FORMULA FEEDING OF CHILDREN

FORMULA FEEDING OF CHILDREN. CLASSIFICATION AND CHARACTERISTICS OF MILK FORMULAS. GUARANTEED COW’S MILK. TECHNIQUE OF FORMULA FEEDING, CRITERIA OF ITS EFFECTIVENESS. ADDITIONAL FOOD AND FEEDING CORRECTION IN FORMULA FEEDING. CHILD’S DAILY NEED IN ENERGY, PROTEINS, FATS AND CARBOHYDRATES IN FORMULA FEEDING

 

 

Infant formula is a manufactured food designed and marketed for feeding to babies and infants under 12 months of age, usually prepared for bottle-feeding or cup-feeding from powder (mixed with water) or liquid (with or without additional water). The U.S. Federal Food, Drug, and Cosmetic Act (FFDCA) defines infant formula as “a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk”.

The composition of infant formula is designed to be roughly based on a human mother’s milk at approximately one to three months postpartum, although there are significant differences in the nutrient content of these products. The most commonly used infant formulas contain purified cow’s milk whey and casein as a protein source, a blend of vegetable oils as a fat source, lactose as a carbohydrate source, a vitamin-mineral mix, and other ingredients depending on the manufacturer.  In addition, there are infant formulas using soybean as a protein source in place of cow’s milk (mostly in the United States and Great Britain) and formulas using protein hydrolysed into its component amino acids for infants who are allergic to other proteins. An upswing in breastfeeding in many countries has been accompanied by a deferment in the average age of introduction of baby foods (including cow’s milk), resulting in both increased breastfeeding and increased use of infant formula between the ages of 3- and 12-months.

A 2001 World Health Organization (WHO) report found that infant formula prepared in accordance with applicable Codex Alimentarius standards was a safe complementary food and a suitable breast milk substitute. In 2003, the WHO and UNICEF published their Global Strategy for Infant and Young Child Feeding, which restated that “processed-food products for infants and young children should, when sold or otherwise distributed, meet applicable standards recommended by the Codex Alimentarius Commission”, and also warned that “lack of breastfeeding—and especially lack of exclusive breastfeeding during the first half-year of life—are important risk factors for infant and childhood morbidity and mortality”. In particular, the use of infant formula in less economically developed countries is linked to poorer health outcomes because of the prevalence of unsanitary preparation conditions, including lack of clean water and lack of sanitizing equipment.^[6] UNICEF estimates that a formula-fed child living in unhygienic conditions is between 6 and 25 times more likely to die of diarrhea and four times more likely to die of pneumonia than a breastfed child. Rarely, use of powdered infant formula (PIF) has been associated with serious illness, and even death, due to infection with Enterobacter sakazakii and other microorganisms that can be introduced to PIF during its production. Although E. sakazakii can cause illness in all age groups, infants are believed to be at greatest risk of infection. Between 1958 and 2006, there have been several dozen reported cases of E. sakazakii infection worldwide. The WHO believes that such infections are under-reported.

Evolution of Infant Formulas

Ø            Breastmilk alternatives have been sought after and used since the Stone Age.

Ø            Infant feeding devices have been found in ancient tombs in Greece.²⁴

Ø            As weaning occurred, it was the common practice to give “pap”, a mixture of grain and water (recorded in the 1600’s). Other foods such as butter, raw meat juices, broth and sugar were also added to the milk mixture. Beer, wine and occasionally drugs were given as a sedative.²⁴

Ø            In the 1700’s, sanitation practices developed and the use of cow’s milk and barley water became popular.²⁴

Ø            In the early 1900’s, evaporated milk was used as the formula base. ²⁴

Ø            The original “formula” often consisted of 13 oz evaporated milk + 13 oz water + 1 tablespoon cod liver oil (for the fat-soluble vitamins) + 1 tablespoon or more of orange juice and sweetener of honey or syrup.

Ø            One of the first commercial formula in the United States was SMA = “synthetic milk adapted”.

Ø            In the 1960’s the use of commercial formula was “vogue” as increased numbers of women entered the workplace.

Ø            Over the last 20 years many new formulas have been developed for use in various clinical situations, such as premature birth, fat malabsorption, metabolic disorders (i.e. PKU) or formulas with decreased electrolytes and minerals for renal disorders.

Ø            Some standard formulas today are now enriched with nucleotides, very long chain fatty acids (DHA and EPA) and all compete to have a nutrient composition “almost identical to breastmilk”.

 

The “standard dilution” of all infant formulas is commonly 20 calories per ounce. The standard dilution of liquid formula concentrate is 1 oz formula concentrate to 1 oz water. Powder is usually mixed as 1 scoop powder in 2 ounces water.

Tips on Formula Feeding: An Alternative to Breastfeeding

There is 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.

But, there are several reasons why a mother may not breastfeed her baby:

• Medical or other health reasons may prevent a mother from breastfeeding.

• 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, which is a mother’s prerogative.

If you cannot, or choose not to, breastfeed your baby, you need to find a safe alternative to breast milk. Infant formulas are an ideal choice because they are manufactured to strict standards of hygiene and formulated according to recognized international nutritional standards.

But infant formula is the safest alternative only if the mother or care giver is educated on the importance of using sterile utensils, boiling the water, washing their hands, and using the exact proportions of water and formula. Proper preparation and storage can make the difference between a healthy or sick baby and even saving a baby’s life.

To ensure that infant formula prepared at home is safe, follow these precautions:

• Choose a clean area to prepare the formula.

• Always wash your hands thoroughly with clean water and soap before handling the items required for formula preparation and when mixing formula.

• When preparing formula, always use safe, clean drinking water as well as clean and boiled bottles and utensils.

• Cool boiled water to body temperature before mixing. Prepare one bottle at a time-accordingly to label instructions-and feed immediately.

• Always start each feeding with a freshly prepared bottle of formula. Do not save unfinished bottle feeds.

In summary, you need to be consistently and meticulously careful or your baby may become ill from dirty water, bottles, nipples or unsanitary conditions in the preparation area.

Here are a few other “don’ts”:

• Do not give ordinary cow or goat’s milk to your baby for the entire first year. This milk does not meet your baby’s vitamin and mineral needs and has a high level of protein that is hard for your baby to digest, straining your baby’s immature kidneys.

• Take into consideration that evaporated, condensed and sweetened condensed milks are too strong for infant’s and need to be diluted. Also, that ordinary milks or milk powders are nutritionally unbalanced for an infant’s needs and should be mixed carefully according to your health care professional’s recommendations. * Avoid gruels made from cassava, rice, maize or other plants, which are totally unsuitable breast-milk substitutes for infants less than 4 months old. They don’t have the proper nutrition and can cause choking if there are any solids in them.

 

History of Breast-milk Substitutes

Throughout history, every generation has needed to develop an alternative to breastfeeding, either because a mother had insufficient milk or chose not to breastfeed. Scientific and historical literature tells us of centuries-old efforts to satisfy an infant’s nutritional needs and to replicate the composition and benefits of breast milk.

In prehistoric cultures, infant mortality was high. Like other mammals, only the hardiest of infants, nursed by their mothers, survived. In ancient cultures, the first doctors encouraged breastfeeding. If, for some reason, the mother could not nurse, wet-nursing — substituting lactating adult women for the birth mother — was recommended for those who could afford it. Ancient art shows us that those who could not afford a wet nurse relied on the milk of domestic animals, such as donkeys, camels and goats. Clay feeding vessels, designed to transfer the milk from the animal to the baby, have been found in ancient tombs and ruins. Historians of Spartan times reported that succession to the throne was interrupted and given to a younger son because he was breastfed by his mother and his older brother was wet-nursed.

Little about infant feeding was documented between ancient times and the Renaissance. During the Middle Ages, wet nursing was the choice for a mother who could not nurse. One pediatric article on breastfeeding describes the characteristics of a good wet nurse as well as information on hiccups, diarrhea and vomiting. In the late 1500s, scientists detailed the therapeutic value of human milk not only for infants, but also for aging men and women. They also recommended the use of ass’ milk as a breast-milk substitute, should a mother need it. If the baby could not be nursed, liquid food made of diluted honey mixed with cereal flour or breadcrumbs was poured through a hollow cow’s horn. However, most efforts to replace breastfeeding were unsuccessful because of the infant’s intolerance or to bacterial contamination.

In eighteenth century Europe, unsanitary conditions were the greatest hazard for mothers and babies. The risk to babies of infection in utero from their mothers or the improper preparation of breast milk alternatives was common. Documents from that time indicate that wealthy English women chose not to nurse their infants because they thought breast-feeding aged them and ruined their figures. And, even though breastfeeding had been identified as a form of birth control, wealthy women preferred to bottle or hand feed, often having 12 to 20 babies instead.

In France during the time of Louis the XVI and Napoleon, breastfeeding – especially by the wealthy — was regarded as bourgeois and simply not done. Wet nursing, as well as animal milk and pap feeding, were the norm. French foundling homes staffed by wet nurses, which carefully regulated their diets and their activities, ensured that infants received proper nutrition.

In the 1800s, breastfeeding again became popular. For those who required an alternative, babies were fed goat or donkey milk, but this had its own drawbacks — high protein and few of the essential trace elements, plus the risk of infection from contamination. Cow’s milk — treated with additives (fat, sugar, limewater and cream) to make it more digestible and then diluted — became a common, low cost alternative. Though often used, it was not recommended because it was low protein, although thanks to the work of Louis Pasteur and Robert Koch, who discovered how to eliminate pathogenous bacteria, contamination was no longer an issue.

Urbanization and technological advances made breast-feeding less popular during the 20th century. The extended family became less of a support, and as women left the home and entered the workplace in record numbers, they tended to see breastfeeding as an unnecessary burden.

During the first half of the 20th century, scientists and physicians began in earnest to elucidate in detail the composition of mother’s milk and looking for ways of imitating it in such a way that substitutes would match more or less its digestibility and nutrient content. Success was rather slow at the beginning, however. But thanks to technological progress most manufacturers marketed bacteriologically safe and nutritionally acceptable infant foods in a powdered form already before the second World War.

The most significant breakthroughs in artificial feeding of infants have happened in the second half of the 20th century. American, Swiss and Japanese food technologists, together with pediatricians and chemists, succeeded in matching the essential nutrients of mother’s milk in formula, making it usable from the first day of a baby’s life. Improvements in the composition of infant formula, along with better sanitary conditions and standards of living helped to decrease mortality of infants who were not breastfed from around 80% to less than 2% in just a few decades.

The last 50 years have brought about the most substantial progress in improving the composition of mother’s milk substitutes ever made in history. As we enter the new millennium, infant formula manufacturers will continue to carry out efforts to develop breast milk substitutes which are closer to the gold standard of breast milk than ever before. Efforts to identify and replicate helpful trace elements, and to conduct important research regarding the addition of immunactive ingredients and enzymes that will make formula products even better, are currently under way.

Infant food manufacturers and health care professionals are united in recommending breast milk as the best way to feed a baby during the first four to six months of life. However, when a woman cannot, or chooses not to breast feed, the infant food industry makes an essential contribution to infant and young child health by offering safe and nutritious alternatives to breast milk.

 

Cow-Milk Based Formulas

Cow-Milk Based Formulas Characteristics:

–         Standard formula used when breastfeeding is not adopted or is stopped before one year of age.

–         Designed to mimic breastmilk composition. Breastmilk is approximately 60% whey and 40% casein, Cow’s milk is 80% casein and 20% whey.

–         Formulas contain at least 50% more protein/dl than breastmilk (1.5 g/100cc).

–         Formulas provide appropriate intake of essential nutrients: iron and linoleic acid.

–         Carnitine and taurine are added to most standard formulas

–         Nucleotides are added to Enfamil and Similac.

Cow-Milk Based Composition:

ü       20 calories/ounce standard dilution

ü       Protein is ideally whey-predominant (similar to breastmilk)

ü       Carbohydrate is lactose (except in Lacto-Free formula)

ü       Fat is a mixture of vegetables oils (LCT)

ü       Approximately 32 ounces of standard formula per day will meet 100% of RDA for vitamins and minerals for term infants.

ü       If infants are only fed ready to feed formula, fluoride supplement of 0.25 mg/day is necessary to meet the RDA based on American Academy of Pediatric guidelines.

Available Brands of Cow-Milk Based Formulas:

v      Enfamil with Iron (or low-iron) (Mead Johnson)

v      Similac with Iron (or low-iron) (Ross)

v      Gerber

v      Good Start (Carnation formula with 100% whey as protein)

v      Similac PM 60/40 (has decreased calcium, phosphorus and potassium content: often used in renal patients.)

 

Soy-Based Formulas

Soy-Based Formulas Indications for Use:

–         Vegetarians

–         IgE mediated reaction to cow’s milk protein

–         Lactose Intolerance or Galactosemia

–         Refeeding after chronic diarrhea (lactose-free)

Soy-Based Formulas Characteristics:

–         Increased protein content than cow-milk based formulas, since using plant source for protein (2.2 g/dl).

–         Increased vitamin and mineral content to compensate for mineral antagonists, such as phytates.

–         Additional methionine added to formula to ensure a “complete” protein

–         Taurine and cysteine added.

–         Sweeter taste than cow-milk based and lower cost.

Soy-Based Formulas Composition:

ü       20 calorie/ounce standard dilution

ü       Protein: Soy protein with added methionine

ü       Carbohydrate: Sucrose, corn syrup solids, tapioca starch

ü       Fat: Blend of vegetable oils

Available Brands of Soy Formulas:

v      Prosobee

v      Isomil

v      Isoyalac

 

Casein Hydrolysate Formulas

Casein Hydrolysate Formulas Indications for Use:

–                                                                   Milk protein or soy protein allergy

–                                                                   Complicated gastrointestinal disorders

–                                                                   Colic

–                                                                   Feeding intolerance to cow-milk or soy formulas

Casein Hydrolysate Formulas Characteristics:

–                                                                   Poor taste and expensive

–                                                                   Not recommended for long-term use in preterm infants due to inadequate vitamin and mineral content and protein source may be difficult to metabolize

–                                                                   Alimentum is only available in ready to feed

–                                                                   Pregestimil is available as a powder for the consumer, but is available in some hospitals as 20 & 24 calorie/oz ready to feed.

–                                                                   Nutramigen is available in liquid concentrate and powder to the consumer, but is available as ready to feed in the hospital setting.

Casein Hydrolysate Formulas Composition:

ü                                         Protein: casein hydrolysate (small peptide considered to be hypoallergenic)

ü                                                                 Carbohydrate: modified tapioca starch and glucose oligosaccharides.

ü                                         Fat: approximately 50% of fat is MCT oil in Alimentum and Pregestimil, and 100% of fat is corn oil in Nutramigen

Casein Hydrolysate Formulas Available Brands:

v                                                                Nutramigen

v                                                                Pregestimil

v                                                                Alimentum

 

Indications for Use of Infant Formulas

 

Premature Infant Formulas

Premature Infant Formulas Characteristics:

–                                                                   Designed for premature infants with birthweight <1800 grams.

–                                                                   Major nutrient composition is partially elemental for easier digestion

–                                                                   Vitamin and mineral content is approximately 3 times that of standard formulas to meet the increased needs premature infants.

–                                                                   Available only in ready to feed in 20 or 24 calorie/ounce.

–                                                                   Designed for premature infants >1800 grams who require increased calories, protein, vitamins and minerals.

–                                                                   22 calories/ounce standard dilution

–                                                                   Available in powder commercially. Ready to feed in the hospital setting.

–                                                                   Appropriate for the first year of feeding.

Premature Infant Formulas Composition:

ü                                                                 Protein: 60% casein and 40% whey

ü                                                                 Carbohydrate: 50% lactose and 50% glucose polymers

ü                                                                 Fat: 50% Medium chain and 50% long chain triglycerides

Premature Infant Formulas Available Brands:

v                                        Enfamil Premature with Iron

v                                        Similac Special Care with Iron

v                                        Similac Natural Care (breastmilk fortifier)

v                                        Similac NeoCare

 

•         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 whey proteins

•         Biologically hydrolyzed lactose

•         Iron fortified (0.8 mg/100 ml)

•         Contains Bifidobacterium Lactis 2´107/1 g

•         w-6 : w-3 = 7.9:1

•         Osmolality 270 mosm/L

 

•         doesn’t contain 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

•         Hypergalactosaemia

•         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.

 

Choosing a Formula

All the major manufacturers of infant formula in the United States provide appropriate nutrition for infants to grow on. Formulas are based on either cow’s milk protein, soy protein or are specially modified for infants with major digestive problems or medical conditions. Most infants do fine on the cow’s milk based formulas; the cow’s milk formulas have been modified to be appropriate for human infants. Straight cow’s milk is not appropriate. Some infants do better on soy based formulas because of a sensitivity, allergy or potential allergy to cow’s milk. Some infants are also sensitive to the lactose or sucrose used in the formula, so consult with the infant’s pediatrician if the first formula you choose does not seem to be easily digested by your infant.

There are many specialty formulas available (at a very high cost) for infants with sensitivity to both cow’s milk and to soy or with other medical or digestive conditions. If there is a strong family history of food allergy on either side of the family, it is advisable that the baby be fed solely breastmilk for the first six months of life. Research has shown that babies with a family history of allergy who are formula fed or supplemented with formula, have more food allergies than infants who are fed breastmilk alone.

Formulas come in three forms: liquid concentrate, powder and ready-to-feed. Prices vary widely and formula can be very expensive.

Ready-to-feed is usually the most expensive because you are paying for the water and more container. If you do not have a safe source of water, ready-to-feed is the only appropriate choice.

Both liquid concentrate and powder need to be mixed with water before use. Be sure to use very scrupulous sanitation practices and to follow the directions on the can carefully. Infants can run into medical and growth problems from under or over diluting the formula. Liquid concentrate is the most popular form, because all you have to do is mix with an equal amount of water. If you have well-water, or are concerned about the safety of your water, have it tested by your local health department or a reputable lab, before using it to make formula. Bottled water is not necessarily safe either, but recent legislation has improved the labeling of bottled water. Read the label carefully to determine the source of any bottled water you use. Baby bottled water is not necessary and is usually expensive. Liquid concentrate must be kept chilled (between 35 and 40 degrees) after the can is opened and/or it is mixed with water. Check the temperature of your refrigerator. All formula should be discarded twenty-four hours after opening.

Powdered formula can be very convenient, but it can be harder to mix accurately. Powdered formula is particularly appropriate for travel, because it does not have to be kept chilled until water is added. If you are going to be out on a hot day, take along bottles of water and pre-measured portions of formula and make up each bottle as needed. No need to worry about the formula going bad. Discard any unused formula after baby is finished.

You can mix and match forms of formula to meet your needs at the moment, but it is best to stick to one brand of formula. Some infants switch between brands easily, but most do not. Careful sanitation for all bottles, nipples and the kitchen where the formula is prepared is very important. Don’t forget to wash your hands before making the formula – human hands are a huge source of bacteria! And never put the nipple in your mouth before or while feeding baby!

All babies need a source of iron in their diet, so choose iron-fortified formula from the start. Some parents are afraid to use iron-fortified formulas because they think that iron will cause intestinal distress. Research shows that this is not the case, all formula fed babies experience these problems. (Pediatrics 66:168-170. 1980)

All babies also need a source of fluoride in their diet. Check with your local water supply to find out if your tap water is fluoridated. If your water is not fluoridated or if you choose to use bottled water, ask your pediatrician for a prescription for fluoride drops. Fluoride is essential for the formation of healthy bones and teeth.

Using the Bottle:

Allow the infant to tell the adult when a feeding is over. Babies have aatural ability to obtain the right amount of food if the adult will allow them that privilege. Babies will change from day to day in the amount of formula they want and need. Allow them to communicate that to the feeder. When a baby closes her mouth, turns her head away, fusses, and refuses to have the nipple replaced, consider the feeding ended and discard any formula remaining in the bottle. Formula left over after a feeding can harbor bacteria, which will grow and then be consumed by the infant if the bottle is reused.

Always hold an infant when feeding. Never prop a bottle. Infants need to be able to see the face of the person feeding them, they need to be able to communicate and enjoy the feeding and they need to be able to get the bottle out of their mouth if they are choking or gagging. None of this is possible with a propped bottle.

Never offer an infant honey or corn syrup. There have been several incidents of serious food poisoning resulting from honey and corn syrup given to infants with immature digetive systems.

Adding Solid Foods:

The energy and nutrient needs of the newborn to six month old infant are well met by breastmilk or commercial infant formula plus a fluoride supplement. By age six months the infant needs an additional source of carbohydrate and amore of vitamins A and C than is provided in a milk based diet alone.

Developmentally, the six month old is ready to sit upright with support, observe a spoon with food coming towards his mouth, open his mouth when ready for the food and move the food from the spoon to a swallow. The six month old is also able to communicate his rejection of the food. The digestive system is mature enough to handle new foods. The younger infant is not developmentally able to do these things and is therefore not ready to be fed solid foods.

The first solid food introduced in usually iron-fortified infant rice cereal mixed with breast milk or formula. Very few people are allergic to rice and it is easily digested, so it makes an excellent choice for a first food. Barley cereal is also an appropriate early solid. Start with just a tablespoon or so of cereal and a few teaspoons of breast milk or formula. This is a new experience and it make take a few feedings before baby is ready for a quantity of cereal

Feed baby in an upright position. Use rolled up towels or receiving blankets in a high chair if the infant needs additional support. Or have one adult hold the infant while another offers the food to baby. Do not try to feed the baby in a semi-reclined position such as an infant carrier or car seat. It is very difficult for her to swallow while reclining and difficult to see the spoon as it comes toward her mouth. It is important that the infant be able to see the spoon coming towards her mouth so that she can open her mouth in anticipation. Do not force the spoon between closed lips as this turns feeding into an unpleasant experience and can cause many feeding problems later on. Use an infant size spoon. Many babies prefer a plastic or rubber coated spoon – cold metal can be an unpleasant experience.

The baby who is developmentally ready for solids will learn to eagerly anticipate the full spoon coming towards their mouth and will be open and ready by the time it gets there. A baby who is reluctant to open and fusses and complains when the parent tries feeding for the first time may not be ready – wait a few days and then offer the food again.

Do not put infant cereal or any other solid into a bottle or infant feeder. It will interfere with the child’s natural ability to obtain the appropriate amount of energy from the milk feeds. It is simply force feeding and inappropriate.

Once the infant is developmentally ready for solids, the parents need to be ready to change quickly. Infants are capable of very fast and rapid transitions from one ability to the next during the next few months. Parents need to be ready for those changes. Trying to stick to any set routine in this stage, or trying to keep the child from progressing from one stage to another, because the parent is not ready can have detrimental results for the growing child, and his transition to mature eating patterns. Allow the child to take the lead as this chewing and swallowing ability progress. Learn to understand the child’s non-verbal communications and relax.

After the child has done well with infant cereal for several weeks, pureed or strained fruits or vegetables may be added to the diet. Experts do not agree on whether to add fruits first or vegetables first, and it probably does not matter. But babies do have an innate preference for a sweet taste, so start with sweeter vegetables such as squash, and sweet potatoes. Purchased infant foods or those made at home may be used. Baby does not need added sugar or salt. If home prepared foods are used, careful sanitation practices should be observed. Wait three to five days between each new food offered to make sure that there is not problem with a food allergy.

Watch baby’s jaw as he is offered foods. When an up and down munching motion begins to be apparent, pureed meats, beans, cooked egg yolk, tofu, cottage cheese and plain yogurt may be added to the diet.

Introducing a Cup:

The six month old, who is sitting up unsupported and is using both hands for play is developmentally ready to begin learning to drink from a cup. Start with a small amount of breast milk, or formula in the cup, hold baby on your lap and show her how to drink. Small amounts of apple, pear or other mild juice may be offered in the cup. Infants who are eating a good variety of fruits and vegetables have no nutritional need for juice, so do not offer more than four ounces a day. This is also a good time to introduce plain water.

Introducing Table Food:

By nine months old the infant should be getting himself into and out of the sitting position, playing with toys with both hands, bringing toys to his mouth, and grabbing for the spoon during feedings. Now is the time to bring the child to the table at meal time with other family members, if you have not already done so. The nine month old is eager to observe other family members and to try to do as they do. He is ready to try self-feeding with a spoon. He is ready to start soft table foods. His digestive system is ready for wheat and mixed grains. Start with small bits of soft fruit such as bananas or vegetables such as soft cooked green beans. Other good finger foods include bits of toast, arrowroot biscuits or other teething biscuits, unsalted soda crackers, cheese cubes, and other fruits and vegetables. He will be interested in what others are eating and willing to try new foods.

Understand your child’s chewing skills and help him progress as quickly as he is able, but do not push him to go too fast. Teeth are not necessary for good chewing skills or the introduction of table foods. Gagging is a good skill to have at this age. Learn the difference between gagging and choking. A parent who panics over gagging will scare the child and she may not progress as well with foods as she should. Gagging is the way a child prevents a choking incident.

As the child’s chewing and swallowing ability progresses, mashed and chopped table food from the family table may be introduced. Spices and herbs are OK. The child from nine months to twelve months is usually a good eater, interested in a variety of tastes and textures. Enjoy this stage and offer as many new foods as you and he are willing to try.

By the child’s first birthday, whole cow’s milk may be offered in the cup. Formula may be discontinued unless needed because of a medical condition. Breastfeeding may be tapered off to just “comfort feedings”; solid foods should be the main source of nutrition after one year of age – breastmilk just a supplement.

Whole eggs and egg whites may be offered after the first birthday, as well as strawberries and other potential allergens. Peanut butter appears to be a very potent allergen and should not be given until after the third birthday. The child is still developing chewing skills though, so do not offer foods which are easy to choke on such as: nuts, seeds, popcorn, raw vegetables, hot dogs, raisins, grapes, peanut butter, meat sticks, hard candies or lollipops. Children do not need fruit flavored, sweetened beverages, fruit punches, or soda. Use plain water for thirst.

Weening:

As the infant begins to walk, the parent will notice a lessening of interest in the bottle. This is the appropriate time to wean from the bottle between eleven and fourteen months. If the cup was appropriately introduced at six months, the child will be fairly proficient with it by twelve months and formula or milk may be given in the cup. The child needs 16 to 24 ounces of milk daily, this is easily obtained from a cup. The child needs four ounces or less of juice each day and this can also be given in the cup.

Length of Feeding – 20-30 minutes from the bottle.

Number of daily feedings:

First 5 months of life: 6 feedings per day every 3,5 hours with night break in 6,5 hrs.

After 6 months: 5 feedings per day every 4 hours with night break in 8 hrs.

 

How to prepare baby’s formula:

Wash your hands before you begin.

Wash all bottle feeding equipment in hot, soapy water. Rinse well with hot water.

Sterilize bottle feeding equipment for the first three or four months of baby’s life. To sterilize, cover items completely with water and boil for five minutes. Cool and remove from water with sterile tongs.

The water for formula should be boiled for five minutes then cooled. Use safe drinking water to prepare the formula.

Mix formula according to package directions. Fill the sterilized bottles. You may prepare up to a 24-hour supply of infant formula at one time.

Store the prepared formula in the refrigerator. When away from home, store it with an ice pack in a cooler. Formula should never be left at room temperature for longer than one hour.

 

How to warm baby’s formula:

Place the bottle in a container of warm water or hold it under warm running tap water. Gently shake the bottle for even warming.

Check the temperature of the formula before feeding a baby. Put a few drops on the inside of your wrist. It should feel slightly cool.

Caution: Never microwave formula. Microwaves heat unevenly and a baby’s mouth could be burned.

Caution: Never prop a bottle. It is a choking hazard and can cause baby bottle tooth decay.

 

Bottles should never be given when a child is put to bed, or when the child is lying down. This is dangerous for choking and can be very detrimental to the development of healthy teeth. If you must put your baby to bed with a bottle, fill it with water only, or just offer a clean pacifier. Tooth decay can occur when any sweet liquids, as well as milk and formula are given to baby throughout the day or night. This is more of a problem if baby falls asleep while drinking these liquids. Make sure you clean baby’s teeth after eating and drinking.

 

Artificial feeding

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

 

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 why a mother may not 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 contraindications to breast-feeding

1.     Hypergalactosaemia.   

2.     Phenylketonuria [PKU].

3.      Lactose intolerance

Medical contraindications to breast-feeding connected with mother

1.     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.     Substance–abuse (drugs, alcohol, marijuana, cocaine, heroin, ets)(See table 3).

5.      

 Other reasons why a mother may not 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 supply that is more responsive to decreased feeds. A woman will rarely “dry up” becayse she has returned to work.

•         Working mothers, however, can easily breast-feed 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 and immediately refrigerated or frozen.

–       If refrigerated, it will stay good for 48 hours.

–       If frozen at 0°F, it will keep for months.

–        

 

 

 

 

•         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.

Drug Ultrapasterisatio	RUU UlUltrapasterisationeported sign or symptomAdvances iutritional modifications of infant formulas in infant or effect on lactation
Bromocriptine	Supresses lactation
Cocaine	Cocaine intoxication
Cyclophos-phamide	Possible immune supression; unknown effect on growth or association with carcinogenesis; neutropenia
Cyclosporine	Possible immune supression; unknown effect on growth or association with carcinogenesis

 

 

 

 

Advances iutritional 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

•         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 %

•         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.

•          

•          

•         Nucleotides and their related products play key roles in many biological processes. Although nucleotides can 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 gastrointestinal and immune systems

•                                                             Cow’s milk

•                                                                           Classification of artificial feeding

•         Not adapted: sweet and sour – 2, 3,4.
Adapted: high adapted (special), adapted (baseline), following (partially adapted).
Treatment: with pre-and probiotics, antireflux to malovahovyh children, for the treatment of anemia, antiallergic.

•                                                                             Dilution of Cow’s Milk:

                                     Benefits concoctions in a dilution of milk over water

•         Contribute to the creation of colloidal milk because casein clots more easily digested;
Some (buckwheat) with a membership of amino acids;
With the broth in the child coming polysaccharides, which reduces fermentation;
Conjee has protective properties;
Slightly increased caloric mixture

•          

•          

•          

•          

•          

•          

•          

•          

•          

•          

•          

•          

•          

•          

•          

•          

•         The need for baby’s first year of life in food ingredients per 1 kg of body weight when artificial feeding

•         Adapted mix: 0 – 6 months – 3.0 g protein;
         Fats – 6,5-6,0 g carbohydrates – 12-14 g;
      12.7 months – proteins – 3.5 g fat – 5,5-5,0 g;
         Carbohydrates – 12-14 g;

•         Not adapted mixture: 0 – 6 months – protein 3.5 g, fat – 5,5-5,0 g carbohydrates – 12-14 g;
    12.7 months – proteins – 4,0 g, fats – 5,5 g, carbohydrates – 13g.

•          

•        

•          

•         Basic formulas

•         is adapted for all food ingredients dry milk mixture as close to breast milk for food, biological value and osmolarity. They contain all the necessary food applications (taurine, L-carnitine, lecithin, etc.) that are particularly important for child development.

•         from 0 till 3 month

•          

•         0 till 3 month

•                                                                                  Next–

•          

•         A mixture that is recommended for children older than 6 months;
This is partly adapted mixture prepared without added protein and whey. Food and energy value of these mixtures is higher than the baseline, except they contain lactose, sucrose and starch.

 

•          

•          

 

 

 

 

•         Treatment feeding

•         Lactose free Diarea syndrom different etiology

 

 

•         Energy needs of the child by artificial feeding

•         When feeding vysokoadaptovanymy formula – the same as in breast feeding;
When fed infant formula – 5% higher than breastfeeding;
When feeding not adapted formula – 10% higher than in breastfed

 

Age

Water

 

Hypoallergenic range of products in stock Humana, key advantages
Background
 One of the urgent problems of modern pediatrics are food allergies, which leads to sensitization of the organism, of complications from the gastrointestinal tract, including intestinal dysbiosis. This intestinal dysbiosis is triggered in the event of both functional disorders and allergic reactions.
 The prevalence of atopic dermatitis in children in the Ukraine is 3,9-4,5%. The first manifestations of atopic dermatitis often mark of 2-3 months of life, when due hypogalactia the mother starts feeding correction.
With more than 160 food allergens
known in our time
and causing IgE-caused allergic reactions
first place belongs to cow’s milk the “great 8” products that have the greatest allergenic include:
1 cow’sn milk
2n Eggs
3n Fish
4 Wheatn
5peanutsn
6n soybean
7crustaceansn
8 nutsn
the most common
food allergens include:
• Cocoa and chocolate
• Citrus
• Strawberry
• Meat of animals and birds
• Honey
• caviar, seafood
• cereals
Major allergens are cow’s milk protein
n B-lactoglobulin
n A-lactoglobulin
n Laktoalbumin
 lactoferrinn
* The most highly antigenic properties vыrazheni in in-lactoglobulin
Risk factors for food allergy in infants
1) Excessive consumption of a mother during pregnancy and lactation period, milk and dairy products.
2) Development of allergy in children who are bottle-fed or mixed promote:
 Usen regular ZHM in children with family history for atopy
n unreasonably early use of dairy products not adapted
 Earlyn introduction of foods and unhealthy foods
1) Excessive consumption of a mother during pregnancy and lactation period, milk and dairy products.
2) Development of allergy in children who are bottle-fed or mixed promote:
 Usen regular ZHM in children with family history for atopy unreasonably early use of dairy products not adapted
 Earlyn introduction of foods and unhealthy foods
primary prevention
          (Aimed at the prevention of allergen sensitization)
secondary (after sensitization)
tertiary (prevention of severe complications)
Primary prevention –
the most efficient level of prevention
Primary prevention (ie, prevention of food sensitization) is raising a healthy child, environmental sanitation, nutrition, elimination obligate allergens, ie suspension order transformation of clinical manifestations of allergic disease and the gradual development of atopic march
Major trends in dietoterapy food allergy in infants
1) The maximum duration of breastfeeding
2) In the absence or lack of breast milk – the right choice hypoallergenic base mix
Classification of mixtures hypoallergenic
n For protein substrate: from whey protein hydrolysates based on casein hydrolysates
n For the degree of hydrolysis: a high degree of hydrolysis moderate degree partial hydrolysis
n In testimony to appointments: therapeutic, preventive, curative and preventive
Protein hydrolysates –
beginning of a new era in the treatment of
and prevention of food allergy in children
As a result of enzymatic hydrolysis of whey protein protein molecule becomes less allergenic
Benefits of mixtures based on whey hydrolysates compared with casein hydrolysates complete
n Serum oligopeptides more physiological, better absorbed in the intestine child than free amino acids, thus providing proteyinohramu blood identical in both children breastfed
n High biological value whey proteins due to higher content nezaminymyh amino acids – cysteine ​​and tryptophan
 osmolarity similarn mixture of breast milk
n A pleasant smell and taste compared with mixtures based on hydrolyzed casein
n weight gain while using whey hydrolysates higher than casein
n Contains lactose (lactose load but reduced – about 50% of the total carbohydrate content).
Requirements ESPHGAN (The European Union pediatricians, gastroenterologists, nutrytsiolohiv, dietolohiv) to the hypoallergenic formula.
n 90% of children stradayuchyh allergic to milk should be good to carry this product
n The mixture should contain a low amount of residual antigen
n Growth and development of children who are fed formula data should not differ from similar figures in children breastfed
Features hypoallergenic mixtures TM Humana
n Comply with requirements ESPHGAN relatively hypoallergenic mixtures
n mixtures is curative and can be used to prevent and treat food allergies Light and Medium severity
n Protein component mixtures of 100% whey protein hydrolyzate represented
n allergenic mixtures of several thousand times lower than conventional ZHM
n Do not include in-lactoglobulin, a major cow’s milk allergen protein
 The mostn optimal flavor compared to similar mixtures
n Low residual number of antigens (high purity compounds) due to the unique cycle
Unique production cycle plant Humana
n Use the most effective way to reduce alerhennosti cow’s milk – protein hydrolysis by enzymes. When the enzymes have a wide range of specificity, which provides the possibility of destruction bonds in molecules of different protein levels

n A special method of cleaning ultrafiltration can remove any highdespertional fraction

n The remaining amount of antigen mixtures depends on the presence of bacterial particles.  method allows clear the product and reduce its allergenicity
Hypoallergenic mixture
TM Humana
 Humana O-AT (premature, little weight)
 Humanan Hypoallergenic IN 1 (0 – 6 months)
 Humana for 2n Hypoallergenic (6 -10 months)
 Humana Hypoallergenicn 3 (from 10 months)
Feeding Program
Name Age Display Features
Humana 0-ON Premature,  Light weight, IUGR Protein 2.2 (provision of additional protein), a protein component mixtures represented 100% whey hydrolyzate, 25% of SLT, low lactose content, LC-PUFA
Humana IN 1
Humana ON 1 + LC-PUFA 0 – 6 months family history of allergies to food. Food allergies are mild to moderate severity 100% hydrolyzed whey, reduced lactose load (64.5% lactose)
LC-PUFA
You can give on demand
Humana by 2 6 – 10 months Burdened family history of food allergies. Food allergies are mild to moderate severity 100% hydrolyzed whey, reduced lactose load (55.7% lactose), contains prebiotics GOS content of vitamins, minerals (iron, calcium) and micronutrient needs of children in the age group of the second half of life
Humalna 3 over 10 months by family history of food allergy. Food allergies are mild to moderate severity
Alternative cow’s milk 100% whey hydrolyzate, lactose reduced pressure (55.7% lactose), contains prebiotics GOS content of vitamins, minerals (iron, calcium) and micronutrient needs of children in the age group of the second half of life

The optimum alternative to cow’s milk in the diet of children with food allergies to 3 years

Humana milk-free meals
1. Dairy-free corn-rice porridge Humana
2. Dairy-free apple porridge Humana
3. Dairy-free buckwheat porridge Humana
4. Dairy-free rice porridge with pumpkin Humana
5. Dairy-free oatmeal Humana
6. Children at risk of food allergy (prepared in a mixture of Humana ON)
7. For children with intolerance to cow’s milk protein and (or) lactose (prepared in a mixture of Humana SL or water)
8. In galactosemia and celiac disease

FORMULA-FEEDING

Objective nutritional studies of growing infants younger than 4–6 mo of age (e.g., rate of growth in weight and length, normality of various constituents in blood, performance in metabolic studies, body composition) differ minimally, if at all, between breast-fed infants and infants fed modern infant formulas. Although such investigations may not allow the detection of small but important variations and/or differences, they attest to the ability of modern infant formulas to support normal growth and development. Thus, the mother who cannot or does not wish to nurse her infant need have no less sense of accomplishment or of affection for her infant than the nursing mother. Moreover, the quality of attachment and mothering and the degree of security and affection provided the breast-fed infant need not be different with formula-feeding.

TECHNIQUE OF FORMULA-FEEDING.

The setting for formula-feeding should be similar to that for breast-feeding, with the mother or caregiver and the infant in a comfortable position, unhurried, and free from distractions. The infant should be hungry, fully awake, warm, and dry. He or she should be held as though being breast-fed. The nipple holes should be of a size that allows the milk to drip slowly, and the bottle should be held so that milk, not air, channels through the nipple. Bottle propping, even with a “safe” holder, should be avoided; this not only deprives the infant of the physical contact and security of being held, but also may be dangerous, particularly for small infants, who may aspirate if unattended. In addition, otitis media is more common in infants fed with a propped bottle.

The bottle of formula is usually warmed to body temperature. This may be tested by dropping milk onto the wrist. However, no harmful effects from feeding formula at room or even refrigerator temperature have been demonstrated.

Eructation of air swallowed during feeding is important for avoiding regurgitation and abdominal discomfort, especially during the 1st 6–7 mo of life. The technique of “burping” should be the same as described for the breast-fed infant. A few infants relieve themselves best after being returned to the crib. All infants occasionally regurgitate or “spit up” a small amount of milk after feeding, a fact that the mother should know. Spitting up seems to occur more often in the formula-fed than in the breast-fed infant.

A feeding may last from 5–25 min, depending on the age and the vigor of the infant. Because the infant’s appetite varies from 1 feeding to another, each bottle should contain more than the average amount taken per feeding, but io case should the infant be urged to take more than desired. Excess formula should be discarded.

COMPOSITION OF INFANT FORMULAS.

The nutrient content of infant formulas marketed in the USA is regulated by the Food and Drug Administration (FDA) according to the Infant Formula Act, and most industrialized as well as many developing countries have similar regulations. All marketed formulas must contain minimum amounts of all nutrients known or thought to be required by infants, and increasing emphasis is being placed on not exceeding a reasonable maximum content of each nutrient. The most recent recommendations for the minimum and maximum nutrient contents of infant formulas marketed in the USA are shown in Table 42-3 . These recommendations were made by a committee appointed by the Life Sciences Research Organization to advise the FDA. Note that the minimum recommended amount of each nutrient is greater than the amount of that nutrient in human milk and, hence, greater than the most recent dietary reference intake (DRI) for that nutrient (see Tables 41-1 and 41-3 ). This, most likely, reflects the perceived lower bioavailability of nutrients in formula compared with human milk.

TABLE 42-3   — Recommended Minimum and Maximum Contents of Various Nutrients for Infant Formula Manufactured in the United States^[*]

	MINIMUM	MAXIMUM
ENERGY (Kcal/dl)	63	71
Fat (g)	4.4	6.4
Linoleic acid (% of fatty acids)	8	35
α-Linolenic acid (% of fatty acids)	1.75	4
Carbohydrate (g)	9	13
Protein (g)	1.7	3.4
ELECTROLYTES AND MINERALS
Calcium (mg)	50	140
Phosphorus (mg)	20	70
Magnesium (mg)	4	17
Sodium (mg)	25	50
Chloride (mg)	50	160
Potassium (mg)	60	160
Iron (mg)	0.2	1.65
Zinc (mg)	0.4	1.0
Copper (μg)	60	160
Iodine (μg)	8	35
Selenium (μg)	1.5	5
Manganese (μg)	1.0	100
Fluoride (μg)	0	60
VITAMINS
Vitamin A (IU)	200	500
Vitamin D (IU)	40	100
Vitamin E (mg α-TE)	0.5	5.0
Vitamin K (μg)	1	25
Vitamin C (mg)	6	15
Thiamine (μg)	30	200
Riboflavin (μg)	80	300
Niacin (μg)	550	2,000
Vitamin B6 (μg)	30	130
Folate (μg)	11	40
Vitamin B12 (μg)	0.08	0.7
Biotin (μg)	1	15
Pantothenic acid (μg)	300	1,200
OTHER INGREDIENTS
Carnitine (mg)	1.2	2.0
Taurine (mg)	0	12
Myoinositol (mg)	4	40
Choline (mg)	7	30

 

*	Amounts/100 kcal, unless otherwise indicated.

 

Manufacturers of infant formulas are responsible for assuring the FDA that each formula contains the minimum recommended amount and no more than the maximum recommended amount of each nutrient for the intended shelf life of the formula and also that the formula was manufactured safely and hygienically. Each batch of manufactured formula is assayed continually over the shelf life of the product. Manufacturers also are responsible for assuring the FDA that each marketed formula, as the infant’s source of nutrition, supports normal growth and development for at least the 1st 4 mo of life. This is usually done by conducting growth studies during all or part of the 1st 4 mo, but at least 2 mo of life, in a sufficient number of infants to detect a 3 g/24 hr difference in rate of weight gain between infants fed the “new formula” compared with a standard formula or human milk. The efficacy and safety of substituting alternative sources of various nutrients also must be demonstrated by appropriate studies.

Most infant formulas contain a protein source, usually a mixture of bovine milk proteins, but also soy protein or a variety of hydrolyzed proteins; lactose and/or other sugars; a mixture of vegetable oils; mineral salts; and vitamins. The composition of selected formulas available in the USA is shown in Table 42-4 . Most are available in powder, concentrated liquid (intended to be diluted 1 : 1 with water), and ready-to-feed forms. Similarities to bovine milk from which they evolved are virtually nonexistent.

TABLE 42-4   — Composition of Standard Formulas for Normal Infants^[*]

Component	Similac[†]	Enfamil[‡]	Good Start[§]	Isomil[†]II	Prosobee[‡]
Protein (g)	2.07 (cow’s milk whey)	2.1 (cow’s milk, whey)	2.4 (whey)	2.45 (soy protein isolate, L-methionine)	2.5 (soy protein isolate, L-methionine)
Fat (g)	5.4 (high-oleic safflower, coconut, and soy oils)	5.3 (palmolein, soy, coconut, and high-oleic sunflower oils)	5.1 (palmolein, soy, coconut, and high-oleic safflower oils)	5.3 (soy, high-oleic safflower, coconut oils)	5.3 (palmolein, soy, coconut and high-oleic sunflower oils)
Carbohydrate (g)	10.8 (lactose)	10.7 (lactose)	11.0 (lactose, corn maltodextrin)	10.3 (corn syrup, sucrose)	10.6 (corn syrup solids)
ELECTROLYTES AND MINERALS
Calcium (mg)	78	78	64	105	104
Phosphorus (mg)	42	53	36	75	82
Magnesium (mg)	6.1	8	7.1	7.5	11
Iron (mg)	1.8	1.8	1.5	1.8	1.8
Zinc (mg)	0.75	1	0.8	0.75	1.2
Manganese (μg)	5	15	7.1	25	25
Copper (μg)	90	75	80.5	75	75
Iodine (μg)	6.1	10	12	15	15
Selenium (μg)
Sodium (mg)	24	27	24	44	35
Potassium (mg)	105	107	101	108	120
Chloride (mg)	65	63	65.5	62	80
VITAMINS
Vitamin A (IU)	300	2,094	302	300	294
Vitamin D (IU)	60	60	60	60	60
Vitamin E (IU)	1.5	2	2	1.5	2
Vitamin K (μg)	8	8	8.0	11	8
Thiamine (μg)	100	80	60	60	80
Riboflavin (μg)	150	140	141	90	90
Vitamin B6 (μg)	60	60	75	60	60
Vitamin B12 (μg)	0.25	0.3	0.25	0.45	0.3
Niacin (μg)	1,050	1,000	750	1,350	1,000
Folic acid (μg)	15	16	15	15	16
Pantothenic acid (μg)	450	500	453	754	500
Biotin (μg)	4.4	3	2.2	4.5	3
Vitamin C (mg)	9	12	9	9	12
Choline (mg)	16	12	12	8	8
Inositol (mg)	4.7	6	18	5	6

 

II Isomil-SF (sucrose-free) has similar composition except that glucose polymers are substituted for corn syrup and sucrose.

 

*	Amount/100 kcal.
†	Ross Laboratories, Columbus, OH.
‡	Mead-Johnson Nutritionals, Evansville, IN.
§	Carnation Nutritional Products, Glendale, CA.

 

NUMBER OF FEEDINGS DAILY.

The number of feedings required daily decreases throughout the 1st year of life from 8 or more shortly after birth to only 3 or 4 at 1 yr of age. The desired interval between feedings differs considerably among infants, but in general, ranges from 3–5 hr during the 1st year of life, averaging approximately 4 hr. For the 1st 1–2 mo, feedings are taken throughout the 24 hr period; thereafter, as the quantity of milk consumed at each feeding increases and the infant adjusts his or her demand to the family pattern of daytime activities, the infant usually sleeps for longer periods at night. As the infant develops psychologically and the relationship between the parent and the infant evolves, demand feeding should gradually be replaced by a feeding regimen that accommodates the needs of the rest of the family as well as those of the infant.

QUANTITY OF FORMULA.

The quantity of formula taken at a feeding varies among infants of the same age and within infants at different feedings. Rarely will an infant want more than 7–8 oz at a single feeding. The desire for formula (or breast milk) is somewhat less during the 1st 2 wk of life than during the following 5–6 mo. After 6 mo of age, formula (or breast milk) is rarely the sole source of the infant’s nutrient intake. However, it remains an important source of many nutrients (calcium).

It is rarely necessary to feed more than 1 qt (960 mL) of formula/day. Ingesting more than this volume has no advantages and may displace intake of other essential foods. By the time the infant is taking this amount, other foods should be added to the diet.

INFANT FORMULA VS BOVINE MILK.

Although current recommendations are to avoid intake of bovine milk, particularly low-fat or skim milk, before 1 yr of age, surveys suggest that a number of infants between 6 and 12 mo of age are fed homogenized bovine milk rather than infant formula, and a number of these are fed low-fat or skim milk, often on the inappropriate advice of their physician.

The consequences of these practices are not known with certainty. However, infants fed bovine milk, on average, ingest roughly 3 times the DRI of protein and 2 or more times the DRI of sodium, but only approximately ⅔ of the DRI of iron and only ½ of the DRI of linoleic acid. Ingestion of bovine milk also increases intestinal blood loss and, hence, further contributes to the development of iron-deficiency anemia.

The protein and sodium intakes of infants fed skim rather than whole bovine milk are even higher, the iron intake is equally low, and the intake of linoleic acid is very low. Interestingly, although the most common reason for substituting low-fat or skim milk for whole milk or formula is to reduce fat and energy intakes, the total energy intake of infants fed skim milk is not necessarily lower than that of infants fed whole milk or formula. This suggests that infants compensate for the lower energy density of low-fat or skim milk by taking more of it and/or increasing intake of other foods.

Whether the high protein and sodium intakes of infants fed whole or skim milk are problematic is not known with certainty. The low iron intake, clearly, is undesirable, but medicinal iron supplementation should prevent the development of deficiency. The low intake of linoleic acid may be more problematic. Whereas signs and/or symptoms of linoleic acid deficiency appear to be uncommon in infants fed either whole or skim milk, an exhaustive search for such symptoms has not been made. Biochemical evidence of essential fatty acid deficiency without overt signs and symptoms occurs in both younger and older infants fed formulas with a low content of linoleic acid; thus, an exhaustive search, including biochemical indices, is likely to reveal a reasonably high incidence of essential fatty acid deficiency. On the other hand, infants who were breast-fed or fed formulas with high linoleic acid content earlier in life may have sufficient body stores to limit the consequences of low intake later. Essential fatty acid deficiency in animals is associated with long-term deleterious effects on development; it is not wise to assume that biochemical essential fatty acid deficiency without clinically detectable symptoms is without consequences.

Resolving the issues concerning the use of bovine milk in feeding the infant is important for economic as well as health reasons. Because the cost of bovine milk is considerably less than that of infant formula, replacing formula with homogenized bovine milk obviously has important economic advantages for most families, particularly those with limited income. If the federal food assistance programs could provide homogenized bovine milk rather than formula to infants, even infants older than 6 mo of age, the program’s current funds would permit expansion of benefits to many more needy infants (see Chapter 43 ).

FEEDING DURING THE 2nd 6 MO OF LIFE

By 4–6 mo of age, the infant’s capacity to digest and absorb a variety of dietary components as well as to metabolize, use, and excrete the absorbed products of digestion is near the capacity of the adult. Moreover, teeth are beginning to erupt, and the infant is more active and beginning to explore his or her surroundings. With the eruption of teeth, the role of dietary carbohydrate in the development of dental caries must be considered as well as the long-term effects of inadequate or excessive intakes during infancy and the psychosocial role of foods during development. These considerations, rather than concerns about delivery of adequate amounts of nutrients, are major factors underlying the feeding practices advocated during the 2nd 6 mo of life.

It is clear that all nutrient needs during the 2nd 6 mo of life can be met with a reasonable amount of currently available infant formulas. In contrast, the volume of milk produced by some women may not be adequate to meet all nutrient needs of the breast-fed infant beyond approximately 4–6 mo of age. This is particularly true for iron. Thus, for breast-fed infants, complementary foods are an important source of nutrients. They also have important psychosocial roles for both the breast-fed and the formula-fed infant.

Complementary foods (additional foods, including formula, given to the breast-fed infant) or replacement foods (foods other than formula given to formula-fed infants) should be introduced in a stepwise fashion to both breast-fed and formula-fed infants, beginning about the time the infant is able to sit unassisted, usually at 4–6 mo of age (see Table 42-2 ). Cereals, a good source of iron, are usually introduced 1st, followed by vegetables and fruits, then meats, and finally, eggs. However, the order in which these foods are introduced is not crucial, but only 1 new food should be introduced at a time and additional new foods should be spaced by at least 3–4 days to allow detection of any adverse reaction(s) to each newly introduced food. This is particularly important if there is a family history of food and/or other allergies.

Either home-prepared or manufactured complementary or replacement foods can be used. The latter are convenient, and many contain supplemental nutrients (iron). These foods also are available in different consistencies to match the infant’s ability to tolerate larger size particles as he or she matures.

Prepared dinners and soups containing meat and 1 or more vegetables are quite popular. However, the protein content of these products is not as high as that of strained meat. Puddings and desserts also are popular items, but aside from their milk and egg content, they are poor sources of nutrients other than energy; thus, intakes of these should be limited. Moreover, intake of egg-containing products generally should be delayed, especially if there is a family history of food and/or other allergies, until after the infant has demonstrated tolerance to eggs (either a mashed hard boiled egg yolk or a commercial egg yolk preparation).

Aside from the association of bottle-feeding with dental caries after teeth have erupted, little is known about either the potential hazards or the non-nutritional role of diet during the latter half of the 1st year of life. Thus, feeding practices during this period vary widely. Nonetheless, recent surveys indicate that infants fed according to current practices receive adequate intake of most nutrients.

FEEDING PROBLEMS DURING THE 1ST YEAR OF LIFE

UNDERFEEDING.

Underfeeding is suggested by restlessness and crying as well as by failure to gain weight adequately. It may also result from the infant’s failure to take a sufficient quantity of food, even when offered. In these cases, the frequency of feedings, the mechanics of feeding, the size of the holes in the nipple, the adequacy of eructation of air, the possibility of abnormal mother-infant “bonding,” and possible systemic disease in the infant should be considered.

The extent and duration of underfeeding determine the clinical manifestations. Constipation, failure to sleep, irritability, and excessive crying are to be expected. Weight gain may be slow, or there may be an actual loss of weight. In the latter case, the skin becomes dry and wrinkled, subcutaneous tissue disappears, and the infant assumes the appearance of an “old man.” Deficiencies of vitamins A, B, C, and D as well as of iron and protein may be responsible for the characteristic clinical manifestations (see Chapters 45–50 [Chapter 45] [Chapter 46] [Chapter 47] [Chapter 48] [Chapter 49] [Chapter 50] ).

Treatment of underfeeding includes increasing nutrient intake, correcting any deficiencies of vitamins and/or minerals, and instructing the caregiver in the art and practice of infant feeding. If an underlying systemic disease, child abuse or neglect, or a psychologic problem is responsible, specific management of that disorder is necessary (see Chapters 36 and 37 ).

OVERFEEDING.

As a rule, postprandial discomfort from excessive intake limits the amount of food an infant voluntarily ingests, but there are exceptions. If intake is excessive, regurgitation and vomiting are the most frequent symptoms. Diets that are too high in fat delay gastric emptying, cause abdominal distention and discomfort, and may cause excessive weight gain. Diets that are too high in carbohydrate are likely to cause undue fermentation in the intestine, resulting in distention and flatulence as well as more rapid weight gain than desirable. Because neither breast milk nor formula contains either excessive fat or excessive carbohydrate, excessive intakes usually result from supplementation. This practice also tends to dilute the protein, vitamin, and mineral contents of formula and, hence, should be avoided (also see Chapter 44 ).

REGURGITATION AND VOMITING.

Regurgitation refers to the return of small amounts of swallowed food during or shortly after eating. Vomiting, on the other hand, is the more complete emptying of the stomach, often occurring some time after feeding. Within limits, regurgitation is a natural occurrence, especially during the 1st several months of life. It can be reduced to a negligible amount by adequate eructation of swallowed air during and after eating, by gentle handling, by avoiding emotional conflicts, and by placing the infant on the right side for a short time immediately after eating (but not for napping or sleeping). The head should not be lower than the rest of the body to help avoid gastroesophageal reflux, which is common during the 1st 4–6 mo of life.

Vomiting is one of the most common symptoms in infancy and may be associated with a variety of disturbances both trivial and serious. Its cause should always be investigated.

LOOSE OR DIARRHEAL STOOLS.

The stool of the breast-fed infant is naturally softer than that of the formula-fed infant. From about the 4th to the 6th day of life, the stools of the breast-fed infant go through a transitional stage of being loose, greenish-yellow in color and containing mucus to the typical “milk stool.” Subsequently, the use of laxatives or the ingestion of certain foods by the mother may be temporarily responsible for a breast-fed infant’s loose stools. Excessive intake of breast milk may also increase the frequency and water content of the stool. Actual diarrhea from overfeeding, however, is unusual; thus, diarrhea should be considered infectious until proven otherwise.

Although the stools of formula-fed infants tend to be firmer than those of breast-fed infants, loose stools also may result from artificial feeding. Overfeeding may cause loose, frequent stools, particularly during the 1st 2 wk or so of life. Later, formulas that are too concentrated or too high in sugar content, especially in lactose, may result in loose, frequent stools. However, as noted earlier, this is unlikely unless sugar has been added to the formula. Many diarrheal disturbances in formula-fed infants result from contaminants that would not disturb an older child. These usually are not serious enough to cause prolonged difficulty for the infant. The ease with which formula-fed infants acquire diarrheal disturbances and their potential seriousness are strong arguments for extreme care in preparation and storage to assure that the formula or food is free of pathogenic bacteria and remains that way until it is fed to the infant.

Mild diarrheal disturbances caused by overfeeding respond quickly to a temporary decrease or cessation of feeding. Withholding all solid food as well as 1 or several feedings and substituting boiled water or a balanced electrolyte solution is usually all that is required.

CONSTIPATION (SEE CHAPTERS 22.4 AND 329.2 ).

Constipation is practically unknown in breast-fed infants receiving an adequate amount of milk and is rare in formula-fed infants receiving an adequate intake. The consistency of the stool, not its frequency, is the basis for diagnosis. Most infants have 1 or more stools daily, but some occasionally have a stool of normal consistency at intervals of up to 36–48 hr.

Whenever constipation or obstipation is present from birth or shortly after birth, a rectal examination should be performed. Tight or spastic anal sphincters may occasionally be responsible for obstipation, and finger dilation is frequently corrective. Anal fissures or cracks may also cause constipation. If irritation is alleviated, healing usually occurs quickly. Aganglionic megacolon may be manifested by constipation in early infancy; the absence of stool in the rectum on digital examination suggests this possibility, but further diagnostic work-up is indicated (see Chapter 329 ).

Constipation may be caused by an insufficient amount of food or fluid. In some cases, it may result from diets that are too high in protein or deficient in bulk. Simply increasing the amount of fluid or sugar in the formula may be corrective during the 1st few months of life. After this age, better results are obtained by adding or increasing the intakes of cereal, vegetables, and fruits. Prune juice (½–1 oz) may be helpful, but adding foods with some bulk is usually more effective. Milk of magnesia may be given in doses of 1–2 tsp, but should be reserved for unresponsive or severe constipation.

Enemas and suppositories should never be more than temporary measures.

COLIC.

Colic is a symptom complex of paroxysmal abdominal pain, presumably of intestinal origin, and severe crying (see Chapter 303 ). It usually occurs in infants younger than 3 mo of age. The clinical manifestations are characteristic. The attack usually begins suddenly, with a loud, sometimes continuous cry. The paroxysms may persist for several hours. The infant’s face may be flushed, or there may be circumoral pallor. The abdomen is usually distended and tense. The legs may be extended for short periods, but are usually drawn up on the abdomen. The feet are often cold, and the hands are usually clenched. The attack may not terminate until the infant is completely exhausted. Sometimes, however, the passage of feces or flatus appears to provide relief.

Some infants seem to be particularly susceptible to colic. The etiology usually is not apparent, but in some infants, the attacks seem to be associated with hunger or with swallowed air that has passed into the intestine. Overfeeding may cause discomfort and distention, and some foods, especially those with high carbohydrate content, may result in excessive intestinal fermentation. However, a change of diet rarely prevents further colic attacks.

Crying with intestinal discomfort occurs in infants with intestinal allergy, but colic is not limited to this group. Colic may mimic intestinal obstruction or peritoneal infection. Attacks commonly occur in the late afternoon or early evening, suggesting that events in the household routine may be involved. Worry, fear, anger, or excitement may cause vomiting in an older child and may cause colic in an infant, but no single factor consistently accounts for colic and no treatment consistently provides satisfactory relief. Careful physical examination is important to eliminate the possibility of intussusception, strangulated hernia, or other serious causes of abdominal pain.

Holding the infant upright or prone across the lap or on a hot water bottle or heating pad occasionally helps. Passage of flatus or fecal material spontaneously or with expulsion of a suppository or enema sometimes affords relief. Carminatives before feedings are ineffective in preventing the attacks. Sedation is occasionally indicated for a prolonged attack. If other measures fail, both the child and the parent may be sedated for a period. In extreme cases, temporary hospitalization of the infant, often with no more than a change in the feeding routine and a period of rest for the parent, may help. Prevention of attacks should be sought by improving feeding techniques, including “burping,” providing a stable emotional environment, identifying possibly allergenic foods in the infant’s or nursing mother’s diet, and avoiding underfeeding or overfeeding. Although it is not serious, colic can be particularly disturbing for the parents as well as the infant. Thus, a supportive and sympathetic physician can be particularly helpful, even if attacks do not resolve immediately. The fact that the condition rarely persists beyond 3 mo of age should be reassuring.

References

а) Basic

 

1. Manual of Propaedeutic Pediatrics / S.O. Nykytyuk, N.I. Balatska, N.B. Galyash, N.O. Lishchenko, O.Y. Nykytyuk – Ternopil: TSMU, 2005. – 468 pp.

2. Kapitan T. Propaedeutics of children’s diseases and nursing of the child : [Textbook for students of higher medical educational institutions] ; Fourth edition, updated and translated in English / T. Kapitan – Vinnitsa: The State Cartographical Factory, 2010. – 808 pp.

3. Nelson Textbook of Pediatrics /edited by Richard E. Behrman, Robert M. Kliegman; senior editor, Waldo E. Nelson – 19^th ed. – W.B.Saunders Company, 2011. – 2680 p.

 

b) Additional

1. Denial Bernstein. Pediatrics for medical Students. – Second edition, 2012. – 650 p.

2. Jam W. Ball, Ruth G. Bindler Pediatric Nursing. Caring for Children. –  Third edition, 2011. – 984p.

3. Guidelines on HIV and infant feeding 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. World Health Organization, 2010.

4.  www.bookfinder.com/author/american-academy-of-pediatrics 

5. www.emedicine.medscape.com

6. http://www.nlm.nih.gov/medlineplus/medlineplus.html