Title: Infant Feeding: Human Milk and Formula Joan C Zerzan MS RD CD
1Infant 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
3Feeding Recommendations
- Nutrient needs
- Programming
- Health, development, and prevention
4Considerations
- 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
5Physiology - GI Maturation
6In 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
7At 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
8Gut 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
9Gut 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)
10Possible Roles for Gut Hormones in Early Infancy
11Pancreas
- 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
12Protein Digestion
13Carbohydrate Digestion
14Fat Digestion
15Motility - 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
16Motility - 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
17Maturation 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.
18Renal
- 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.
19Potential Renal Solute Load
20Renal 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
21RSL
- Water balance
- RSL in diet
- Water in
- Water out
- Renal concentrating ability
22Urine 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
23Programming 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
24Allergies 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
25Allergies 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
26Allergies 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)
27Feeding 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
28Infant 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
30Human Milk
- Complements Immaturities of these systems
- Promotes maturation
- Epithelial growth factors and hormones
- Digestive enzymes - lipases and amylase
31Characteristics 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
32AAP 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.
33Protein
- 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
34Distribution of Kcals
35Allergies 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.
36AAP 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.
37AAP 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.)
38AAP 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.
39AAP 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.
40AAP 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.
41AAP 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.
43Formulas 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.
44Formula
- Human Milk Substitutes
- History
- Regulation
- Composition and indications
45Human 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
46Human 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
47Human 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
48Human 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
49Science, Medicine, and Industry
- Infant Morbidity and Mortality
- Recognition of association with human milk
substitutes, and infection - Industrial development
- Storage
- Safety
- Food industry
50Science, Medicine, and Industry
- Growth of child Health and welfare in early 20th
century
51Historical 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
52Historical timeline
- 1940
- Homogenized milk widely marketed
- 1960
- Further advances in technology and packaging
- Commercially prepared infant formula becoming
increasingly popular
53Infant 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
54Soy Formulas
- First developed in 1930s with soy flour
- Early formulas produced diarrhea and excessive
gas - Now use soy protein isolate with added methionine
55Infant 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.
56Regulation 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
57Regulation 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
58Formula 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.
59Regulation 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)
60Formula 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
61Standard Infant Formulas, Milk or Soy Based..
62Cows 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
63Formula Brands
- Ross
- Similac/Isomil/Alimentum
- Mead Johnson
- Enfamil/Prosobee/Enfacare
- Nestle
- Good Start
- Wyeth
- Generic in USA Gold Brands SMA
- SHS
- NeoCate, DuoCal
64Milk 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
65Milk Based FormulasCharacteristics
- Blend of Whey and Casein Proteins (8.2-9.6
total calories) - Carbohydrate lactose
- Fats long chain
- Meet needs of healthy infant
66Protein, 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.
67Cows 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.
68Infant Formulas AAP
- Cows milk based formula is recommended for the
first 12 months if breast milk is not available
69Soy 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
70Soy Formulas
- Protein soy protein isolate with added
methionine - Fat vegetables oils
- Cho usually corn based products
71Soy 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
72Possible 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
73Health 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.
74Figure 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).
75Should 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
76American 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
77Contraindications 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.
78Soy 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.
80Cows 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.
81Predigested protein based infant formulas
82Protein 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
83Hydrolysate 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.
84AAP Policy Statement Re Hypoallergenic Infant
Formulas (August, 2000)
85AAP 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
88AAP Policy Statement Re Hypoallergenic Infant
Formulas (August, 2000)
- Currently available, partially hydrolyzed
formulas are not hypoallergenic.
89AAP 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
90Formulas 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.
91Specialty Formulas
- Elemental - Neocate
- Premature Follow Up - Neosure, Enfamil 22
- Other highly specialized for metabolic conditions
92Elemental formula for infants
93Elemental 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
94Premature 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
95Premature 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
96Post Premature Infant formula
97Post 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
98Other 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
99Indications
- 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
-
100Know 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
101Finding 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(No Transcript)
103Addition of DHA ARA
- 2001 FDA approves as GRAS
- 2002 Ross Mead Johnson introduce products
with DHA and ARA - Cost 15-20 above standard formulas
104Formulas with DHA ARA
105Additional concerns/issues
- Appropriate infant feeding
- Cows milk, goats milk, homemade formulas
- safety
- Preparation
- miscellaneous
106AAP 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
107Cows milk and goats milk
- Protein
- RSL
- Folic acid, iron, vitamin D
- pasteurization
108Formula 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
109Formula safety
- FDA recall list 2005-2006
110Milk 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.
111Cooper, 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
112Cooper, 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
113Keating
- 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
114Lucas
- 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
115Formula 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
116Bright 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.
117Newborn 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.
118Newborn 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.
119Newborn 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.
120First 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.
121One Month
- Delay the introduction of solid foods until the
infant is four to six months of age. Do not put
cereal in a bottle.
122Four 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.
123Four 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. .
124Six 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.