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Title: Infant Feeding: Human Milk and Formula Joan C Zerzan MS RD CD


1
Infant Feeding Human Milk and Formula Joan C
Zerzan MS RD CD
2
Feeding Recommendations
  • Considerations
  • Growth in infancy
  • Physiology of infancy
  • GI
  • Renal
  • Infant Development
  • Nutrient requirements
  • Programming
  • Health and prevention

3
Feeding Recommendations
  • Nutrient needs
  • Programming
  • Health, development, and prevention

4
Considerations
  • Coordinated sucking and swallowing
  • Gastric emptying
  • Intestinal motility
  • Secretions salivary, gastric, pancreatic,
    hepatobiliary
  • Enterocyte function in terms of enzyme synthesis,
    absorption, mucosal protection
  • Metabolism of products of digestion and
    absorption
  • Expulsion of undigested waste products

5
Physiology - GI Maturation
6
In utero
  • Fetal GI tract is exposed to constant passage of
    fluid that contains a range of physiologically
    active factors
  • growth factors
  • hormones
  • enzymes
  • immunoglobulins
  • These play a role in mucosal differentiation and
    GI development as well as development of
    swallowing and intestinal motility

7
At Birth
  • Gut of the newborn is faced with the formidable
    task of passing, digesting, and absorbing large
    quantities of intermittent boluses of milk
  • Comparable feeds per body weight for adults would
    be 15 to 20 L

8
Gut Hormones
  • Gastrointestinal peptides are found in venous
    cord blood at birth in levels similar to those of
    fasting adults
  • In fetal distress a number of gut peptides are
    elevated which might account for passage of
    meconium
  • With enteral feeding levels of gut hormones
    (motilin, neurotensin, GIP (gastric inhibitory
    peptide), gastrin, enteroglucagon, PP -
    pancreatic polypeptide, rise rapidly

9
Gut Hormones Influenced By
  • Choice of breast or formula feeds
  • Enteric intake (induces epithelia hyperplasia and
    stimulates production of microvillous enzymes)
  • Early enteral feeding (enteral feeding is
    strongly encouraged to promote GI function and
    differentiation)

10
Possible Roles for Gut Hormones in Early Infancy
11
Pancreas
  • Pancreatic function is relatively deficient at
    birth and mature levels of pancreatic enzymes are
    not achieved until late infancy
  • Pancreatic amylase activity increases after 4 to
    6 monthsLipase levels do not approach adult
    efficiency until about 6 months

12
Protein Digestion
13
Carbohydrate Digestion
14
Fat Digestion
15
Motility - Upper GI
  • Esophageal motility is decreased in the newborn
  • LES is primarily above the diaphragm
  • LES pressure is less for first months
  • Gastric Emptying may be delayed

16
Motility - Intestinal
  • Intestinal motility is more disorganized
  • Prolonged transit time in upper intestines may
    improve absorption of nutrients
  • Rapid emptying of ileum and colon may reduce time
    for water and electrolyte absorption and increase
    risk of dehydration

17
Maturation in First Year
  • LES tone increases after 6 months and is
    associated with less reflux in most infants
  • Gastric acid and pepsin activity do not reach
    adult levels until 2 years
  • Pancreatic amylase increases by 6 months
  • Retention of lactase activity is typical until 3
    to 5 years.
  • Fat absorption does not approach adult efficiency
    until about 6 months
  • Lipase reaches adult levels by 2 years.

18
Renal
  • Limited ability to concentrate urine in first
    year due to immaturities of nephron and pituitary
  • Potential Renal solute load determined by
    nitrogenous end products of protein metabolism,
    sodium, potassium, phosphorus, and chloride.

19
Potential Renal Solute Load
20
Renal solute load
  • Samuel Foman J Pediatrics Jan 1999 134 1
    (11-14)
  • RSL is important consideration in maintaining
    water balance
  • In acute febrile illness
  • Feeding energy dense formulas
  • Altered renal concentrating ability
  • Limited fluid intake

21
RSL
  • Water balance
  • RSL in diet
  • Water in
  • Water out
  • Renal concentrating ability

22
Urine Concentrations
  • Most normal adults are able to achieve urine
    concentrations of 1300 to 1400 mOsm/l
  • Healthy newborns may be able to concentrate to
    900-1100 mOsm/l, but isotonic urine of 280-310
    mOsm/l is the goal
  • In most cases this is not a concern, but may
    become one if infant has fever, high
    environmental temperatures, or diarrhea

23
Programming by Early Diet
  • Nutrient composition in early diet may have long
    term effects on GI function and metabolism
  • Animal models show that glucose and amino acid
    transport activities are programmed by
    composition of early diet
  • Animals weaned onto high CHO diet have higher
    rates of glucose absorption as adults compared to
    those weaned on high protein diet

24
Allergies Areas of Recent Interest
  • Early introduction of dietary allergens and
    atopic response
  • atopy is allergic reaction/especially associated
    with IgE antibody
  • examples atopic dermatitis (eczema), recurrent
    wheezing, food allergy, urticaria (hives) ,
    rhinitis
  • Prevention of adverse reactions in high risk
    children

25
Allergies Infancy
  • Increased risk of sensitization as antigens
    penetrate mucosa, react with antibodies or cells,
    provoking cellular response and release of
    mediators
  • Immaturities that increase risk
  • gastric acid, enzymes
  • microvillus membranes
  • lysosomal functions of mucosal cells
  • immune system, less sIgA in lumen

26
Allergies IDDM
  • Theory sensitization and development of immune
    memory to food allergens may contribute to
    pathogenesis of IDDM in genetically susceptible
    individuals.
  • Milk, wheat, soy have been implicated.
  • Breastfeeding and delay in non-milk feedings may
    be beneficial.
  • There is little firm evidence of the
    significance of nutritional factors in the
    etiology of type 1 diabetes. (Virtanen SM, Knip
    M. Am J Clin Nutr , 2003)

27
Feeding the Infant
  • Choices
  • Human Milk
  • Standard Infant Formula (Cow, Soy)
  • Hypoallergenic (hydrolysates vs amino acid based
  • Other specialty formulas
  • Preterm
  • Post discharge formulas for preterm infants

28
Infant Feeding Historical Perspective
  • Breast feeding
  • Human Milk Substitutes
  • Science, Medicine and Industry

29
  • No two hemispheres of any learned professors
    brain are equal to two healthy mammary glands in
    the production of a satisfactory food for
    infants
  • - Oliver Wendell Holmes

30
Human Milk
  • Complements Immaturities of these systems
  • Promotes maturation
  • Epithelial growth factors and hormones
  • Digestive enzymes - lipases and amylase

31
Characteristics and Advantages of Human Milk
  • Low renal solute load
  • Immunologic, growth and trophic factors
  • Decrease illness, infection, allergy
  • Improved digestion and absorption
  • Nutrient Composition CHO, Protein, Fatty Acid,
    etc
  • Cost
  • Other

32
AAP Breast milk and allergy
  • 1.Breast milk is an optimal source of nutrition
    for infants through the first year of life or
    longer. Those breastfeeding infants who develop
    symptoms of food allergy may benefit from
  • a.maternal restriction of cow's milk, egg, fish,
    peanuts and tree nuts and if this is
    unsuccessful,
  • b.use of a hypoallergenic (extensively hydrolyzed
    or if allergic symptoms persist, a free amino
    acid-based formula) as an alternative to
    breastfeeding.

33
Protein
  • Predominant protein of human milk is whey
    predominant protein in cows milk is casein
  • Casein proteins of the curd (low solubility at
    pH 4.6)
  • Whey soluble proteins (remain soluble at pH
    4.6)
  • Ratio of casein to whey is between 4060 and
    3070 in human milk and 8218 in cows milk
  • some formulas provide more whey proteins than
    others

34
Distribution of Kcals
35
Allergies Breastmilk
  • May be protective due to sIgA and mucosal growth
    factors
  • Maternal avoidance diets in lactation remain
    speculative. May be useful for some highly
    motivated families with attention to maternal
    nutrient adequacy.

36
AAP Breastfeeding and the Use of Human Milk,
1997
  • Exclusive breastfeeding is ideal nutrition and
    sufficient to support optimal growth and
    development for approximately the first 6 months
    after birth.It is recommended that breastfeeding
    continue for at least 12 months, and thereafter
    for as long as mutually desired.

37
AAP Breastfeeding and the Use of Human Milk,
1997
  • Human milk is the preferred feeding for all
    infants
  • Breastfeeding should begin as soon as possible
    after birth
  • Newborns should be nursed 8 to 12 times every 24
    hours until satiety, usually 10 to 15 minutes per
    breast. (Crying is a late indicator of hunger.)

38
AAP Breastfeeding and the Use of Human Milk,
1997
  • Formal evaluation of breastfeeding by trained
    observers at 24-48 hours and again at 48 to 72
    hours.
  • No supplements should be given unless a medical
    indication exists.
  • When discharged at lt48 hours, should have FU
    visit at 2 to 4 days of age, assessment at 5 to 7
    days, and be seen at one month.

39
AAP Breastfeeding and the Use of Human Milk,
1997
  • Should hospitalization of the breastfeeding
    mother or infant be necessary, every effort
    should be made to maintain breastfeeding
    preferably directly or by pumping the breasts.

40
AAP statement on breastfeeding (continued)
  • Supplements (water, glucose, formula) should be
    avoided (unless medically necessary). Pacifiers
    should also be avoided.
  • Exclusive breastfeeding is ideal for the first 6
    months. Breastfeeding should continue for at
    least 12 months.

41
AAP statement on breastfeeding (continued)
  • In the first 6 months, water, juice and other
    foods are generally unnecessary. Vitamin D and
    iron may be needed. Fluoride should not be given
    during the first 6 months.

42
  • a.Breastfeeding mothers should continue
    breastfeeding for the first year of life or
    longer. During this time, for infants at risk,
    hypoallergenic formulas can be used to supplement
    breastfeeding. Mothers should eliminate peanuts
    and tree nuts (eg, almonds, walnuts, etc) and
    consider eliminating eggs, cow's milk, fish, and
    perhaps other foods from their diets while
    nursing. Solid foods should not be introduced
    into the diet of high-risk infants until 6 months
    of age, with dairy products delayed until 1 year,
    eggs until 2 years, and peanuts, nuts, and fish
    until 3 years of age.

43
Formulas containing hydrolysed protein for
prevention of allergy and food intolerance in
infants (2006)
  • There is no evidence to support feeding with a
    hydrolysed formula for the prevention of allergy
    compared to exclusive breast feeding. In high
    risk infants who are unable to be completely
    breast fed, there is limited evidence that
    prolonged feeding with a hydrolysed formula
    compared to a cow's milk formula reduces infant
    and childhood allergy and infant cows milk
    allergy. In view of methodological concerns and
    inconsistency of findings, further large, well
    designed trials comparing formulas containing
    partially hydrolysed whey, or extensively
    hydrolysed casein to cow's milk formulas are
    needed.

44
Formula
  • Human Milk Substitutes
  • History
  • Regulation
  • Composition and indications

45
Human Milk Substitutes
  • Early evidence of artificial feeding
  • Majority of infants received breast milk
  • Maternal BF
  • Wet nurses
  • Wealthy women
  • Orphans, abandoned, illegitimate
  • Prematurity or congenital deformities

46
Human Milk Substitutes
  • Wet nurses
  • Other mammalian milk (cow, goat, donkey, camel)
  • Pablum bread/flour, mixed with water
  • bread, water, flour, sugar and castille soap to
    aid digestion

47
Human Milk Substitutes
  • 1915 Gerstenberger developed first complete
    infant formula marketed as SMA (synthetic milk
    adapted)
  • Base was defatted and diluted cows milk with
    beef tallow added to mimic the fat content of
    human milk

48
Human Milk Substitutes
  • 1920-1950s evaporated or fresh cows milk,
    water and added CHO (prepared at home)
  • 1950s to present commercially prepared infant
    formulas have replaced home recipes

49
Science, Medicine, and Industry
  • Infant Morbidity and Mortality
  • Recognition of association with human milk
    substitutes, and infection
  • Industrial development
  • Storage
  • Safety
  • Food industry

50
Science, Medicine, and Industry
  • Growth of child Health and welfare in early 20th
    century

51
Historical timeline
  • 1900
  • Pasteurization of milk in US
  • Association between bacteria and diarrhea
  • 1912
  • U.S Childrens Bureau
  • Public Health and Pediatricians efforts to
    improve infant/child health and decrease
    mortality
  • 1920
  • Intro evaporated milk
  • Cod liver oil prevents rickets
  • Curd tension of milk altered
  • Increased availability of refrigeration
  • Vitamin C isolated
  • Vitamin D prepared in pure form
  • Improved sanitation

52
Historical timeline
  • 1940
  • Homogenized milk widely marketed
  • 1960
  • Further advances in technology and packaging
  • Commercially prepared infant formula becoming
    increasingly popular

53
Infant Formulas - History
  • Cows milk is high in protein, low in cho,
    results in large initial curd formation in gut if
    not heated before feeding
  • Early Formulas
  • from 1920-1950 majority of non-breastfed infants
    received evaporated milk formulas boiled or
    evaporated milk solved curd formation problems
  • cho provided by corn syrup or other cho to
    decrease relative protein kcals

54
Soy Formulas
  • First developed in 1930s with soy flour
  • Early formulas produced diarrhea and excessive
    gas
  • Now use soy protein isolate with added methionine

55
Infant Formula - History, cont.
  • 50s and 60s commercial formulas replaced home
    preparation
  • 1959 iron fortification introduced, but in 1971
    only 25 of infants were fed Fe fortified formula
  • Cows milk feedings started in middle of first
    year between 1950-1970s. In 1970 almost 70 of
    infants were receiving cows milk.

56
Regulation of Infant Formula
  • FDA
  • Infant Formula Act
  • Manufacturers
  • Voluntary monitoring
  • AAP, National Academy of Sciences, other
    professional organizations
  • Guidelines for composition and intake (e.g.
    DRIs)
  • Guidelines for preparation and handling of
    formula/human milk in health care facilities

57
Regulation of Infant Formulas
  • Infant Formula Act The purpose of the infant
    formula act (1980) is to ensure the safety and
    nutrition of infant formulas including minimum
    and in some cases maximum levels of specified
    nutrients. The act authorizes the FDA to
    establish appropriate regulations for 1) new
    formulas, 2) formulas entering the U.S. market,
    3) major changes, revisions, or substitutions of
    macronutrients 4) formulas manufactured in new
    plants or processing lines, 5) addition of new
    constituents 6) use of new equipment or
    technology 7) packaging changes

58
Formula Regulation
  • Regulation is by the Infant Formula Act of 1980,
    under FDA authority
  • Nutrient composition guidelines for 29 nutrients
    established by AAP Committee on Nutrition and
    adopted as regs by FDA
  • Nutrient Requirements for Infant Formulas.
    Federal Register 36, 23553-23556. 1985. 21 CFR
    Part 107.

59
Regulation of Infant Formulas
  • Infant Formula Act
  • Manufacturing regulations
  • Quality control
  • Non specific testing requirements, case by case
    basis, growth outcomes
  • Recall Procedures
  • Nutrient content and labeling
  • Panel convened 1998 and 2002 (recommended
    revisions including exemptions)

60
Formula Composition
  • Breast Milk as gold standard
  • Attempt to duplicate composition of breast milk
  • ? Bioactivity, relationship, function of all
    factors present in breast milk
  • ? Measure outcome growth, composition,
    functional indices

61
Standard Infant Formulas, Milk or Soy Based..
62
Cows Milk Based Formula
  • Commercial formula designed to approximate
    nutrients provided in human milk
  • Some nutrients added at higher levels due to less
    complete digestion and absorption

63
Formula Brands
  • Ross
  • Similac/Isomil/Alimentum
  • Mead Johnson
  • Enfamil/Prosobee/Enfacare
  • Nestle
  • Good Start
  • Wyeth
  • Generic in USA Gold Brands SMA
  • SHS
  • NeoCate, DuoCal

64
Milk Based Formulas
  • Standard 0-12 months
  • Similac with iron
  • Enfamil with iron
  • Good Start Essentials/Good Start Supreme
  • Wyeth Generic
  • Standard 0-12 mos with DHA/ARA
  • Similac Advance with iron
  • Enfamil Lipil with iron
  • Good Start Supreme DHA/ARA
  • Wyeth formulas

65
Milk Based FormulasCharacteristics
  • Blend of Whey and Casein Proteins (8.2-9.6
    total calories)
  • Carbohydrate lactose
  • Fats long chain
  • Meet needs of healthy infant

66
Protein, cont.
  • whey proteins of human and cows milk are
    different and have different amino acid profiles.
  • Major whey proteins of human milk at a
    lactalbumin (high levels of essential aa) ,
    immunoglobulins, and lactoferrin( enhances iron
    transportation)
  • Cows milk has low levels of these proteins and
    high levels of b lactoglobulin
  • Infants appear to thrive equally well with either
    whey or casein predominant formulas.

67
Cows Milk Based Formula Fat CHO
  • Fat butterfat of cows milk is replaced with
    vegetable fat sources to make the fatty acid
    profile of cows milk formulas more like those of
    human milk and to increase the proportion of
    essential fatty acids
  • Cho Lactose is the major carbohydrate in most
    cows milk based formulas.

68
Infant Formulas AAP
  • Cows milk based formula is recommended for the
    first 12 months if breast milk is not available

69
Soy Formulas
  • Isomil/Isomil DF /Isomil Advance/Isomil Advance 2
  • Prosobee/Prosobee Lipil/Next Step Prosobee
  • Good Start Essentials Soy/Good Start 2 Essentials
    Soy
  • Wyeth All iron fortified

70
Soy Formulas
  • Protein soy protein isolate with added
    methionine
  • Fat vegetables oils
  • Cho usually corn based products

71
Soy FormulasCharacteristics compared to Milk
Based
  • Higher protein (lower quality)
  • Higher sodium, calcium, and phosphorus
  • Carbohydrate Corn syrup solids, sucrose, and/or
    maltodextrin lactose free
  • Fats Long chain
  • Meet needs of healthy infants

72
Possible Concerns about Soy Formulas AAP
  • 60 of infants with cowmilk protein induced
    enterocolitis will also be sensitive to soy
    protein - damaged mucosa allows increased uptake
    of antigen.
  • Contains phytates and fiber oligosacharides so
    will inhibit absorption of minerals (additional
    Ca is added)
  • Higher levels of osteopenia in preterm infants
    given soy formulas
  • Phytoestrogens at levels that demonstrate
    physiologic activity in rodent models
  • Higher aluminum levels

73
Health Consequences of Early Soy Consumption.
Badger et al. J Nutr. 2002
  • US soy formulas made with soy protein isolate
    (SPI)
  • SPI has several phytochemicals, including
    isoflavones
  • Isoflavones are referred to as phytoestrogens
  • Phytoestrogens bind to estrogen receptors act
    as estrogen agonists, antagonists, or selective
    estrogen receptor modulators depending on tissue,
    cell type, hormonal status, age, etc.

74
Figure 1. Hypothetical serum concentrations
profile of isoflavones from conception through
weaning in typical Asians and Americans. The
values represent the range of isoflavonoids
reported by Adlercreutz et al. (6 ) for Japanese
(dotted lines) or reported by Setchell et al. (3
) for Americans fed soy infant formula (dashed
line).
75
Should we be Concerned? - Badger et al.
  • No human data support toxicity of soyfoods
  • Soyfoods have a long history in Asia
  • Millions of American infants have been fed soy
    formula over the past 3 decades
  • Rat studies indicate a potential protective
    effect of soy in infancy for cancer

76
American Academy of Pediatrics Committee on
Nutrition. Soy Protein-based Formulas
Recommendations for Use in Infant Feeding.
Pediatrics 1998101148-153.
  • Soy formulas given to 25 of infants but needed
    by very few
  • Offers no advantage over cow milk protein based
    formula as a supplement for breastfed infants
  • Provides appropriate nutrition for normal growth
    and development
  • Indicated primarily in the case of vegetarian
    families and for the very small number of infants
    with galactosemia and hereditary lactase
    deficiency

77
Contraindications to Soy Formula AAP
  • preterm infants due to increased risk of
    inadequate bone mineralization
  • infants with cow milk protein-induced enteropathy
    or enterocolitis
  • most previously well infants with acute
    gastroenteritis
  • prevention of colic or allergy.

78
Soy formula for prevention of allergy and food
intolerance in infants (Cochrane, 2006)
  • Feeding with a soy formula cannot be recommended
    for prevention of allergy or food intolerance in
    infants at high risk of allergy or food
    intolerance. Further research may be warranted to
    determine the role of soy formulas for prevention
    of allergy or food intolerance in infants unable
    to be breast fed with a strong family history of
    allergy or cow's milk protein intolerance.

79
  • Those infants with IgE-associated symptoms of
    allergy may benefit from a soy formula, either as
    the initial treatment or instituted after 6
    months of age after the use of a hypoallergenic
    formula. The prevalence of concomitant is not as
    great between soy and cow's milk in these infants
    compared with those with nonIgE-associated
    syndromes such as enterocolitis, proctocolitis,
    malabsorption syndrome, or esophagitis. Benefits
    should be seen within 2 to 4 weeks and the
    formula continued until the infant is 1 year of
    age or older.

80
Cows milk protein avoidance and development of
childhood wheeze in children with a family
history of atopy(Cochrane, 2003)
  • Breast-milk should remain the feed of choice for
    all babies.
  • In infants with at least one first degree
    relative with atopy, hydrolysed formula for a
    minimum of four months combined with dietary
    restrictions and environment measures may reduce
    the risk of developing asthma or wheeze in the
    first year of life.
  • There is insufficient evidence to suggest that
    soya-based milk formula has any benefit.

81
Predigested protein based infant formulas
82
Protein Hydrolysate Formulas
  • Alimentum Advance
  • Pregestimil/Pregestimil Lipil
  • Nutramigen Lipil
  • Protein Casein hyrolysate free AAs
  • Fat (Alimentum and Pregestimil) Medium chain
    Long chain triglycerides (Nutramigen) Long chain
    triglycerides
  • Carbohydrate Lactose free

83
Hydrolysate Formulas
  • Whey Hydrolysate Formula Cows milk based
    formula in which the protein is provided as whey
    proteins that have been hydrolyzed to smaller
    protein fractions, primarily peptides. This
    formula may provoke an allergic response in
    infants with cows milk protein allergy.
  • Casein Hydrolysate Formula Infant formula based
    on hydrolyzed casein protein, produced by
    partially breaking down the casein into smaller
    peptide fragments and amino acids.

84
AAP Policy Statement Re Hypoallergenic Infant
Formulas (August, 2000)
  • Recommendations

85
AAP Breast milk and allergy
  • 1.Breast milk is an optimal source of nutrition
    for infants through the first year of life or
    longer. Those breastfeeding infants who develop
    symptoms of food allergy may benefit from
  • a.maternal restriction of cow's milk, egg, fish,
    peanuts and tree nuts and if this is
    unsuccessful,
  • b.use of a hypoallergenic (extensively hydrolyzed
    or if allergic symptoms persist, a free amino
    acid-based formula) as an alternative to
    breastfeeding.

86
  • 2.Formula-fed infants with confirmed cow's milk
    allergy may benefit from the use of a
    hypoallergenic or soy formula as described for
    the breastfed infant.

87
  • 3.Infants at high risk for developing allergy,
    identified by a strong (biparental parent, and
    sibling) family history of allergy may benefit
    from exclusive breastfeeding or a hypoallergenic
    formula or possibly a partial hydrolysate
    formula. Conclusive studies are not yet available
    to permit definitive recommendations. However,
    the following recommendations seem reasonable at
    this time

88
AAP Policy Statement Re Hypoallergenic Infant
Formulas (August, 2000)
  • Currently available, partially hydrolyzed
    formulas are not hypoallergenic.

89
AAP Policy Statement Re Hypoallergenic Infant
Formulas (August, 2000)
  • Carefully conducted randomized controlled studies
    in infants from families with a history of
    allergy must be performed to support a formula
    claim for allergy prevention. Allergic responses
    must be established prospectively, evaluated with
    validated scoring systems, and confirmed by
    double-blind,placebo-controlled challenge. These
    studies should continue for at least 18 months
    and preferably for 60 to 72 months or longer
    where possible

90
Formulas containing hydrolysed protein for
prevention of allergy and food intolerance in
infants (2006)
  • There is no evidence to support feeding with a
    hydrolysed formula for the prevention of allergy
    compared to exclusive breast feeding. In high
    risk infants who are unable to be completely
    breast fed, there is limited evidence that
    prolonged feeding with a hydrolysed formula
    compared to a cow's milk formula reduces infant
    and childhood allergy and infant cows milk
    allergy. In view of methodological concerns and
    inconsistency of findings, further large, well
    designed trials comparing formulas containing
    partially hydrolysed whey, or extensively
    hydrolysed casein to cow's milk formulas are
    needed.

91
Specialty Formulas
  • Elemental - Neocate
  • Premature Follow Up - Neosure, Enfamil 22
  • Other highly specialized for metabolic conditions

92
Elemental formula for infants
93
Elemental Infant Formula
  • NeoCate (SHS)
  • Protein Free Amino Acids
  • Fat Long chain
  • Carbohydrate Lactose Free
  • Indications for use Food Allergy or intolerance
    to peptides or whole protein

94
Premature Infant Breast Milk Additives and
Formulas
  • Enfamil Human Milk Fortifier
  • Similac Human Milk Fortifier
  • Powdered breast milk additives
  • Similac Natural Care Advance
  • Liquid breast milk additive
  • Similac Special Care Advance
  • Enfamil Premature /- Lipil

95
Premature FormulasGeneral Characteristics
compared to Standard
  • Increased Protein,Vitamins Minerals
  • For infants born at lt1.5kg
  • up to 2000-2500gm
  • Feeding of infants gt 2500 gm
  • risk of vitamin toxicities
  • Premature formulas vary in nutrient content

96
Post Premature Infant formula
97
Post Premature Formulas
  • NeoSure Advance
  • EnfaCare Lipil
  • Standard Dilution 22 kcal/oz
  • Protein between standard and Premature
  • Vitamins Higher than standard,significantly
    lower than Premature
  • Calcium and Phosphorus between standard and
    Premature

98
Other Specialty Formulas
  • Portagen (Mead Johnson)
  • 85 fat MCT, 15 fat Corn oil
  • Used for infants with chylothorax
  • Similac PM 60/40 (Ross)
  • Low in Ca, P, K and NA 21 CaP ratio
  • Used for infants with Renal Failure
  • Formulas for Metabolic Disorders
  • Several condition specific products by Ross and
    Mead Johnson

99
Indications
  • Cows milk based
  • Health term infant
  • Soy
  • Vegetarian
  • Galactosemia
  • Protein Hydrolysates
  • Protein intolerance/allergy
  • other
  • Preterm Formulas
  • Post-discharge Preterm formulas
  • Other Specialty Formulas
  • Specific medical, metabolic indications

100
Know What You Are Feeding
  • Caloric density, protein, fat and carbohydrate
    vitamin and mineral content.
  • Osmolality
  • Renal Solute Load Evaluate RSL in context of
    solute intake, fluid intake and output.
  • Evidence Based
  • Rationale
  • Cost and availability

101
Finding Up to Date Information
  • www.ross.com Similac products
  • www.meadjohnson.com Enfamil products
  • www.verybestbaby.com Nestle products
  • www.wyethnutritionals.com generic products
  • www.brightbeginnings.com lower cost formulas
    made by Wyeth
  • www.shsna.com/html/Hypoallergenic.htm
  • Neocate formulas

102
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103
Addition of DHA ARA
  • 2001 FDA approves as GRAS
  • 2002 Ross Mead Johnson introduce products
    with DHA and ARA
  • Cost 15-20 above standard formulas

104
Formulas with DHA ARA
105
Additional concerns/issues
  • Appropriate infant feeding
  • Cows milk, goats milk, homemade formulas
  • safety
  • Preparation
  • miscellaneous

106
AAP Cows Milk in Infancy
  • Objections include
  • Cows milk poor source of iron
  • GI blood loss may continue past 6 months
  • Bovine milk protein and Ca inhibit Fe absorption
  • Increased risk of hypernatremic dehydration with
    illness
  • Limited essential fatty acids, vitamin C, zinc
  • Excessive protein intake with low fat milks

107
Cows milk and goats milk
  • Protein
  • RSL
  • Folic acid, iron, vitamin D
  • pasteurization

108
Formula Safety Issues - 2002
  • Enterobacter Sakazakii in Intensive care units
  • Powered formula is not sterile so should not be
    used with high risk infants
  • FDA recommends mixing with boiling water but this
    may affect availability of vitamins proteins
    and also cause clumping
  • Irradiation proposed

109
Formula safety
  • FDA recall list 2005-2006

110
Milk Feedings Cautionary Tales
  • Cooper et al. Pediatrics 1995. Increased
    incidence of severe breastfeeding malnutrition
    and hypernatremia in a metropolitan area.
  • Keating et al. AJDC 1991. Oral water
    intoxication in infants.
  • Lucas et al. Arch Dis Child. 1992. Randomized
    trial of ready to fed compared with powdered
    formula.

111
Cooper, cont.
  • 5 breastfed infants admitted to Childrens
    hospital in Cincinnati over 5 months period for
    breastfeeding malnutrition and dehydration
  • age at readmission was 5 to 14 days
  • mothers were between the ages of 28 and 38, had
    prepared for breastfeeding
  • 3 had inverted nipples and reported latch-on
    problems before discharge
  • 3 families had contact with health care providers
    before readmission including calls to PCP and
    home visit by PHN

112
Cooper, cont.
  • at time of readmit none of presenting complaints
    related to ss of dehydration, only one infant
    presented with feeding complaint
  • wt. Loss at admission 23, range 14-32
  • Serum Na - mean 186 mmol/l, range 161-214
    (136-143 is wnl)
  • 3 infants had severe complications multiple
    cerebral infarctions, left leg amputation
    secondary to iliac artery thrombus

113
Keating
  • 24 cases of oral water intoxication in 3 years at
    Childrens Hospital and St. Louis
  • Most were from very low income families and were
    offered water at home when formula ran out
  • Authors suggest provision of adequate formula
    and anticipatory guidance

114
Lucas
  • 43 infants randomized to RTF or powdered formula
  • Infants given powdered formula had increased body
    wt. And skinfold thickness at 3 and 6 mos..
    Compared to RTF and breastfed
  • Powdered formula - 6 of 19 were above the 90th
    percentile wt/ht, but only 1 of 19 RTF infants
  • Authors suggest errors in reconstitution of
    formula

115
Formula Preparation Microwave Protocol
(Sigman-Grant, 1992)
  • Heat only 4 oz or more refrigerated formula with
    bottle top uncovered
  • 4 oz bottles lt 30 seconds
  • 8 oz bottles lt 45 seconds
  • Invert 10 times before use
  • Should be cool to the touch
  • Always test drops of formula on tongue or top of
    hand

116
Bright Futures
  • AAP/HRSA/MCHB
  • http//www.brightfutures.org
  • Bright Futures is a practical development
    approach to providing health supervision for
    children of all ages from birth through
    adolescence.

117
Newborn Visit Breastfeeding
  • Infant Guidance
  • how to hold the baby and get him to latch on
    properly
  • feeding on cue 8-12 times a day for the first
    four to six weeks
  • feeding until the infant seems content.
  • Newborn breastfed babies should have six to eight
    wet diapers per day, as well as several
    "mustardy" stools per day.
  • Give the breastfeeding infant 400 I.U.'s of
    vitamin D daily if he is deeply pigmented or does
    not receive enough sunlight.

118
Newborn Visit Breastfeeding
  • Maternal care
  • rest
  • fluids
  • relieving breast engorgement
  • caring for nipples
  • eating properly
  • Follow-up support from the health professional by
    telephone, home visit, nurse visit, or early
    office visit.

119
Newborn Visit Bottle-feeding
  • type of formula, preparation
  • feeding techniques, and equipment.
  • Hold baby in semi-sitting position to feed.
  • Do not use a microwave oven to heat formula. To
    avoid developing a habit that will harm your
    infant's teeth, do not put him to bed with a
    bottle or prop it in his mouth.

120
First Week
  • Do not give the infant honey until after her
    first birthday to prevent infant botulism.
  • To avoid developing a habit that will harm your
    infant's teeth, do not put her to bed with a
    bottle or prop it in her mouth.

121
One Month
  • Delay the introduction of solid foods until the
    infant is four to six months of age. Do not put
    cereal in a bottle.

122
Four Months
  • Continue to breastfeed or to use iron-fortified
    formula for the first year of the infant's life.
    This milk will continue to be his major source of
    nutrition.
  • Begin introducing solid foods with a spoon when
    the infant is four to six months of age.
  • Use a spoon to give him an iron-fortified,
    single-grain cereal such as rice.

123
Four Months, cont.
  • If there are no adverse reactions, add a new
    pureed food to the infant's diet each week,
    beginning with fruits and vegetables.
  • Always supervise the infant while he is eating.
  • Give exclusively breastfeeding infants iron
    supplements.
  • Continue to give the breastfeeding infant 400
    I.U.'s of vitamin D daily if he is deeply
    pigmented or does not receive enough sunlight.
  • Do not give the infant honey until after his
    first birthday to prevent infant botulism. .

124
Six Months, cont.
  • Let the infant indicate when and how much she
    wants to eat.
  • Serve solid food two or three times per day.
  • Begin to offer a cup for water or juice.
  • Limit juice to four to six ounces per day.
  • Give iron supplements to infants who are
    exclusively breastfeeding.
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