:• Breast milk is available all the time and is

practically free from pathogenic bacteria.• It needs no time for preparation• It is available at the optimum temperature.• It contains antibodies as IgG and IgA and and

protects against certain infections such as protects against certain infections such as E.ColiE.Coli, cholera, polio, tetanus, measles etc. , cholera, polio, tetanus, measles etc. IgA antibodies prevent the microorganisms IgA antibodies prevent the microorganisms to adhere the intestinal mucosa and to adhere the intestinal mucosa and provide local GIT immunity.provide local GIT immunity.

• β-lactose is called Bifidus factor, which promotes the growth of lactobacillus and helps to lower the gut pH, thus inhibiting the growth of E.Coli and yeasts.E.Coli and yeasts.

• Breast milk contains lactoferrin (an iron-binding whey protein), which inhibits bacterial growth by depriving them of iron, which is necessary for growth.

• Breast milk contains cystine and tyrosine, which are not synthesized by infants but they are essential for proper growth and development.

• Breast milk contains taurine that is Breast milk contains taurine that is synthesized in inadequate amounts in synthesized in inadequate amounts in infants. It is important for normal infants. It is important for normal differentiation of CNS.differentiation of CNS.

• Breast milk contains nonspecific factors of immune difence: lisozyme, macrofagocytes, neutrofiles, lymphocytes, complement system.

• There are 5 times more essential fatty acids (polyunsaturated: arachidonic, docosahexacnoic, linoleic, and α-linolenic) in breasts milk than in cow’s milk.

• Breast milk contains ferments (lipase, lactase) and mothers hormones.

• Breast milk is ‘species specific’ and therefore allergy to breast milk is rare.

Dilution of Cow’s Milk:Child’s Age Cow’s Milk Water

First 10 days 1 part 2 parts

10 to 20 days

1 part 1 part

Up to 2 mo 2 parts 1 part

• If dilution of cow’s milk is required, add 1 TSF of sugar to each ounce of water (5 %) – isocaloric formula)

Advances in nutritional modifications of infant

formulas• Proteins: their amount is adopted to the

needs of infant’s organism. Almoust all formulas contain whey:casein ratio as 60:40 and adopted amino acid content.

Amino acid Breast milk

Cow’s milk

“Vitalact” “Similac”

Valine Valine 8.2 %

6.6 4.6 % 6.8 %

Lysine Lysine 10.9

57.8 9.7 % 8.4 %

Trypto-Trypto-phan phan

2.29 1.4 2.4 % 1.4 %

• Fats: long-chain polyunsaturated fatty acids are added in amounts similar to those in human milk. Infants fed these formulas or human milk have higher tissue concentrations of long-chain polyunsaturated fatty acids and reportedly have better visual acuity than do infants fed nonsupplemented formulas.

• Carbohydrates: they are presented by β-lactose, sakcharose, dextrin-maltose, which improve the growth of Bifidum-bacteria. The total quantity of carbohydrates in formulas is 7.5 %

• Nucleotides and their related productsucts play key roles in many biological processes. Although nucleotides can be be synthesized endogertously, they are considered "conditionally essential." Nucleotide concentrations in human milk are higher than in unsupplemented cow milk-based formulas, and studies in animals and human infants suggest that dietary nucleotides play a role in the development of the gasgastrointestinal and immune systems

Vitamins and mineralsBreast milk

Cow’s milk

Fortified formulas

•Vitamin E

0.63 mg%

0.18 0.4-0.6

•Vitamin C

4.2 mg% 1.5 4.5-5.0

•Potassium

55 mg% 140 70-95

•Selenium 15 to 20

µg/L 2 to 8 µg/L

11 to 15 µg/L

•OsmolalitOsmolality y

260 mosm/L

420 mosm/L

320 mosm/L

• For infants 0 to 12 months

• Whey proteins:casein = 60:40

• Close to breast milk spectrum of amino acids

• Contains taurine.• Milk fats – 74 % and

plant fats – 26 %• Linoleic : α-linolenic

ratio is optimal for absorption 9.9:1

• Osmolality is equal 270 mosm/L

• The level of proteins is 2.2 %

• Whey proteins:casein = 40:60

• Inriched with bifidum-bacteria

• Fortified with vitamins

• Biologically hydrolyzed casein and and whey proteins

• Biologically hydrolyzed lactose

• Iron fortified (0.8 mg/100 ml)

• Contains Bifidobacterium Lactis 2107/1 g

-6 : -3 = 7.9:1• Osmolality 270

mosm/L

• It doesn’t containtain lactose

• Only whey proteins are present, 20 % of them are amino acids

• Contains nucleotides and selen

• Iron and Iodine fortified

• Contains taurine, inositol, L-karnitine.

For infants with• Hypergalactosaemi

a • Lactose intolerance• Strong allergy to

cow’s milk proteins• Vegetarian babies

• For premature and low-birth-weight (less than 2500 g) babies

• Proteins – 2.3 %• Whey : casein ratio =

70:30• Proteins are particly

hydrolyzed (oligopeptids)

• Contains lysine, cystine, tryptophan, L-histidine, and taurine.

• Polyunsaturated fatty acids (arachidonic, docosahexacnoic, linoleic, and α-linolenic) are present

• For ‘hungry’ babies• For infants with

often regurgitation• Contains 77 % of

casein• Iron, Iodine, Vit. D,

A, E and C enriched.

• NAN H.A.1• NAN H.A.2• For children with

strong family allergy• Contains 100 % of

whey proteins, which are hydrolyzed to oligopeptids (80 %) and aminoacids (20 %)

•Alfaré• Hypoallergenic

elemental diet for children with malarbsorption syndrome, diarrhea, for tube feeding

• Contains hydrolyzed whey proteins: 80 % of oligopeptids and 20 % of aminoacids

• Hydrolyzed lactose• Short-chain fatty

acids

Other commercial infant formulas

Formula Protein source

Carbohy-drate s.

Fat source

For full-term and premature infants with no special nutritional requirements

SMA SMA (Wyeth)(Wyeth)

Nonfat cow's milk, reduced mineral whey: whey/casein ratio: 60:40

Lactose Oleo, coconut, oleic (saf-flower) and soy oils

Enfamil Enfamil (Mead (Mead Johnson)Johnson)

Nonfat cow's milk, deminer-alized whey: whev/casein ratio: 60:40

Lactose Soy, coconut oils

Similac (Ross)

Nonfat cow's milk; whey/ casein ratio: 18:82

Lactose Soy and coconut oils, mono- and diglycerides

Baby formula (Gerber)

Nonfat cow's milk; whey/ casein ratio: 18:82

Lactose Soy

FOR MILK PROTEIN-SENSITIVE INFANTS (‘MILK ALLERGY’), LACTOSE INTOLERANCE,

GALACTOSEMIA

Prosobee Prosobee (Mead (Mead Johnson)Johnson)

Soy protein isolate Corn syrup solids. Lactose and sucrose free

Soy and coconut oils

Isomil Isomil (Ross)(Ross)

Soy protein isolate Corn svrup, sucrose Lactose free

Soy and coconut oils

Nursoy Nursoy (Wyeth)(Wyeth)

Soy protein isolate

Sucrose (liquid formula). Corn syrup solids (powdered formula)

Oleo, coconut, oleic, and soy

oils

FOR INFANTS WITH MALABSORPTION SYNDROME

RCF (Ross Carbohydrate Free) (Ross)

Soy protein isolate

Absent Soy and coconut oils

Portagen (Mead Johnson)

Sodium caseinate

Corn syrup solids, sucrose, lactose

MCT (coconut source) and corn oil

Pregestimil (Mead Johnson)

Casein hydrolysate and L-amino acids

Corn syrup solids, modified tapioca starch

Corn oil, MCT For infants with disaccha-ridase deficiencies, malabsorption svndromes, cystic fibrosis.

Specialty formulasFormula

(manufacturer)Indication for use Comments

Lonalac (Mead

Johnson) Powder

For children with congestive

cardiac failure, who require

reduced sodium intake.

For long-term management,

additional sodium must be given.

Supplement with vitamins C and D and iron. Na = 1 mEq/L

Similac PM 60/ 40 (Ross)

Powder

For newborns predisposed to

hypocal-cemia and infants with impaired renal, digestive, and

cardio-vascular functions.

Low calcium, potassium, and

phosphorus. Relatively low

solute load. Na — 7 mEq/L

Lofenalac (Mead Johnson)

For infants and children with phenylketonuria.

111 mg phenylalanine per quart of formula

Phenyl-free (Mead Johnson)

For children over 1 year of age with phenylketonuria.

Phenylalanine free. Permits increased supplementation with normal foods.

PKU 1 (Milupa) For infants with phenylketonuria (Available as PKU 2 for children over 1 year of age.)

Phenylalanine- and fat-free. Contains vitamins,minerals, and trace elements

Low Methionine Diet Powder (Product 3200K) (MeadJohnson)

For infants with homocystinuria

Nutritionally complete, but requires monito-ring of amino acid levels

Developmental milestones Developmental milestones associated with feedingassociated with feeding

Age (months) Development• Birth

– Has sucking, rooting, and swallowing reflexes;– Feels hunger and indicates desire for food by crying; – Expresses satiety by falling asleep

• 1 - Has strong extrusion reflex• 3-4

– Extrusion reflex is fading; – Begins to develop hand-eye coordination

• 4-5 - Can approximate lips to the rim of a cup• 5-6 - Can use fingers to feed self a cracker• 6-7

– Chews and bites; Chews and bites; – May hold own bottle, but may not drink from it May hold own bottle, but may not drink from it

(prefers for it to be held)(prefers for it to be held)

• 7-9– Refuses food by keeping lips closed; has taste

preferences;preferences;– Holds a spoon and plays with it during Holds a spoon and plays with it during

feeding; feeding; – May drink from a straw; May drink from a straw; – Drinks from a cup with assistanceDrinks from a cup with assistance

• 9-12– Picks up small morsels of food (finger foods)

and feeds self– Holds own bottle and drinks from it– Drinks from a household cup without

assistance but spills some– Uses a spoon with much spilling

• 12-18– Drools less– Drinks well from a household cup, but may

drop it when finished– Holds cup with both hands

• 24– Can use a straw– Chews food with mouth closed and shifts food in

mouth– Distinguishes between finger and spoon foods– Holds small glass in one hand; replaces glass

without dropping

• 36– Spills small amount from spoon– Begins to use fork; holds it in fist – Uses adult pattern of chewing, which involves rotary

action of jaw

• 48– Rarely spills when using spoon– Serves self finger foods – Eats with fork held with fingers

• 5454 Uses fork in preference to spoon

• 7272 Spreads with knife